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community based participatory research has commonly been utilized in low income communities and communities of color to address the complex health issues they face the federal agency for healthcare research and quality defines cbpr as a collaborative … approach designed to ensure and establish structures for participation by communities affected by the issue being studied representatives of organizations and researchers in all aspects of the research process to improve health and wellbeing through taking action… a core attribute of cbpr is the academiccommunity partnership in which both collaborate in an equal partnership to identify and address community health issues and to share knowledge and expertise with one another to further action and change within a community this partnership must cross social economic political and cultural barriers to reach goals and become sustainable cbpr has been commended as a process that facilitates community capacity building in terms of health promotion poole indicated that the purpose of capacity building is to foster conditions that strengthen the characteristics of communities that enable them to plan develop implement and maintain effective community programs capacity building encourages community members to address their own health issues and allows health practitioners and organizations to assist in the process thus promoting sustainable solutions through community empowerment and leading to improved health outcomes evaluation and measurement of capacity building within community projects has posed challenges to researchers which include but are not limited to a lack of valid and reliable instrumentation ever evolving community capacity constructs and length of time required for community capacity building however evaluation and measurement of capacity are critical in order to better define constructs of and track progress toward building community capacity and consequent health outcomes as well as to understand elements and processes that contribute to capacity building various community capacity frameworks have been described which include a number of common constructs among them resources leadership asking why communication with community members partnerships and social or external networks qualitative methods including semistructured interviews and focus groups with academic representatives community leaders and members in addition to the case study approach have been extensively used to assess community capacity a few studies have employed a mixed methods approach to evaluate community capacity an approach that is considered to offer promise in better understanding its role in health promotion background hub city steps is a cbpr walking intervention involving a collaboration among a public university a local city government and community members in a southern small city a primary aim of this intervention is to lower blood pressure in participants who are drawn primarily from the africanamerican population of the community elements of the intervention include empowerment culturally tailored health education and motivational interviewing to identify and track progress toward personal health goals as a cbpr project a primary aim is to build community capacity to promote health through physical activity and nutrition aspects of the project that foster community capacity and therefore attainment of this aim include 1 inclusion of staff and faculty with a vested interest in the community 2 involvement of project staff a community advisory board local city government local agencies and project participants in program development implementation evaluation and overall guidance of project activities and 3 development of participants skills and knowledge of health promotion to attain individual and community change these are accomplished via core activities including 1 recruiting and training community walking coaches a to serve as role models and champions who will motivate their fellow residents to engage in physical activity and choose better eating habits and b to establish walking groups which will provide social support to program participants for healthy lifestyle changes 2 conducting monthly nutrition education and physical activity sessions focused on making more healthconscious choices 3 providing health screenings for program participants 4 using motivational interviewing to encourage participants to identify lifestyle change priorities and 5 promoting local community walking tracks to increase their visibility and use by residents the hub city steps intervention also aims to assess community capacity for health promotion through the life of this cbpr project the first step in this process was to engage the cab in a collaborative process to identify and define a framework for assessing community capacity through workshops conducted by research staff during the first project year having adopted the community capacity framework of lempa et al and its constructs project staff guided the cab in developing a working definition of each construct from a community perspective the cab also developed a project mission statement and action plan for each community capacity construct the hub city steps community capacity framework and constructs then formed the basis for assessing perceptions of community capacity over the life of the project this paper describes perceptions early in the life of this cbpr community intervention after intervention planning and walking coach recruitment and training but before intervention kickoff across three groups of project stakeholders using a mixed methods design methods this assessment included two components described in more detail below the quantitative component assessed community capacity perceptions using a questionnaire adapted from an instrument developed and empirically tested by lempa and colleagues with participants from community initiatives across the us the qualitative component involved focus group type listening sessions in which responses to the quantitative questionnaire were elaborated further community capacity questionnaire community capacity scales developed by lempa and colleagues were utilized asking representatives of each stakeholder group to rate the hub city steps collaboration and its performance relative to selected community capacity constructs from a total of eight leadership resources external networking visibility and recognition personnel sustainability ability and commitment to organize action communication with community members and relationships with influential others item response was an 11point likert scale with 0 denoting strongly disagree and 10 denoting strongly agree lempa and colleagues 44item sixfactor scale for leaders was administered to the rs and cab and included items on leadership resources external networking visibility recognition ability and commitment to organize action and personnel sustainability the 38item fivefactor scale for nonleaders was administered to the wc and included items on leadership resources ability and commitment to organize action relationships with influential others and communication with community members three scales leadership resources and ability and commitment to organize actiontermed universal constructs were common to all groups questionnaires were distributed to rs through office mailboxes to cab members at a regular meeting and to walking coaches at a training meeting respondents were asked to complete the anonymous questionnaires at their convenience and return to research staff for analysis purposes a construct score was calculated for each construct by averaging all items under the construct and transforming to a 10 point scale total community capacity scores were calculated by averaging the construct scores spss 170 was used for all analyses total community capacity scores were compared between rs and cab groups using an independent ttest and across groups for the three universal constructs using an anova manova was used to examine differences 1 between the rs and cab for the six constructs in the leader scale and 2 among the three groups for the three universal constructs for the manovas the pillais trace test was interpreted to examine model significance due to the negative skew of the data this test is robust to such violations of multivariate analysis assumptions gameshowell posthoc tests were utilized to examine differences between groups due to unequal group sizes listening sessions separate listening sessions were conducted with volunteers from the rs cab and wc groups questions were developed based on the results of the quantitative analysis the listening session question guide included a total of 27 questions divided across 8 constructs special attention was given to the constructs for which there were significant quantitative differences between groups the same listening session questions were used across all three groups to elicit more detailed information about why the differences existed and how to address differences listening sessions were audio recorded and transcribed verbatim themes elicited from the transcripts were used to develop a qualitative analysis codebook which contained descriptions or definitions for each of the codes the codebook was developed by a team of two researchers one project staff and one cab member the qualitative analysis team determined meaning and context using the eight constructs to help guide the interpretation this method was utilized in order to increase internal consistency of code assignment once there was agreement across team members on context and meaning for each construct quotes were extracted from the transcripts to provide examples for the interpretation the team compared interpretations across groups and identified any notable differences between groups results community capacity questionnaire table 1 indicates the number of stakeholders from each group whose data were used in the analyses three cab and three wc questionnaires were excluded from the analysis due to missing data on more than one construct researchers and staff and community advisory board six constructs table 2 indicates the mean total score and construct scores for the rs and the cab the cab scored total community capacity slightly higher than the rs the cab scored five of the six constructs higher than the rs visibilityrecognition was scored lowest and ability and commitment to organize highest by both the rs and the cab based on manova the model examining the differences in construct scores between the rs and the cab was significant at f 565 p 03 as shown in table 2 perception of leadership and personnel sustainability differed between the rs and the cab with the cab scoring these constructs higher than the rs walking coaches five constructsthe total community capacity score for the wc calculated from the five constructs rated by this group was 870 among the constructs communication with community members had the lowest score leadership resources and ability and commitment to organize all reached a mean score of 9 out of 10 relationships with influential others was scored as 834±193 out of 10 rs cab and wc three universal constructsthe total community capacity score for the three universal constructs was 827±093 for the rs 836±120 for the cab and 876±076 for the wc manova analyses indicated a significant difference across the groups for the three universal constructs at f 360 p 04 post hoc analyses indicated differences between the rs and the cab and the rs and the wc for leadership with the rs scoring leadership significantly lower than the cab and the wc listening sessions two listening sessions were conducted with the rs one with the cab and one with the wc notable quotes for each construct from all groups are listed in table 4 data from the listening sessions on project leadership was examined closely because the cab and the wc scored this construct significantly higher than the rs in the quantitative assessment of the nine questions asked concerning project leadership one was how do you think we can make the leadership more visible to people in our community there were several similar themes identified in the data analysis including project members could attend community events outside of the project to build relationships with other community people and organizations and they could make people aware of the project activities through networks such as faithbased community organizations sororities and fraternities another theme viewed by project staff as a capacity building opportunity was that the community does not participate and understand the research aspect of the project another question asked related to the leadership construct was in what ways or areas could the leadership increase their follow through on commitments that have been made the cab felt that the leadership was doing a great job although the rs expressed reservations one theme elicited from the rs reflected the need for more collaboration in the action plan like the wc the rs felt that the community may not understand the research aspect of the project the cab also expressed concerns in the area of leadership one question was in what ways or areas does the leadership need to show more compassion this elicited the theme that project members are not flexible by allowing the community to guide the project conversely another theme was that staff and community share openly and staff gives clear direction when asked in what ways or areas could the leadership increase their followthrough on commitments that have been made walking coaches viewed themselves as the leadership indicating that project and community members working with the project may not motivate others in the community to adopt or maintain healthy physical lifestyle because they themselves did not display sufficient motivation the qualitative data focused on personnel sustainability was also examined closely since the cab scored this construct significantly higher than the rs in the quantitative assessment the first question asked concerning this construct was if hub city steps leaders left today what do you think would happen with the project themes elicited for the rs and the cab included such things as all involved agree and understand the project all people are present that are needed to carry out the goals and objective of the project training for community members to take on leadership roles and be effective in those roles community and staff input in action plan and personnel preparation for sustaining project conversely the rs expressed the sentiment that project and community members would not continue to actively participate over the length of the project perhaps explaining the quantitative difference between the rs and cab a similar question asked if hub city steps leaders left today what would need to happen for the goals of the project to be achieved themes elicited from the rs and the cab suggested opportunities for building capacity the cab noted availability of such things as money people community groups and organizations to carry out the goals and objectives of the project and that the project allows individuals to take on leadership roles themes elicited from the rs reflected different perceptions of needs or limitations and included such things as all people are not present that are needed to carry out the goals and objectives of the project and the project is not connected with all needed community groups and organizations to help carry out the goals and objectives as previously stated of the five constructs assessed quantitatively for the wc four were rated 8 out of 10 or above the fifth construct communication with community members had the lowest score among the constructs the elicited themes related to this construct were that the community does not participate and understand the research aspect of the project and that information diffusion to the community may not be as effective as it could be discussion and conclusion the assessment of perceptions of community capacity for health promotion associated with the hub city steps project described here was a baseline assessment before implementation of the walking intervention phase but after considerable planning and training of walking coaches had been completed this mixed methods assessment will be implemented annually to monitor changes in perceptions of capacity over the life of the project and to identify areas that need additional targeting for capacity building the results suggest that the project is strong in its ability and commitment to organize however communication with community members and visibilityrecognition of the project needs to improve we are hopeful that this construct will be scored higher in the next round of data collection because we have taken suggestions from the listening sessions on the best ways to communicate and also better ways to make the project more visible the project is naturally becoming more visible the longer it is in the community in the quantitative analysis leadership was viewed significantly lower among researchers and staff compared to the other two groups the researchers and staff also perceived personnel sustainability significantly lower when compared to the cab members neither of these differences was apparent in the qualitative analysis this may have occurred because the researchers and staff may not have felt as comfortable sharing their thoughts in the listening sessions because they were not anonymous as was the case with the selfadministered questionnaire alternatively this group may not have felt as confident about its own leadership role and performance on the project prior to the implementation of the intervention as stated previously there have been few quantitative instruments measuring community capacity that have been developed and empirically tested community capacity is an abstract concept and difficult to measure quantitatively therefore it seems helpful to use a mixed methods approach in order to obtain more comprehensive information as a basis for evaluation and future action a limitation of this study is the small sample size therefore decreasing the power to detect differences across groups thus additional areas that needed to be addressed to increase the capacity may have been missed in this mixed methods assessment the quantitative assessment allowed objective identification of specific areas where there were differences in group perceptions the qualitative component then allowed further assessment of the reasons for these differences and ways to address them this assessment has been a useful evaluation tool for this project in that it provides indications of strengths that are in place as well as weaknesses that need to be addressed to assure adequate community capacity for sustainability of project aims and accomplishments developing identifying and utilizing methods to evaluate community capacity is an important adjunct to cbpr due to its importance in promoting sustainable community change cab a coalition between the university and the community in helping the underserved wc i think its just going to take time …it takes time to build relationships… the proof is in the pudding visibility recognition rs people have started bringing their teenagers to learn because the word has gotten out that it is educational so they bring friends and family cab and so the program is kind of saying we are taking these average joes in the community and taking these average joe coaches… and were doing this i think creating awareness that people can be responsible for their own health the first step and how they can involve their friends and other communities wc like i said its word of mouth cause when people see you out walking and with the tshirt on… they are curious and want to know what kind of program is this and how can they be a part of it ability and commitment to organize action rs originally as the cab we were supposed to have them review the procedures and other things more thoroughly and then we were supposed to teach them more of the research aspects of things im not sure how much follow through has transpired with that and i think that is something we need to strive for cabor if we didnt want to lose hub city steps… since its such as wonderful program we could incorporate and become our own 501c3 and board of directors and make sure every year we rotate on and then the information wont just evaporate and we could just put it into place and keep rolling wc realistically if the project leadership left today you will not have that much cause some people are motivated by what we get… incentives and so forth but i do think a high percentage of the people will move on… cause im not turning back personnel sustainability rs i think its always a good thing no matter who is doing it… whether it be us more on the research end or the community end just making sure we reaffirm we want the feedback so we can improve things for participants coaches and community cab keeping the program interactive…most people are working so and taking time out of their busy schedules so making it interactive so it doesnt feel like work wc and another thing is like the thing… people just knowing that youve lost weight that opens the door for you being able to talk about it you know you know saying ive been walking cause i find myself saying that people say you know it looks like youve been losing weight and i say yeah im in a group communication with community members rs i know one of the goals was to help the community to understand research thats one of the goals of cbpr and then…sustainability so i think thats something that needs a little follow up… maybe showing them some of the reports were coming out with so they understand some of our procedural aspects… cab cause i was at a housing meeting and when i brought up the information and i had the little shoes and letting them know and she was saying how she was turned down but it made her more aware of her health cause she was a diabetic… but she wasnt taking care of herself… and her saying just because i couldnt participate in this program i started anyways… thats a testimony wc and the tv has been good and the media but the main thing is sharing the success stories one of the things i mentioned to the projects community coordinator and i hope she can do and community capacity constructs notable quotes i recognize the idea of confidentiality in giving those numbers but at our next assessment if she could provide us as a walking coach with stats not by name if participant one cholesterol went down overall or if blood pressure went down so there i could go and say this is my team and we lost overall this amount of pounds…if we could get this type of data similar and we could share this type of data relationship with influential others rs …and with the mayor i think its been a big deal having him involved because he reaches way outside out community you know he took some of our pedometers to meet with michelle obama cab bonding with the city was a huge move the biggest thing was partnering with the city wc i say that one avenue would be the churches… if you could get the churches involved get the preachers involved they follow them quite well and i think that would be a way to say basically be healthy this is how were going to serve the lord

hub city steps is a five year communitybased participatory research walking intervention designed to help lower blood pressure in a majority africanamerican population in southern mississippi via community collaboration and capacity building increased walking culturally tailored health education sessions and motivational interviewing building community capacity for physical activity is a key component of this intervention qualitative and quantitative methods have been used assess how project stakeholders perceive the community capacity building efforts of the project this paper illustrates the baseline results of this mixed methods approach from the perspective of three groups of stakeholders project researchers and staff rs community advisory board cab and intervention walking coaches wc eight constructs were examined including leadership resources external networking visibility and recognition personnel sustainability ability and commitment to organize communication with community members and relationships with influential others quantitative results indicated significant differences among stakeholder groups for project leadership and personnel sustainability qualitative perspectives provided an opportunity to examine possible reasons for these differences overall findings provide direction related to improving intervention outcomes and sustainability

i introduction language is a doubleedged sword its use depends on the motive of the users in the disruptive era the other side of the coin is technology technology is an integral part of culture and its development it cannot be separated from the society that owns it since language is the social mirror language cannot be separated from technology as in information digital and internet technology furthermore it should be emphasized that the close relationship between language and technology has great implications for the development of the study of language fields under the umbrella of linguistics of course the greatest impact is on the study of meaning or pragmatic meanings in verbal communication where language is the means of communication the study of meaning focuses on pragmatics it continues to shift from the most conventional pragmatics called systemic pragmatics or semanticopragmatics due to its systemic and semantic dimensions to the general pragmatics to the culturespecific pragmatics and is now developing into a new branch of pragmatics called cyberpragmatics the latest pragmatics is the most closely related to technology especially digitalbased technology and internetbased technology furthermore it should be emphasized that the study of a speakers meaning is bound to context be it socialsocietal cultural or situational dimensions the three types of context in pragmatics play a simultaneously important role in determining the speakers meaning ignoring contexts in interpreting the speakers meaning will result in misunderstanding fuzziness and ambiguity however each type of context in pragmatics plays a significant role in determining what to mean the socialsocietal context plays an important role in determining the meaning of societal pragmatics introduced by cultural context is very important in determining the speakers meaning from the perspective of cultural pragmatics both in the sense of intercultural pragmatics crosscultural pragmatics and culturespecific pragmatics proposed by blumkulka and halliday the situational context plays an important role in determining meaning in the general pragmatics perspective and subsequent pragmatic developers thus in the various types of pragmatics it is clear that there is evidence of meaning triadicities instead of meaning disabilities as the focal point in semantics this article should contribute to pragmatic studies both in and outside of indonesia which have not been explored fully the development of pragmatic studies has lagged behind other fastgrowing and everincreasing research in linguistic and nonlinguistic phenomena the development of digital technology and internet technology impacts the increasing use of language in social media which inevitably results in various hoaxes and hate speech the use of language in social media is not accommodated well in various research in language studies consequently the issues of meaning in verbal communication are not elaborately researched the ensuing consequence is the rampant cases of confusion fuzziness and misunderstanding in social media communication now is the right momentum for the study of pragmatics to evolve from general pragmatics to virtual or cyberpragmatics similarly the study of contexts in pragmatics must evolve from conventional external contexts to virtual external contexts this short paper focuses only on the sociosocietal context from the cyberpragmatic perspective the dimensions of the socialsocietal context to be described in this paper deal with the nature of changes namely the changes to the elements of context in certain cases the description of the changes will be more exhausted to the aspects of each element of the socialsocietal context as mentioned earlier the changes are the results of the development of information technology digital technology and internet technology it is important to describe the evidence and aspects of the element changes so that the interpretation of digital and virtual dimension speech is easier and clearer based on the description the research problem is formulated as what is the evidence of the socialsocietal context element changes found in cyberpragmatics in agreement with the formulated problem this articles objective is to describe the evidence of the socialsocietal context element changes in cyberpragmatics ii theoretical reviews in this article two basic theories are discussed as a framework of reference namely the theory related to the changes from systemic pragmatics to cyberpragmatics and the theory linked to the changes from conventional external context to virtual external context regarding the first theory it is worth noting that the study of the speakers meaning is not independent of the semantic meaning the pragmatic study is still oriented to two branches namely semantics and pragmatics the systemic semantic meaning study is known as the systemic pragmatics era or semanticopragmatics thus the study of meaning is still dependent on the study of semantic meaning which is dyadic the rigor of the study of meaning emerged coincidentally with the interdisciplinary linguistic sciences such as ecolinguistics ecolinguistics was further developed into metaphorical ecolinguistics and naturalistic ecolinguistics both branches of ecolinguistics emerged to respond to formalists perspectives in linguistics who view language as being homogeneous in its development the sociology of language evolved into sociolinguistics focusing on language variations contexts in sociolinguistics are needed to identify language variations while contexts in ecolinguistics are needed to identify the role of the environment as metaphorical and naturalistic thus from the functionalists perspective the entity of contexts is seen as important as its existence functionalism in linguistics assumes that language is heterogeneous language is never singular and homogeneous as the formalists believe the study of meaning is understood along that line originally the study of meaning focuses on the dyadic meaning of a word recently the study of meaning has focused on the triadic meaning of a word the triadic meaning is derived from the involvement of and dependence on contexts because language is never independent of the context although the study of meaning has shifted from the pure semantic meaning to the study of the speakers meaning in its early development the functionalists had their footings on two sides namely the semantic side and the pragmatic side the next stage is the development of general pragmatics the development of pragmatic rules is linked to pragmatic parameters pragmatic principles cooperative principles politeness principles and other linguistic principles based on western languages and cultures the study of language in noneuropean and nonamerican countries has not been widely explored thus the pragmatic rules formulated based on the study of european and american languages are followed borrowed and applied blindly to the study of mediterranean and asian languages of course the rules are not always applicable to all the principle of linguistic politeness and its maxims for example cannot always be implemented in asian society and cultures similarly the cooperative principle and its maxims are not always suitable for nonwestern communities and cultures thus the development of general pragmatics which led to the study of meaning based on external linguistic factors was admittedly phenomenal in its heyday however it is no longer appropriate to apply it to the local languages and cultures meanwhile local cultures possess a wealth of cultural wisdom and extraordinary cultural values hence the rigor to study meaning based on a specific local culture began this development inspired cultural pragmatics such as intercultural crosscultural and culturespecific pragmatics therefore pragmatics evolved into intercultural pragmatics crosscultural pragmatics and culturespecific pragmatics from systemic pragmatics to cultural pragmatics and its variations pragmatics development confirms the pragmatic studies gap as described earlier however along with pragmatic development globalization is also crucial in affecting all aspects of social life the industrial revolution and the emergence of globalization gave birth to the glocalization perspectives proposed by graddol in turn they led to remarkable developments in information technology language is increasingly complex as it involves aspects of information technology and digital devices the development of increasingly complex matters is driven by the internet of things perspective of life language is inseparable from the technologyridden reality the original and simple function of a language to develop common sense and a vehicle for strengthening interpersonal cooperation seems to have been distorted the growing use of language for different genres and purposes on social media has inevitably created hoaxes hate speech and other language function abuse a new perspective in pragmatics called cyberpragmatics which is virtual emerged in 2011 interpreting language cannot be independent of the virtual contexts as an inevitable impact of digital and internet technology manifested in various social media contexts such as facebook instagram twitter etc with the advent of cyberpragmatics the basis and concern of sociolinguistic studies have shifted from the social community to the virtual community in the past the similarity of the verbal repertoire between individuals creates a speech community now the parameter has changed the speech community has shifted to a virtual community the virtual community is not based on the similarity of verbal repertoire or the similarity of language competence the virtual community is characterized by the common interest in certain public figures making the news in the digital media and the internet therefore the netizens or the virtual community may not know each other do not speak the same language do not share the same cultural roots and live thousands of kilometers away despite the long distance across different time zones digital technology makes it possible for them to form a virtual community communication and interaction can be built and established well they can even go beyond the social community in the past this has led the researcher to examine the evidence of socialsocietal context elements and their aspects it guides researchers to examine and observe more carefully and deeply the evidence of changes in socialsocietal context elements and their aspects the preliminary study context is divisible into three namely the socialsocietal context cultural context and situational context the socialsocietal context is based on society the social context has a horizontal dimension while the societal context is vertical social contexts are intertwined with social distance and social equality while societal contexts are intertwined with social status and social ladder the social and societal contexts are very crucial to determine the speakers meaning from the perspective of sociopragmatics and pragmalinguistics proposed by leech and the societal aspects proposed by mey the social contexts have been identified while the local context is elaborated by rahardi mey further explains the social context and the local context is developed further by rahardi the socialsocietal context is also intertwined with the cultural context this context refers to the various cultural dimensions shared in society including cultural knowledge cultural behavior cultural artifacts and the cultural wisdom held by society the nature of cultural context has been discussed by blumkulka halliday rahardi suszczynska and wierzbicka the last type of context is situational context verschueren has specifically featured the situational context in pragmatics the general pragmatic studies typically address this general situational context subsequently the virtual external context is currently being studied by rahardi this virtual external context will be very useful to study pragmatics from the perspective of cyberpragmatics in rahardis observation the conventional external context has changed the contexts elements and aspects the result of the change is what rahardi refers to as a virtual external context the evidence of the changes is described in his articles such as the change in the speaker and addressee and other interlocutors in the conventional external context the three elements of context are usually seen from the dimensions of age gender and background however from the perspective of cyberpragmatics the elements to consider in the interlocutors are aspects of their life life philosophy social circle daily life life mission etc the aspects attached to the interlocutors are very complex information on the interlocutors gender and age alone will only inform the language variations the pragmatic meaning of the speech will be correctly interpreted by taking into account the complex aspects mentioned earlier consider the other contextual elements such as the channel of speech the channels used to speak and communicate in the present are very different from those in the past people needed to use amplifiers to hear their voices clearly by people from a long distance for example in remote villages devices of pasimology such as the sound of slit bamboo drums bells etc are still used to signal incidents and summon villagers at present such a device is ubiquitous and within a hands reach as in the digital gadget with digital devices such as smartphones people can spread the news worldwide in just a matter of seconds by simply clicking or tapping the share button on the one hand the speed of information transmitted with the digital gadget device is an advantage news travel in a fast timeefficient and effective manner on the other hand information speed is at the expense of language use which is used carelessly this may lead to longterm irrevocable damage to the language it is so easy for religious groups delinquent juveniles and anarchist groups to plan and organize a crime or terrorist attack and in just a matter of seconds they orchestrate a series of attacks to destroy their targets in this paper pragmatic theory shifts from systemic pragmatics to the cyberpragmatics similarly the theory of context changes from conventional external contexts to virtual external contexts these contexts are used as a reference framework in this article iii methods this research is descriptivequalitative type the source of this researchs locational data is a variety of social media available on smartphones the substantive data sources are texts on social media in which there are objects and data of this research furthermore the object of this research is the evidence of a shift in the sociosocietal context this researchs data are excerpts of speech containing the object of research which proves the shift in the socialsocietal context therefore it is obvious that the object of research and its context is the manifestation of the data in this study the data were collected using the observation method which is equipped with notetaking techniques and recording techniques the recording and recording results are then transcribed for identification selection classification and data typification furthermore the data were analyzed by applying the contextual analysis method this contextual analysis method is applied by basing and linking the context this contextual analysis method is also called the equivalent analysis method especially the extra lingual equivalent analysis the contextual analysis method or the extra lingual analysis method is applied because this researchs perspective is the cyberpragmatics perspective with a virtual external context as the main determinant of its meaning before applying the analysis data that has been classified and typified properly is triangulated with the expert and consulted on relevant theories the purpose of implementing data triangulation is to ensure the validity of the analyzed data after the triangulation process is complete and the data analysis process is done properly the final step is to present the results of this studys analysis presentation of the analysis results is carried out by applying informal methods iv results in this section two things are presented namely research findings and discussions of the research findings the researcher deliberately separates the research results from the discussion with the intention that these two things are clear and have a deep description the following shows the presentation of the two parts presented one by one elements of socialsocietal contexts change following the development of digital and internet technology in addition to the context elements changes aspects of each socialsocietal context element are likely to change the context elements are based on dell hymes speaking grid a classificatory grid as a descriptive framework for the ethnography of communication speaking is the mnemonic device to describe the setting participants ends act sequence keys instrumentalities norms and genre in this research the setting can be differentiated into two namely the setting of place and the setting of time the participants element can be seen as two kinds namely speakers as participants and hearers as participants the element of objectives or ends can also be differentiated into two namely the single and multiple ends in addition the element of norms can be divided into two namely the norms of interaction and interpretation the following table shows evidence of the changes norms if interpretation √ genres √ v discussions table 1 shows that the changes occur in the following grids participants setting ends and instrumentalities changes in the setting element occurred in the aspects of venue time and atmosphere changes in the participant element occurred in the aspects of perception of gender age and social status changes in the end element occurred in the aspects of monodimensional goal manifestation and multidimensional goal manifestation changes in the instrumentalities element occurred in the aspects of the kind of tools and the range of errand communication each piece of evidence of changes will be discussed in detail the element of participants can be seen as two kinds namely speakers as participants and hearers as participants the element of settings can be differentiated into two namely the setting of place and time the element of objectives or ends can also be differentiated into two namely the monodimensional and multidimensional ends each of the above elements will be discussed in detail below a evidence of context change in the participants element the speaker and the addressee play very important roles in speaking and communication with the speaker and the addressee the other participants are the third party or audience involved in a conversation in a reallife conversation the presence of an audience determines the linguistic codes being used the presence of a third party who has no theory and practice in language studies business in the subject matter may cause the speaker and the addressee inconvenience the third party can be anyone who intentionally appears on the scene and wants to hear the conversation or any passersby who accidentally appear on the scene and overhear what is being said the thirdparty could be any individual or a group of individuals the age and gender of the speech participants were relevant to determining linguistic codes in the past for instance talking to children is different from talking to adults or the elderly similarly the linguistic codes used to talk to men are different from those used to talk to women in the study of language variations and the study of meaning these elements are considered important from the perspective of cyberpragmatics the aspects of participants are not the same as the ones presented earlier when digital and internet technology is crucial to determine meaning in communication the aspects discussed earlier do not play a significant role such aspects are not needed in a virtual conversation on social media whose participants have different cultural and social backgrounds when we send a message share news and upload information and images on social media should such aspects be considered the answer is no anyone can share anything on social media in an instant and it will be available online for anyone to see regardless of their background social interest sociopolitical background social circles etc in other words there has been a change in the boundaries of a region communication has become completely borderless from one person to another the aspects of age and gender are not important to be discussed in a virtual conversation the comment sections in social media posts may involve people from different gender and age groups the linguistic codes and manifestations are not determined by aspects of participants as identified earlier this proves that in the virtual external context the elements of participants have changed understanding the speakers meaning by considering the change of the elements of the participants in cyberpragmatics will not result in the interpretation of the true meaning thus the pragmatics focus should be on different aspects from the earlier pragmatics because the aspects and context elements are different from those in the past table 2 showed the socialsocietal context changes in the element of participants b evidence of context change in the settings element one of the most important socialsocietal elements to be considered in interpreting the meaning of an utterance is the setting setting refers to the situation where an utterance is spoken however the setting is limited to the situation and the physical and social setting in which the utterance occurs in a specific social setting such as a family gathering in a javanese community people tend to speak formally and politely the language used considers acceptable manners and etiquette to ensure that everyone feels valued and respected by others in contrast in the factory setting factory workers in a particular factory will use different linguistic codes from those who work in a different setting in a different region it is evident that in the socialsocietal context a speech events physical setting will greatly determine the linguistic codes in a sacred physical setting such as the funeral service in a javanese village people tend to behave solemnly and speak in a hushed tone it is culturally understood that on such a sacred occasion people speak softly and behave politely in the church the mosque or other places of worship people are expected to behave politely and speak softly in a hushed tone the social setting determines the linguistic codes used in speech events this cultural norm was a part of a social convention in the past however in the era when people believe in freedom of speech and democracy the physical social and environmental settings seem to have changed dramatically social settings are no longer considered in social media speech events in the digital era people no longer care about the social setting which required politeness from past participants in this day and age people are more concerned with the messages urgency once again urgency is the sole determinant in times of grief people can send messages without considering the addressees psychological setting for instance a student may text a lecturer through social media as if nothing special happened even though he knows that the lecturer is in a grieving psychological state a few decades ago when a neighbor died people in the whole neighborhood came to pay respect to the dead and to help around the house not a single kiosk or food stall opened no one went to school or work and children stopped playing the whole neighborhood was mourning the bereaved family in the digital era the setting of the speech event has changed dramatically it is no longer relevant to interpret the speakers meaning in the current pragmatic study from the conventional external contexts as in the past someone is forced to compromise delay or even cancel herhis intention when heshe considers the conventional elements too seriously instead of the virtual external contexts thus the evidence of a change of setting is very important to note to understand the speakers meaning in communication in the era of disruption this proves that pragmatic studies should focus on more complex dimensions unlike systemic pragmatics general pragmatics and culturespecific pragmatics socialsocietal context changes in the element of settings c evidence of context change in the ends element the ends element refers to the speakers purpose in communicating with the addressee and other participants in communicating and interacting with each other people almost always have a goal or purpose in mind a person who habitually greets his neighbor positively is considered a polite member of society on the contrary a person who does not socialize with their neighbors let alone greet them is considered arrogant unfriendly and antisocial the javanese people use the expression ilang jawane to refer to someone who no longer observes the javanese cultural norms while waiting at a train station before a train ride people normally strike up a polite conversation with fellow passengers in such a setting people tend to use phatic speech function to break the silence when indonesians meet fellow indonesians in a foreign country say in europe or america they will greet each other and strike up a conversation even though they have not known each other previously simply because they are foreigners in the country thus it is obvious that people greet each other and communicate for a purpose whether the purpose is substantive phatic or others people have a communicative purpose when speaking the linguistic codes people use may serve the function of small talk a phatic function or a substantial referential function commonly happening in verbal communication the notion of ends occurs in speech events and is considered to be true in sociolinguistics systemic pragmatics general pragmatics and culturespecific pragmatics the question remains whether in cyberpragmatics the notion of ends still applies in other words has the notion of ends changed in manifestations it is safe to say that people have their ends in mind when they converse with others however the goals and purpose of communication in the present time are more multidimensional than the monodimensional goals and purposes of communication in the past the multidimensional goal or end occurs because life is getting more complex nowadays an utterance that was interpreted individually in the past may have multiple meanings now the utterance may have multiple ends metaphorically in the past when people shot a target the bullet only hit one target at a time in the era of cyberpragmatics when people shoot the bullet may hit several targets simultaneously thus interpreting the purpose of peoples speech in the era of cyberpragmatics is not as simple as it was in the past people may not show their true colors in social media posts behind their seemingly good image they may have bad or even devilish intentions this illustrates the changes from conventional external contexts to virtual external contexts it is important to understand the new phenomena to warn people to be vigilant against strangers with hidden motives prowling in social media socialsocietal context changes in the element of ends d evidence of context change in the instrumentalities element the element of socialsocietal contexts is related to the notion of a channel or medium to express the speakers meaning to the addressee in the past to speak to a big audience people used a loudspeaker or amplifier so that the meaning or purpose can be delivered well as technology advances the development of audio and video technology makes an impressive replacement to measure the success of a stage performance the quality of audiovisual equipment during the show becomes the main consideration news broadcasts are conveyed through loudspeaker devices to ensure the good quality of channels or instrumentalities in delivering the message it is common to consider this as the conventional external context that applies to various pragmatics outside cyberpragmatics in todays internet era the medium or channel to deliver meaning has changed dramatically the medium to spread information is a small device within a hands reach through smartphones any information can go viral in a matter of seconds in the past tools to amplify the message were limited by time and space however from the perspective of cyberpragmatics the channel is identified as smartphones through smartphones the spread of the message or intention is done simultaneously by tapping the sharing button in the smartphone the dissemination speed of the messages or information should go hand in hand with the quality of the information being delivered unconfirmed errors or inaccuracies in the information no matter how small will be irrevocable once they have spread to the world the rampant spread of fake news or hoaxes in social media lately is disconcerting as they are available to be read and accessed by everyone all over the world regardless of their inaccuracies in the presentday world one person can have several smartphones they are also constantly connected to social media through their smartphones when a person gives inaccurate information instantly many people respond to the errors for everyone to see the dramatic changes in the instrumentalities of the virtual external context should be seriously heeded by the speakers and other speech participants from the perspective of cyberpragmatics socialsocietal context changes in the element of instrumentalities vi conclusion in a nutshell it is important to restate the four pieces of evidence of changes in the socialsocietal context from the perspective of cyberpragmatics the four pieces of evidence are in the elements of participants setting ends and instrumentalities the shift of elements of socialsocietal contexts from the conventional type to the virtual one determines the quality of communication in the disruptive era linguistics studies especially about the branch of pragmatics must refocus the core of the study that is the study of the speakers meaning must be based on virtual external contexts the impacts of informational digital and internet technology must be wisely considered in the study so that this branch of linguistics focusing on the study of speakers meaning will run on the right track in the disruptive era more extensive and indepth observations of other elements of other socialsocietal contexts are called for to formulate evidence of changes more holistically the detailed description and illustration of the evidence will significantly contribute to the growing research in the field of cyberpragmatics understanding the meaning of utterances in the digital and internet contexts will be easier to be done similarly language will evolve with the community and culture where it is spoken instead of being left behind due to limited research and observations of the communitys language phenomena research rigors to examine the linguistic phenomena involving digital and digital technology must be encouraged in these modern times

this article aims to describe evidence of change to the socialsocietal context seen from the cyber pragmatic perspective the substantive data sources were texts on social media in which there were objects and data of this research the data were collected by using the observation method equipped with notetaking techniques and recording techniques data were analyzed by applying the contextual analysis method we applied the contextual analysis method or the extra lingual analysis method because of the cyberpragmatic perspective of this research with a virtual external context as the main determinant of its meaning before the analysis data that were classified and typified properly were triangulated with the expert and consulted on relevant theories the results show that the socialsocietal context element changes occur in the following context elements 1 setting 2 participants 3 ends and 4 instrumentalities setting element changes occurred in the aspects of venue time and atmosphere the instrumental element changed in the aspects of the kinds of tools and the range of errand communication the participant element changed in the aspects of perception of gender age and social status and the last element changed in the aspects of monodimensional goal manifestation and multidimensional goal manifestation

elder mistreatment is a public health problem that takes a devastating toll on the independence health and wellbeing of millions of older americans a national prevalence study indicated that six million people aged 60 and older are victims annually or about 1 in 10 older adults estimates are even higher globally reaching one in six older adults if em were thought of as an illness or syndrome it would be recognized as a public health crisis em has been defined by the national research council as intentional actions that cause harm or create a serious risk of harm whether or not intended to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder as well as failure by a caregiver to satisfy the elders basic needs or to protect the elder from harm because this definition focuses on a caregiver or trusted other it excludes selfneglect but does pertain to physical and psychological mistreatment financial exploitation and caregiver neglect in this article we focus on mistreatment by a caregiver defined as a person who bears or has assumed responsibility for providing care or living assistance to an adult in need of such care or assistance although the magnitude of em indicates a need for developing and testing prevention strategies evidencebased interventions and primary prevention programs for em are lacking primary prevention which refers to interventions that intercede to stop abuse from occurring has not been systematically studied in em however research has been conducted on a small number of secondary and tertiary preventive interventions which seek to stop ongoing abuse andor mitigate its detrimental effects em research can however benefit from evidence developed in other areas of family violence for example primary prevention programs have been developed to address child maltreatment and intimate partner violence offering possible applications for em because family violence occurs throughout the lifespan and similar risk factors are found for child maltreatment ipv and em prevention strategies for em should be developed by building on what has been learned from research into other areas of family violence indeed hamby grych describe abuse in families as webs of violence wherein exposure at any point in the lifecourse increases risk of eventually experiencing andor perpetuating violence they urge researchers to follow these complex webs across different parts of the lifecourse comparing and contrasting risk factors treatment approaches and relevant theories em and caregiving approximately onequarter of adults aged 65 and older reported relying to some extent on assistance from a caregiver because of physical andor cognitive impairments although studies indicate that most em is committed by family members the extent to which family caregivers are perpetrators of em is unclear two studies found that 26 of those receiving care from a family member reported experiencing either physical mistreatment or exposure to potentially harmful behaviors at the hands of a family caregiver in another study which focused on those caring for family members with alzheimers disease and related dementias 47 acknowledged committing at least one type of mistreatment often psychological mistreatment even as family members are increasingly called upon to provide care to older relatives training and support available to caregivers may be sparse or nonexistent and some proportion of family members may have little ability to adequately provide care given the vulnerability of older adults who rely on family caregivers and the documented high rates of mistreatment prevention programs geared to families would seem to offer a promising first step to reducing the high levels of em given this and the limited state of knowledge on primary mistreatment prevention in this population approaches to evidencebased prevention interventions in other fields of family violence seem to offer a useful starting point shared theoretical mechanisms in family violence because em shares several risk factors with other forms of family violence strategies based on relevant theories and causal mechanisms from other areas can help researchers identify adaptable prevention strategies that lower risk when developing interventions we discuss several theories divided into three categories addressing relationship quality and skills stress and reaction and knowledge and experience although the precise mechanisms of each theory are distinct intervention components and outcomes discussed subsequently broadly follow this trifurcation relationship quality and skills social learning theory previous exposure to family violence is associated with future perpetration of abuse as the adverse childhood experiences study demonstrates exposure to negative experiences early in life increases the likelihood of participating in ipv those with high ace scores have five times greater odds of perpetrating physical ipv than those with low scores as the web of violence concept suggests patterns of violence developed over the lifecourse can yield devastating results in old age shedding light on such patterns though interviews pickering and colleagues observed that adult daughters who reported that they were abused as children often engaged in reciprocal aggression towards their elderly mothers particularly verbalpsychological abuse experiences of childhood trauma have also been associated with increased risk of perpetration of neglect among caregivers social learning theory explains this patterned violence wherein behavior is learned through observation and replicated extrapolating from this theory one can posit that abusive behaviors are learned through observation and are replicated after having been established as normative behaviors attachment theory poor relationship quality between potential victims and perpetrators is also related to risk of child maltreatment ipv and em in cases of child maltreatment this includes low levels of maternal warmth associated with physical abuse and neglectand low levels of attachment attachment theory indicates that positive caregiver interactions with a child promote emotional and behavioral regulation while increasing the parents investment in the childs wellbeing poor attachment in grown children has been implicated as a factor contributing to neglect of their older parents stress and reaction caregiver stress high stress levels among perpetrators have been identified as a risk factor for family violence including em although the evidence is mixed pillemer finkelhors seminal study showed that higher care needs among recipientsbelieved to raise levels of caregiver stresswere not associated with em rather those who mistreated older adults were more likely to have experienced other life stresses within the year in which mistreatment occurred a more recent study found that among caregivers for older adults more hours spent providing care and higher levels of subjective burden were predictive of physical and psychological mistreatment similarly parents who commit child maltreatment find parenting more stressful than other parents suggesting that subjective assessments of caregiving are central to understanding the role of stress in risk of mistreatment specifically parents who commit maltreatment are more reactive to stressful events than those who do not commit mistreatment and may have lower capacity for emotional regulation although the em field is still learning about mechanisms underlying the relationship between stress and mistreatment recent findings in caregiving show similar results as research in child maltreatment high subjective burden among caregivers is predictive of potentially harmful behaviors coping styles are another avenue that should be explored to explain the relationship between stress and mistreatment as coping can alter the outcome of stress experiences reactive abuse rather than care needs per se certain behaviors are associated with risk in child maltreatment ipv and em aggressive behaviors from the victim are associated with abuse potentially eliciting negative reactions from perpetrators similarly older adults who exhibit aggressive behaviors related to behavioral symptoms of dementia are more likely to experience mistreatment than those without dementia knowledge and experience low levels of knowledge and experience among caregivers are associated with increased risk of mistreatment for example parents with poor understanding of their childrens behaviors are at risk of participating in harmful behavior towards children children displaying certain challenging behaviors are also at greater risk of maltreatment possibly due to the higher degree of childrearing skills required of parents poor understanding of recipient behaviors may similarly explain high rates of mistreatment among caregivers to people with dementia although highdemand caregiving can contribute to em through stress inexperience on how to provide care is another factor indeed some cases of criminal neglect are nearly indistinguishable from those where caregiver is overwhelmed factors unique to em although applying risk factors and theories from different forms of family violence it is important to recognize dynamics that make em unique aging is associated with illnesses and disabilities that may change an adults status from independent to dependent requiring different behaviors from others for example family norms of giftgiving may become exploitative if the older adult loses financial decisionmaking capacity further although the dependency and need for care among some older adults may mirror that seen in children an important distinction in older adults is the assumption of autonomy unless it is legally determined that the older adult lacks capacity they retain their decision making autonomy which includes the autonomy to make seemingly poor decisions or to place themselves in harmful or detrimental situations communitybased intervention models in family violence like theories and risk factors communitybased prevention models for other types of family violence offer useful lessons for addressing em we largely focus on home visiting models seen primarily in the child maltreatment field there are several reasons for doing so as with parents raising children family caregiving for older adults takes place primarily within the home a home setting is valuable for an intervention because it gives providers insight into contextual risks that may not be apparent in other settings further these approaches enable tailored interventions appropriate for the diverse needs of families as opposed to more groupbased interventions home visiting models are particularly attractive in an em prevention context as a strong tradition of homebased intervention already exists for family caregivers in reviewing approaches to communitybased intervention this section aims to identify components that contribute most to success table 1 summarizes the intervention models described home visiting programs to prevent child maltreatment home visiting programs in child maltreatment date back to the 1970s some programs provide generalized supportive services such as the healthy start program which connects new parents to community resources other interventions target specific mechanisms thought to underlie child maltreatment this strategy is used in the promoting first relationships intervention which aims to improve parents sensitivity to child needs and promote attachment still other programs are multicomponent offering a range of services and support to families despite variation some designs and strategies are consistently more successful than others for example home visiting interventions that include a training component outperform those without training aiming to break cycles of violence and improve relationship quality using tenets of social learning and attachment theories parents participating in parentchild interaction therapy are taught parenting skills over 12 to 14 training sessions other training approaches focus on improving parents perceptions of children in an adapted version of the healthy start program atrisk families were trained to alter negative appraisals of children at followup the control group had a 24 rate of physical abuse at follow up whereas those receiving the enhanced version of the healthy start intervention showed a rate of 4 although not specifically designed to prevent child maltreatment the family checkup model offers several promising approaches a home visiting program addressing maladaptive behavior patterns in children it is tailored to the unique needs of families over the course of three visits parents are interviewed about their situation during the first visit assessed and observed interacting with the child during the second visit and receive feedback during a final visit to discuss parenting strengths and weaknesses as well as available services and supports to meet the familys needs although its impact on preventing child maltreatment remains largely unstudied recent findings by dishion and colleagues show lower levels of neglect originally aimed at parent with children aged two to seven with behavioral problems this intervention is provided over the course of 12 to 14 weekly sessions and aims at improving relationship quality and disrupting coercive tendencies between parents and children during the first seven sessions parents follow the childs lead during play in order to strengthen the relationship in the final seven sessions the parents are taught skills to direct the childs behavior thereby better managing it toth et al 2013 family checkup comprised of three sessions the family checkup begins with an interview with the parent to learn about the family situation and engage in motivational interviewing techniques this is followed by an assessment which includes a questionnaire and observation of the parent and child interacting at the third session feedback is provided on the familys strengths and weaknesses as well as a discussion of accessing additional supportive services men respond to program recruitment invitations and are asked to complete a survey about their interpersonal relationships and engagement in aggressive or violent behaviors towards their partners they are provided with a personalized survey summary which presents their responses alongside answers from the general population which often serves to highlight participants deviation from societal norms participants then engage in individual telephone counseling with study personnel trained in motivational interviewing techniques to promote change mbilinyi et al 2011 prevention relationship enhancement program couples are taught skills to better manage negative affect and improve communication skills are taught during five sessions scheduled 1 week apart with three to five other couples lasting for 3 hr each sessions are devoted to one or two topics and led by trained psychology undergraduate and graduate students outside of sessions couples are assigned reading and asked to complete exercises markman et al 1993the gerontologist 2019 vol 59 no 4 among families participating in the family checkup program 2 years after the intervention the family checkup model is based on the transtheoretical model of change a dynamic and personcentered approach that encourages behavior change in stages based on readiness moving forward through stages is believed to improve selfefficacy which supports behavior change in the case of the family checkup model motivational interviewing techniques prepare parents to change reactions contributing to difficult behaviors such as defiance and poor selfregulation feedback helps parents recognize areas of strength and areas where they can improve communitybased programs to prevent intimate partner violence although home visiting approaches are far more common in child maltreatment interventions some ipv interventions offer valuable lessons especially given overlapping dynamics with em that are not seen in child maltreatment drawing on child maltreatment the family checkup model has also been effectively revised to prevent ipv in the form of the mens domestic abuse checkup a secondary prevention approach the program is like the family checkup but provides the intervention via telephone to men who selfidentify as engaging in violent behaviors toward their partners as with the family checkup motivational interviewing and feedback are central in addition because perpetrators of ipv overestimate the normality of violent behaviors the program provides participants with a brochure detailing the actual prevalence of interpersonal violence within the general male population revealing the discrepancy between participants perceptions of ipv occurrence and what is normal promotes selfawareness and draws upon social learning theory encouraging men to accept a more accurate perspective of ipv in addition to or as part of home visiting interventions to improve communication skills between partners reduce revictimization in a seminal study markman and colleagues tested the prevention relationship enhancement program where couples learned techniques such as active listening and expressive communication during therapy sessions researchers found that during 4and 5year followups participants in the intervention reported better communication and lower levels of violence in their relationships than controls the success of these programs may be attributed to their accounting for varying stages of risk an important factor to consider since potentially abusive behaviors often increase over time building on family violence interventions to identify key components for a home visiting model to prevent em drawing on lessons learned from child maltreatment and ipv we argue for the adoption of a home visiting model delivered as a primary prevention intervention for em based on successful models in child maltreatment and ipv the structure of an intervention should target caregivers facing new or changing conditions take place over several months and be tailored to individual and family needs preferences and culture components should include regular assessments training and strengthsbased feedback how such an intervention might look is illustrated in figure 1 although not exhaustive these approaches reflect the most promising practices from family violence readers seeking additional information about specific program structure and components should review macleod nelson and whitaker and colleagues although we propose a standardized structure and several key components for an intervention the exact intervention tools will depend on specific risk factors in each family previously we suggested risks fall into three general theoretical categoriesthose related to relationship quality stress and knowledge responses to risk factors identified during assessment should link to selected tools by way of underlying theory whereas training for someone who is experiencing high levels of stress might focus on behavior management and assistance accessing respite caregivers who are struggling with a difficult relationship history will likely receive greater benefits from counseling however because there will likely be overlap in these categories some cases responses will look very similar figure 2 illustrates an intervention based on a hypothetical case where stressbased risk factors are central supplementary figures 1 and2 illustrate what an intervention might include for the other theoretical mechanisms discussed target caregivers at the start of caregiving and those facing changing conditions as teresi and colleagues point out interventions in child maltreatment are most effective when delivered before maltreatment occurs similarly primary em prevention programs implemented near the beginning of a caregiving journey or at critical junctures after a change in care level occurs may be most effective for example an intervention could target caregivers following a hospital transition however unlike new parents who readily identify with this role caregivers who are just beginning this role may require additional guidance during recruitment given a tendency to not yet perceive themselves as caregivers take place over an extended period further in reviews of both child maltreatment and ipv interventions the most successful home visiting programs were found to be relatively intensive and moderately long in duration based on studies from other forms of family violence regular and frequent visitsperhaps 12 or more over at least 6 months are most likely to improve the chances of success of a home visiting intervention even longer intervention periods may be appropriate possibly lasting 2 years or more depending on other design components tailored to individual and family needs preferences and culture interventionists should utilize the flexibility of a multicomponent approach to deliver services and supports that meet the unique needs of families wherever they are on the spectrum between a healthy and abusive relationship for example interventionists in the healthy start program individualize the intervention to families by guiding them to relevant services based on specifically identified needs and decrease the number of visits as parent competency grows multicomponent options may also be preferable compared to onesizefitsall approaches as some families will be more amendable to and will engage with some interventions tools more than others in addition an em intervention should meet the needs of culturally and ethnically diverse caregiving dyads and families the family checkup models success in racially and ethnically diverse samples has been attributed to its ability to address multiple types of stressors linked to culturally specific norms and attitudes guided by regular assessment to effectively meet specific and evolving needs and identify whether progress has been made toward reducing risk family assessment at baseline and regularly thereafter is necessary assessment as described here is both a means of evaluating a program and a component of the intervention itself in the family and mens check up models assessment is the cornerstone of increased selfawareness underlying behavior change in these transtheoretical modelinspired programs although assessment should avoid being burdensome it is important to include contextual factors such as family dynamics as well as characteristics of the caregiving situation that are likely to evolve an assessment should inform a care plan that is specific to the needs of the family success is attributed not only to skillbuilding in areas of weakness but also increase in selfefficacy supporting behavior change like training options offered in caregiver and child maltreatment interventions content for an em intervention might include practical demonstrations on how to provide care money management and managing difficult care recipient behaviors training could also address relationship quality especially in situations involving recipients with dementia or those who may have difficulty appropriately expressing their needs in line with promoting first relationships relationship quality can be improved by assisting caregivers in understanding recipient needs dyad training on communication skills could be useful in some cases however because there are likely limitations of such training in families with longstanding relationship conflicts such training if used should include realistic goals as to what can be accomplished this approach is supported by the transtheoretical model where progress is tailored to the individual inclusion of a training component provision of strengthsbased feedback strengthsbased feedback builds selfefficacy encourages participant retention and motivates progress toward acquiring the skills necessary to provide quality care such feedback should be provided following assessment reassessment and while providing training modules components of social learning theory found in the transtheoretical model of change suggest that selfefficacy can encourage engagement in interventions which has been illustrated in family checkup programs although selfefficacy has long been considered an outcome of caregiver interventions an em intervention should also consider selfefficacy as a moderator conclusion evidencebased primary prevention strategies from other fields of family violence offer a useful starting place for interventions to prevent em of particular interest are home visiting models aimed at caregivers which offer opportunities and approaches to target underlying risk factors shared among different forms of family violence we describe starting points for such an intervention but acknowledge that any program will be shaped by the available resources and specific agency goals regardless given what we know about prevention programs from child maltreatment and ipv we believe there is adequate information to pilot a promising prevention intervention for em supplementary material supplementary data are available at the gerontologist online conflict of interest none reported

elder mistreatment em is a public health problem that harms millions of older americans each year despite growing recognition of its occurrence there are no evidencebased primary prevention programs although em is distinct from other areas of family violence including child maltreatment and intimate partner violence common risk factors and theoretical underpinnings point to opportunities for prevention strategies drawing on evidencebased best practices found in other fields of family violence we identify approaches that could be tested to prevent em at the hands of family caregivers who are among the most likely to commit mistreatment specifically we examine home visiting approaches primarily used in the child maltreatment field and identify components that have potential to inform em interventions including prevention we conclude that there is enough information to begin testing a prevention intervention for em that targets caregivers

background lifelong treatment with antiretroviral compounds is currently the gold standard in the clinical management of human immunodeficiency virus infection while antiretrovirtal therapy is effective in restoring health and minimizing secondary hiv transmission it falls short of achieving virus eradication effective curative treatment could provide a sustainable solution to prevention and control 1 despite increasing research with the accumulation of scientific evidence for hiv cure such therapy is not yet in sight 2 despite the uncertainties a survey of over 400 people living with hiv in the united states showed that more than half were willing to participate in different hiv cure studies 3 elimination of the hiv virus in the berlin patient offered new hope in the plhiv communities about the ultimate goal of cure 4 destigmatization was particularly valued by plhiv who favored curative treatment when it becomes available 56 in the interim animal studies and human trials suggested that functional cure of hiv infection may become a reality in the coming years 78 unlike sterilizing cure functional cure strategy aims to achieve effective suppression of hiv viral load so that antiretroviral therapy becomes unnecessary while functional cure could represent different strategies the term is now consistently used in referring to the attainment of virus control without art 7 while ones hiv infection status remains unchanged willingness of plhiv in receiving noneradication cure treatment or joining functional cure research would be an important consideration especially that current generations of antiretrovirals are safe and extremely effective plhivs decision may hinge on ones understanding of the concept of cure and how this is explained 9 in the united states many participants in a study did not consider functional cure as an improvement to conventional art 5 experiences with art may also affect plhivs decision about participation in functional cure research in hong kong art coverage in plhiv receiving care at the public service is high with the increasing reports of the promising outcome of functional cure it is timely that their attitude towards participation in functional cure research be explored we hypothesized that the degree of knowledge and attitudes towards hiv cure and functional cure differed between artexperienced and artnaïve plhiv in addition education needs in the specific area of functional cure among newly diagnosed patients could be identified which may in turn ease subject recruitment for a clinical trial and improve expectation management of participants as such we undertook to examine the attitude of msm living with hiv towards functional cure in hong kong and contrast the awareness and perceptions between newly diagnosed and veteran plhiv who have been on long duration of art methods data for analyses came from a questionnaire survey administered on artnaïve and artexperienced men who have sex with men living with hiv participating in two separate cohort studies in hong kong the former study comprised the collection of data from newly diagnosed msm attending any one of the three hiv specialist clinics over a twoyear period while the latter study involved treatmentexperienced msm receiving art at the largest hiv clinic during the same period of time as a followup round of a study on the sex networking behaviors following hiv diagnosis 10 informed consents were obtained prior to the conduct of the surveys approval of the joint chinese university of hong kongnew territories east cluster clinical research ethics committee and ethics committee of department of health were obtained a selfadministered questionnaire was designed with mutual topics in both surveys covering demographics and hiv diagnosis year perceptions about hiv cure and their impacts and awareness and anticipation of hiv functional cure considerations of and concerns about participating in an hiv functional cure clinical trial functional cure was the specific theme for this survey the definition of which was clearly described in order to avoid the misinterpretation of the results as there could be confusion between different forms of hiv curative treatment hypothesizing that sexually active plhiv would have a higher awareness anticipation and interest in hiv functional cure sexual behaviors in the preceding year including sexually transmitted infection diagnosis sexual activity and use of psychotropic drugs for sex were inquired clinical data were separately transcribed which included the age of hiv diagnosis acquired immunodeficiency syndrome status and longitudinal cd4 cell count and viral load the most recent readings prior to the trials community education updated information and appropriate medical advice would be needed safety is a major concern for potential enrollees in hiv functional cure trials keywords hiv functional cure men who have sex with men awareness time of questionnaire for the latter two measures were recorded for analyses on the perceived impacts of hiv cure participants were asked to choose from seven options no longer needing to take hiv medications restoration and stabilization of effective immune function not getting hiv for a second time no longer needing to visit a doctor for hiv no longer at risk of aids or hivrelated morbidity no longer transmitting hiv to the others and being considered as a person not living with hiv awareness of hiv functional cure was categorized into knew of it and understood what it is heard of the idea but not the details and had no idea of it after giving a brief introduction on hiv functional cure participants were asked to rate their anticipation on a scale of 0 to 10 willingness to join an hiv functional cure study was assessed by a 6point likert scale participants were inquired about the importance of each of the following factors which they would consider in joining an hiv functional cure trial safety duration of the clinical trial incentives for participation view and support from family and peers advice from healthcare professionals credibility of the research institution and need for interruption of art medications potential adverse consequences of participating in the trial included cd4 count going down hiv viral load going up becoming infectious to the others presence of aids or other related complications and side effects arising from the therapy the levels of importance and concern were ranked in descending order as very importantconcerned moderately importantconcerned somewhat importantconcerned and a minimally importantconcerned differences in perceptions on hiv cure and hiv functional cure trial between artnaïve and experienced groups were assessed by participants sociodemographic and behavioral factors in logistic regression determinants of anticipation of hiv cure awareness of hiv functional cure and willingness to join an hiv functional cure trial were analyzed by univariable and multivariable logistic regression models participants were defined as having a high degree of anticipation if they gave a score of 10 awareness of hiv functional cure was reflected by at least knowing the idea without details the importance of factors associated with joining functional cure trials and the concerns were dichotomized by defining the lower two levels as zero and the rest as one only variables with p 010 were included in the initial multivariable models for stepwise backward elimination based on the aic value intercorrelations between cureand trialrelated consideration factors and concerns were explored using logistic regression models all statistical analyses were conducted in r results demographics between march 2019 and january 2020 153 treatmentnaïve msm were recruited which accounted for about onethird of all newly diagnosed male plhiv in hong kong while data from 203 treatmentexperienced msm were collected between april 2019 and november 2020 the median age of msm included in the analyses was 37 years with treatmentnaïve ones at 30 years and treatmentexperienced ones at 42 years of age among those receiving treatment the median duration of hiv diagnosis and receiving art was 9 years and 8 years respectively the median age of hiv diagnosis of all enrolled msm was 31 years as regards sexual behaviors about onethird did not have any sexual activities in the preceding year while 39 had engaged in chemsex among whom 12 injected drugs about 90 of treatmentexperienced participants have achieved a viral load below 20 copiesml while almost all treatmentnaïve counterparts gave a value of at least 1000 copiesml regarding cd4 cell count a smaller proportion of treatmentnaïve participants had at least 500 cellsul whereas threequarters in the treatmentexperienced group had attained the same level perceived benefits of hiv cure perceptions on hiv cure differed between the treatmentexperienced and naïve group the most commonly perceived impact of hiv cure was restoration and stabilization of effective immune function with lower odds among those on art compared to artnaïve participants about half considered untransmittability as an important impact of curing hiv infection lowered risk of aids or related morbidity was considered more important in the treatmentnaïve group whereas reduced need for clinic visit was accorded higher importance among treatmentexperienced participants those who considered immune function stabilization as an important impact of hiv cure had a lower cd4 cell count and were less likely to have recently been engaging in sex perceived importance of reduction of clinic visits was associated with being sexually active and a higher cd4 level participants having attained postsecondary education level and younger than 40 years of age regarded being free from the risk of aids or hivrelated morbidity as an important impact for hiv cure older adults did not consider reduced transmittability important delabelling was an important impact for those with a higher education level awareness of hiv functional cure overall less than half of the participants were aware of hiv functional cure compared with those having no knowledge of it treatmentexperienced msm were more likely to have heard of hiv functional cure but without detailed knowledge awareness was associated with sti history in the past year and being sexually active those who were aware of hiv functional cure did not consider restoration and stabilization of effective immune function an important impact nor were they concerned about potential adverse effects of therapies for functional cure anticipation of hiv functional cure among all participants the median anticipation score for hiv functional cure was 10 with more than half giving a score of 10 and it did not differ between art treatmentnaïve and experienced participants among treatmentexperienced msm those having been diagnosed with hiv for more than 8 years had higher odds of scoring 10 for their level of anticipation for hiv cure those anticipating hiv functional cure were more likely to be of age 50 years or above and to have a lower awareness of the idea higher level of anticipation was associated with the consideration of not needing to take longterm hiv medications following functional cure but negatively with untransmittability of hiv acceptance of an hiv functional cure trial should there be an hiv functional cure trial the vast majority would consider joining therapy safety advice from healthcare professionals and credibility of the research institution were the top three factors participants took into account when considering whether to join such a trial participants interested in joining the trial were more likely to have been diagnosed with an sti in the past year and to take advice from healthcare professionals when making such a decision when deciding whether to participate in an hiv functional cure trial view and support from family and peers were important for those who ceased to have sex and who had attained lower education level credibility of the research institution was important to those who had received higher education participating in such a trial is not without concerns major concerns included the potential risk of developing aids and complications hiv viral load going up and adverse effects of the therapy they were concerned about adverse effects on their cd4 level hiv viral load going up and becoming infectious following functional cure therapy considering trial duration important was associated with concerns about adverse effects participants who considered trial safety important were concerned about all five potential adverse consequences of participating in the trial those looking forward to the prospect of restoring effective immunity following hiv cure had concerns about cd4 count going down after joining the trial discussion hiv functional cure is a relatively new concept for plhiv despite their generally low awareness msm living with hiv had as shown in this study a high level of anticipation for hiv functional cure especially those who had been diagnosed and put on art for some years the effective achievement of functional cure carries the potential prospect of getting rid of repeated clinic visits and taking longterm medications 11 the benefit of being untransmittable may however not be regarded as an important impact for hiv cure because in the current era of undetectable equals untransmittable adherence to art is already effective in minimizing the risk of transmission in our cohorts of msm living with hiv the attitudes differed by ones art treatment experience treatmentnaïve participants were more concerned about their immune function and aids progression than those artexperienced as deteriorated health was perceived by newly diagnosed patients an imminent consequence brought on by hiv 12 anticipation for hiv functional cure was apparently lower among those who were aware of it although some 42 had heard about functional cure most had limited knowledge of it and cared little about the potential benefit of restoring their immune function and potential adverse effects arising from the new therapy with the increasing likelihood that functional cure may soon become the next major advance in hiv treatment 7 there is the need for promoting community education on the rationale and strategy for hiv functional cure as in many countries msm accounted for a high proportion of plhiv in hong kong 13 and who continued to be significantly impacted by the epidemic 14 the msm community especially those living with hiv would need to be targeted in anticipation of the introduction of functional cure therapy in our study msm engaging in higher risk sexual behaviors were more likely to be aware of the recent advancement on hiv science such as preexposure prophylaxis 15 this echoed our results that sexually active plhiv particularly those engaged in condomless sex as indicated by their sti history were more likely to be aware of hiv functional cure there are diverse reasons for plhiv to look forward to receiving functional cure therapy it is intuitive that plhiv with a weaker immune system were less likely to be sexually active and they wished to restore and stabilize their immune function and were at the same time more concerned about adverse hiv outcomes after joining functional cure trials the fact that younger plhiv cared more about disease development and transmittability was likely because they were newly diagnosed and would remain sexually active for a longer time in the future plhiv with higher education level regarded delabelling of hiv an important impact of hiv cure in hong kong public stigma against plhiv 16 and perceived discrimination 17 have been reported it is therefore an ideal vision for them to remove the label of hiv after achieving some sort of cure discrimination in workplace and difficulty in career development could be experienced by plhiv 18 although highly educated plhiv were found to deal better with workplace discrimination and improve employment quality than those with lower education level 19 they were more concerned with their career development that removing stigma means removing a barrier in their career paths from the perspective of the general public increased awareness and knowledge in hiv science advancement might be able to reduce stigma a previous study showed that heterosexually active adults who were aware of the untransmittable nature of plhiv achieving undetectable viral load had a lower level of anticipated hiv stigma 20 as this study focuses on plhiv a followup study in the general population and the msm community would be needed to assess the impact of functional cure on general and datingand sexrelated enacted stigmas overall the idea of an hiv functional cure trial was well accepted by our cohorts of msm living with hiv with over 90 indicating their willingness to join similar to the high acceptance rate of 95 in a previous study 11 potential trial participants were more likely to have engaged in higher risk sexual activities as reflected by their report of sti in the preceding year this might be precipitated by a prospect of continuation or reengagement in adventurous condomless behaviors upon cure 21 safety is a major concern for clinical trials involving the use of novel agents like neutralizing antibodies or therapeutic vaccines careful monitoring of plhiv in the trial would be warranted not just for protecting participants health but also easing their concerns of side effects and adverse hiv outcomes hesitation would arise if the trial requires interruption of art or if it takes a long time in relation to the risk of rebound and potential adverse effects 11 trusting relationship between plhiv researchers and healthcare workers could be beneficial for ensuring the delivery of optimal health outcomes 22 based on potential participants trust on healthcare professional advice collaboration with hiv clinics on explaining the details and safety issues of the trial would be paramount this study carries some limitations like other epidemiological studies there were inherent recall and social desirability biases in the administration of behavioral questionnaires we had minimized these biases by adopting a shorter recall period and omitting fine details about sexual activities the adoption of a selfadministering approach should have reduced embarrassments in response to interviewers questions incorporation of clinical data by transcription benefited the study by providing objective measurements of participants hiv outcomes in the absence of any functional cure trials the exploration of ones willingness to participate in a hypothetical trial without having one in place could be postulational nevertheless the systematic inquiries into the awareness and anticipation of functional hiv cure among msm living with hiv and their inclination in joining a hypothetical study have generated useful results which could be of reference for the planning of a functional cure trial conclusions to plhiv hiv cure means restoring and stabilizing their immune systems that they no longer need to take longterm medications nor do they need to visit hiv clinics repeatedly while virus eradication cannot be achieved hiv functional cure is a promising strategy in which msm living with hiv had a high level of anticipation despite relatively low awareness while a high acceptance rate of a functional cure clinical trial was elicited msm living with hiv were concerned about adverse hiv outcomes their appreciation of the objectives of functional cure understanding of the study procedures and recognition of potential adverse events are crucial and all of which need to be accessible well before a functional cure trial begins enrolment abbreviations hiv human immunodeficiency virus plhiv people living with hiv msm men who have sex with men sti sexually transmitted infection aids acquired immunodeficiency syndrome iqr interquartile range or odds ratio aor adjusted odds ratio art antiretroviral therapy supplementary information the online version contains supplementary material available at doi org 10 1186 s1287902207346x additional file 1 questionnaire s1 crude odds ratio for factors of importance to be considered and concerns related to participation in functional cure trial among msm table s2 crude odds ratio for important factors to be considered about and concerns related to the trial among msm additional file 2 table authors contribution the study was conceptualized by ssl data was collected by thk cpc and nsw data analysis was performed by cpc results were interpreted by all authors the first draft of manuscript was written by thk all authors participated in the critical revision of the manuscript and read and approved the final manuscript • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from had no role in the study design in the collection analysis and interpretation of the data in the writing of the report and in the decision to submit the paper for publication competing interests the authors declare they have no competing interests to report publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

background human immunodeficiency virus hiv functional cure is a novel biomedical strategy characterized by sustained viral suppression without the need for lifelong medications the attitude of people living with hiv plhiv towards functional cure and clinical trials are understudied we aimed to examine the awareness and levels of anticipation for hiv functional cure among men who have sex with men msm living with hiv and their willingness to join trials as differentiated by their antiretroviral treatment status methods msm living with hiv with and those without treatment history were recruited from hong kongs hiv specialist clinics selfadministered questionnaires covering behavioral profile perceived impact of hiv cure attitude towards hiv functional cure and related clinical trials were collected clinical data were separately transcribed determinants of perceptions and attitudes were identified by logistic regression models results of 356 msm living with hiv recruited less than half 42 were aware of hiv functional cure but they had a high level of anticipation for it treatmentexperienced participants were more likely to be aware of hiv functional cure awareness was associated with continued engagement in sexual activities after hiv diagnosis and sexually transmitted infection sti diagnosis higher anticipation was observed among older msm living with hiv but it was negatively associated with ones awareness over 90 were willing to join functional cure trials especially those who had previously been diagnosed with sti and had engaged in chemsex in the past year advice from healthcare professional was an important factor considered by those willing to join clinical trials younger better educated msm and those with lower cd4 counts were more concerned about potential risk of aids and potential complications upon trial participation conclusions msm living with hiv especially those sexually active showed positive attitude towards functional cure and willingness to join related clinical trials despite low awareness to enhance preparedness for hiv functional cure

introduction european populations are ageing faster than populations in many other parts of the world 1 despite a continued increase in healthy life expectancy a substantial proportion of people in early old age in europe suffer from some degree of impairment which often limits their work capability 2 in fact reduced health functioning and disability are major determinants of involuntary early exit from the labour market 3 4 in view of the strong economic need for extending labour market participation of older people in european countries 2 it is important to know more precisely the sociodemographic socioeconomic and workrelated characteristics of older men and women whose work capability is limited due to impairment or disability such knowledge may provide useful information on entry points for preventive measures within and beyond occupational settings previous investigations documented a social gradient of disability prevalence in early old age leaving men and women in lower socioeconomic positions at higher risk 5 6 7 8 9 10 however given the bidirectional pathways between health functioning and socioeconomic position including employment status in a life course perspective 3 a clearcut interpretation of this association is difficult moreover measures of socioeconomic position in terms of occupational position or earnings are often confounded by distinct occupational exposures which may trigger early onset of disability 11 it is therefore important what the paper adds ▸ previous investigations demonstrated a social gradient of disability in older populations but were restricted to single countries or cohorts were mostly crosssectional or did not use a comprehensive measure of disability ▸ in this study we followed the guidelines of the international classification of functioning and used multiple variables to construct and validate two different disability indices in the frame of a longitudinal crosscountry study ▸ our findings based on employees aged 5064 years from 11 european countries demonstrate a social gradient of both indices of disability which is in part mediated by adverse psychosocial working conditions ▸ investment into reduction of psychosocial work stress in particular among employees in lower socioeconomic positions is a relevant entry point of policies that aim at maintaining work ability in the ageing workforce to disentangle these effects and to test their robustness in a large dataset which offers opportunities of adjusting for relevant confounders in this study we set out to test associations of sociodemographic socioeconomic and workrelated factors with disability in a prospective study design using strictly comparable indicators based on a large sample of male and female employees in early old age from 11 european countries more specifically we test the hypothesis that low socioeconomic position and exposure to a stressful psychosocial work environment contribute to later disability furthermore we claim that the association of socioeconomic position with disability is partly mediated by exposure to a stressful psychosocial work environment as measured by core components of two established theoretical models the demandcontrol 12 and the effortreward imbalance 13 models the demandcontrol model defines work stress in terms of a distinct job task profile where jobs defined by high quantitative demands in combination with low decision latitude or low task control are stressful 12 a complementary model eri focuses on the work contract and the principle of social reciprocity lying at its core 13 rewards received in return for efforts spent at work include money esteem and career opportunities the model asserts that lack of reciprocity occurs frequently in modern economies and generates strong negative emotions and psychobiological stress responses with adverse longterm effects on health a second aim of this study concerns the development of indices of core dimensions of disability taking note of a more comprehensive approach to this notion as documented in basic work resulting in the international classification of functioning disability and health 14 disability is no longer interpreted as a fixed attribute of an individual but rather as a dynamic continuum of experiences at different levels as disability results from an interaction of vulnerable individuals with a broad range of environmental factors including working conditions 15 16 it seems mandatory to assess this condition in a multidimensional quantitative frame of analysis at least two crucial components need to be distinguished the level of bodily impairment and the level of restriction in activities and social participation since people with the same impairment can experience very different types and degrees of restriction depending on the context 16 a person with an amputation may for instance not be restricted in activities and participation when she is provided with appropriate prostheses and supports another reason for this distinction is related to their potentially different role in predicting morbidity and mortality in a recent study of older british women it was observed that restrictions in participation and restrictions in complex activities were associated with increased risk of mortality but no such effect was found for impairment in the fully adjusted models 17 therefore embedded in the framework of icf we aim at developing a comprehensive continuous measure of core dimensions of disability based on available data methods data source data were obtained from the first two waves of the survey of health ageing and retirement in europe share is the first longitudinal research project comparing data on working conditions retirement health and wellbeing and social position among people aged 50 years and older in a variety of european countries 18 data from the two first waves include 11 european countries data collection is based on probability household samples where all people above 50 years of age plus their partners were interviewed using computer assisted personal interviews due to different institutional settings in the participating countries the sampling was either drawn as a stratified simple random selection from the national population register or as a multistage sampling using regional and local registers or telephone directories in share information is available for 28 517 respondents in wave 1 where the country average of household response rate is 606 for the total sample ranging from 388 in switzerland to 792 in france in wave 2 18 742 of these individuals remain in the sample with an attrition rate of 279 35 because we were interested in associations between working conditions in late midlife in wave 1 and disability in wave2 we excluded people not aged 5064 years at wave 1 and those reporting no employment at baseline from the longitudinal sample moreover we conducted a complete case analyses thus excluding respondents with missing data on any of the variables this results in a final sample size of 4864 respondents in order to compensate for unit nonresponse and for attrition between the first and the second waves calibrated longitudinal weights were applied these weights are defined for the longitudinal sample only and are calculated for each country separately measurement disability based on icf and its definition of disability we divided between two indices of disability one measuring impairment and another measuring restriction in activity and participation 20 accordingly all share modules were screened for questions related to disability and respective items were linked to the two dimensions using established linking rules 20 21 since most original items were dichotomous we dichotomised the remaining items such that one category was indicative of having at least a moderate problem in its respective domain as a next step we applied a principal component analysis to evaluate the chosen items based on wave 1 data in the results two factors with eigenvalues above 20 were extracted confirming the assumed dimensions of disability however two candidate items for the a p factor did not load as expected and were excluded from further analysis not considering the dropped items the two factors explained around 34 of the variance of all items and 45 of the a p and 23 of the impairment items were explained by the twofactor solution next we performed a confirmatory factor analysis for item responses at wave 2 using the stata module confa 22 the first item of the respective index was used as scalar results show that our index solution meets the statistical criteria however one item on the impairment factor and two items on the a p restrictions factor displayed marginal loadings only probably due to their low prevalence but were nevertheless included in the final index solution in case of a p restrictions it should be noted that the included items turned out to be part of two other existing scales yet not all items of these two latter scales were included and instead of dichotomising both scales into no limitations versus one or more limitations we created one single scale with additional information on the number of a p limitations we constructed sum indices for impairment and a p restrictions 21 each of those is a count variable ranging from 0 to 12 we plotted both indices against a poisson distribution which was confirmed in both cases expectedly the impairment scale showed a high correlation with subjective health while the a p scale showed a lower correlation of r017 both scales were correlated with r02 this demonstrates convergent as well as divergent validity that is the scales seem to measure different constructs working conditions quality of work was assessed by a short battery of items derived from the job content questionnaire measuring the demandcontrol model 23 and from the eri model questionnaire 24 the psychometric properties of both questionnaires were previously tested 24 given the constraints of a multidisciplinary approach in share project the inclusion of the full questionnaires was not possible thus items with best psychometric properties in their respective scales were selected with regard to the first model the measurement was restricted to the control dimension this decision was based on evidence that the predictive power of control by far exceeded the power of demand and that tests of the interaction term demand×control had produced inconsistent results 25 low control at work was measured by the sum score of two likertscale items ranging from 2 to 8 with higher scores indicating lower control at work scores in the upper tertile of each country were defined as representing poor quality of work in terms of low control to measure eri two out of six items measuring effort and five out of 11 items assessing reward at work were included for the selected items allitem total correlations were far beyond the established threshold of 030 26 ranging from 093 to 081 and from 067 to 042 effortreward imbalance was defined by a ratio of the sum score of the effort items and of the sum score of the reward items as previous analyses showed that quality of work in terms of this model varies across countries under study in share tertiles of the ratio were calculated for each country separately 24 participants scoring in the upper tertiles of this ratio of imbalance were considered experiencing poor quality of work additional measures age gender income and education were included as additional measures income information is based on the total annual household income composed by the sum of different income components that were assessed in the questionnaire in case income components were missing information was obtained through imputation 27 to adjust for household size we divided the value of income in accordance with the oecd equivalent scale and categorised it into countryspecific tertiles based on all available cases in each country education was measured according to the international standard classification of educational degrees that was categorised into low education medium education and high education these two indicators are introduced as proxy measures of socioeconomic position but are analysed separately as they point to different dimensions of social inequality 28 analyses as a first step table 2 gives an overview of the study sample and the core variables additionally associations between disability and all covariates are analysed using analysis of variance thereafter we calculated poisson regression models to predict disability 20 in wave 2 given the multilevel structure of the data we estimated a random intercept multilevel model with individuals nested within countries 29 this model contains two components a socalled fixed component that explains systematic variability in the data and a random component which accounts for unobserved variability between countries this procedure allows for accurate adjustment for country affiliation maximum likelihood estimation is used for parameter estimation in the results section for each one of the two disability outcomes we display findings based on three consecutive models all adjusted for age gender and level of impairment at wave 1 this procedure allows for exploring to what extent the predicting variables are associated with change in disability between wave 1 and wave 2 30 model 1 investigates the joint effect of income and education on disability in model 2 the joint effects of the two workstress measures are presented model 3 includes all variables of the first two models with the aim of examining potential mediation effects in respective tables we present incidence rates ratios together with the level of statistical significance and cis calculations were done using the xtmepoisson procedure in stata 11 results descriptive findings in table 2 sample characteristics are given and mean scores of the two disability factors impairment and a p restrictions are displayed according to covariates a total of 2655 men and concerning the scores of impairment and a p restrictions we first observe that overall levels of a p restrictions are much lower than those of impairment scores impairment scores varied according to gender age and socioeconomic position as shown in figure 1 this social gradient is consistent across all countries using income as an indicator of socioeconomic position less clear findings are obvious in case of a p restrictions as expected we observe higher scores of the two disability factors among men and women experiencing chronic stress at work in terms of the two workstress models again relatively consistent trends are observed across the countries under study as exemplified by measuring work stress in terms of eri multivariate findings in tables 3 and 4 results of multivariate analyses are presented in both tables we present findings of the three regression models described in the methods section first for impairment and second for a p restrictions significant effects of gender age socioeconomic position and work stress on impairment scores were confirmed in multivariate analysis if the indicators of socioeconomic position and the two workstress models are included simultaneously we observe an attenuated effect of the two indicators of socioeconomic position on impairment pointing to a partial mediation of the association between socioeconomic position and impairment by a high level of work stress results are not as consistent in case of a p restrictions effects of gender and age are not significant in the multivariate model whereas the remaining effects correspond to those of impairment discussion based on two summary indices of impairment and restrictions of activities and participation we tested sociodemographic socioeconomic and workrelated predictors of disability among working men and women of early old age across 11 european countries using data from two waves of share study after adjusting for baseline disability and relevant confounding variables low socioeconomic position and chronic stress at work exerted significant effects on disability scores 2 years later effects were more consistent for impairment than for a p restrictions in addition we found some support of the hypothesis that the association of socioeconomic position with disability is partly mediated by work stress to our knowledge no former study analysed these associations in a prospective design comparing data across a variety of european countries a further innovative aspect of this investigation concerns the construction of linear indices of two core components of a comprehensive concept of human functioning that was developed in the frame of icf 14 previous studies found similar associations of socioeconomic position with measures of disability but were restricted to single cohorts or single countries 5 6 7 8 9 10 huisman 5 for instance found that inequalities were lowest in the oldest age group particularly among women however due to the crosssectional nature of this study it cannot be determined if this is an ageing or cohort effect moreover it is unclear if the reported socioeconomic differences in longterm disability are in part due to differential working conditions similarly a few investigations tested prospective associations of job strain 31 32 or eri 31 32 33 with reduced functioning often measured by the sf36 or short versions 34 stansfeld 31 found for example that high demands and eri and negative aspects of close relationships were independent predictors of poor sf36 functioning however other indicators of socioeconomic position such as income and education were not analysed in this study we add information on the combined effect of socioeconomic position and work strain on two core indicators of disability and further on a partial mediating role of work stress in this former association several limitations need to be mentioned first most items we used for construction of the disability indices were based on selfreported data rather than on functional testing therefore the validity of our indices may be limited even more so due to potential reporting bias however graded associations with age and in case of impairment consistent variations with gender and socioeconomic position point to a valid assessment as reporting bias is assumed to vary across countries it is unlikely that it inflates the findings of the total sample nevertheless future studies should aim at integrating more objective functional measures and determining differences between selfreported and observational data a second limitation concerns the assessment of stressful work with abbreviated scales a test of the full models using original measures of all respective scales may reduce the risk of underestimating their effects on prospective disability third we restricted our analyses to the assessment of work stress at wave 1 additional information on the duration of exposure available from the assessment of work stress at wave 2 could enrich the current analyses also we did not consider data on nonworkrelated or extracurricular exposures or information on the cause of impairment for example injury versus disease this will be possible with data from share wave 3 that was focused on retrospective assessment of the participants life courses since previous analyses indicate that healthier people were more likely to participate in wave 2 35 we also cannot rule out some selection bias where people with low levels of disability are more likely to participate in survey research however this may rather lead to an underestimation of disability levels and its association with work stress due to health selection furthermore while our analyses focussed on individual predictors future research may also explore the role of distinct national disability policies and their interactions with working conditions 2 36 similarly albeit the conducted multivariate analyses account for country affiliation future research may invest in more detailed differences between countries and measurement equivalence of our two indices in this regard additional explorative principal component analysis by country showed that a p items mostly loaded on the same factor which did not hold true for several impairment items these limitations are balanced by several strengths first the share study applied strictly comparable procedures in data collection based on identical measures and study designs across all countries 19 second by applying multilevel statistical modelling in the analysis of data from two measurement waves by including relevant confounding factors in multivariate analysis and by providing quantitative indices of two relevant dimensions of disability our results can be considered rather robust even more so as they are based on a large sample representative of working men and women aged 5064 years within the respective countries third our analysis is based on two established theoretically grounded notions of stressful work lack of control and failed reciprocity between effort and reward 37 both models were previously tested in a range of prospective cohort studies and were shown to contribute to the prediction of stressrelated disorders such as coronary heart disease 38 and depressive episodes 39 available evidence on healthadverse effects of an adverse psychosocial work environment strengthens the significance of current findings with regard to reduced functioning in terms of impairment and restricted activities and social participation furthermore additional analyses based on share data demonstrate that the experience of stressful work in terms of these models increases the likelihood of intended early retirement 37 in conclusion low socioeconomic position and stressful work are prospectively associated with two core indices of disability in a large cohort of working men and women of early old age from 11 european countries investing in good quality of work and reducing social inequalities in health and functioning are relevant entry points of policies that aim at maintaining work ability in early old age competing interests none patient consent obtained ethics approval ethical commissions of the study countries provenance and peer review not commissioned externally peer reviewed

objectives prevention of disability in the ageing workforce is essential for sustaining economic growth in europe in order to provide information on entry points for preventive measures it is important to better understand sociodemographic socioeconomic and workrelated determinants of disability in older employees we aimed to test the hypothesis that low socioeconomic position and exposure to a stressful psychosocial work environment at baseline contribute to later disability we further assumed that the association of socioeconomic position with disability is partly mediated by exposure to adverse working conditions methods we studied longitudinal data from the first two waves of the survey on health ageing and retirement in europe comprising 11 european countries sociodemographic socioeconomic and workrelated factors low control effortreward imbalance and baseline disability of 2665 male and 2209 female employees aged between 50 and 64 years were used to predict disability 2 years later following the international classification of functioning icf disability was subdivided into the components impairment and restriction in activities and participation two multilevel poisson regressions were fitted to the data results after adjusting for baseline disability and relevant confounding variables low socioeconomic position and chronic stress at work exerted significant effects on disability scores 2 years later we found some support for the hypothesis that the association of socioeconomic position with disability is partly mediated by work stress conclusions investing in reduction of work stress and reducing social inequalities in health functioning are relevant entry points of policies that aim at maintaining work ability in early old age

should always be made in education about evd with a special focus on districts neighboring countries where the disease is consistently being reported keywords ebola virus disease qualitative research focus group discussion cross sectional study rwanda background ebola virus disease formerly known as ebola hemorrhagic fever is a severe and often fatal illness that affects humans it was first discovered in 1976 near the ebola river in what is now the democratic republic of the congo 1 the average evd case fatality rate is around 50 and the case fatality rates have varied from 40 to 90 in past outbreaks 2 originally transmitted to humans from wild animals the spread of evd is driven by humantohuman transmissions 3 consequently community engagement is pivotal in the fight against evd and successfully containing and controlling outbreaks for effective outbreak control the provision of comprehensive interventions including case management infection prevention and control practices surveillance and contact tracing reliable laboratory services safe and dignified burials and social mobilization are required 45 according to the world health organization evd vaccines have been used to help control the spread of ebola outbreaks in guinea and in the drc 6 there are currently two treatments approved by the us food and drug administration to treat evd caused by the ebola virus species zaire ebolavirus in adults and children the first drug approved in october 2020 inmazeb ™ is a cocktail combination of three monoclonal antibodies the second drug ebanga ™ is a single monoclonal antibody and was approved in december 2020 78 the 20142016 west african evd outbreak was the longest deadliest and most complex outbreak since the discovery of the virus in 1976 59 it was not until march 29 2016 that the who lifted the public health emergency of international concern status of this outbreak with an estimated total cost of 43 billion usd this epidemic resulted in 11310 deaths and 28616 laboratory confirmed cases this was reflected by the substantial decrease in economic output in the three affected countries 21011 guinea subsequently declared a new ebola outbreak in february 2021 necessitating the establishment of preventative measures and mandates among its neighboring countries 12 since august 2018 the drc has been facing a largescale evd outbreak in the eastern provinces of north kivu and ituri spanning as far as goma and south kivu provinces 13 the drc announced its tenth outbreak on august 1 2018 between april 30 2018 and november 17 2019 3296 cases and 2196 mortalities were reported among the five most affected areas those being benin with 697 cases katwa with 674 mabalako with 416 butembo with 288 and mandima with 344 this outbreak has become the second largest evd outbreak documented followed only by the 20142016 west african outbreak 14 the unprecedented growth in cases prompted the who to declare the ebola outbreak in drc a public health emergency of international concern 1516 from 1 june 2020 to 18 november 2020 a total of 130 evd cases including 119 confirmed and 11 probable cases were reported in the country 17 in february 2021 a new evd case was detected in butembo a city in drcs north kivu province 18 unstable conditions due to armed conflict 19 outbreaks of violence and social economic problems in affected areas complicated the public health response and increased the risk of disease spread both locally within the drc and to other countries in the region including uganda rwanda burundi zambia south sudan and central african republic 20 on 20 september 2022 uganda declared an evd outbreak caused by the sudan ebolavirus species after the confirmation of a case in mubende district in the central part of the country during this outbreak a total of 164 cases 77 deaths and 87 recovered patients were reported from september 20 to january 10 2023 21 to date uganda has reported four sudv outbreaks in 2000 2011 two in 2012 and one in 2022 2223 the increased frequency of evd outbreaks in drc guinea and uganda might be attributed to increased humanwildlife contact caused by extensive deforestation hunting and mining practices which demonstrates a need for a robust monitoring system to inform future preventative policy measures 1424 rwandas dense population and frequented public transportation system render it highly susceptible to the rapid spread of evd sharing borders with the drc and uganda increases rwandas risk of cross border evd transmission due to the unmonitored crossborder movement of people and goods and weak border control systems the increase in magnitude of the 2019 drc evd outbreak in goma and the mwenge health zone in south kivu further increased the risk of cross border evd transmissions in rwanda borders between rwanda drc and uganda are particularly vulnerable as they are only separated by border check points these borders especially those shared with drc are characterised by intense trade activities and a high volume of population movement migration the threat of crossborder evd transmissions is an emerging and increasing cause for concern not only for rwanda but burundi as well rwandas constant vulnerability to cross border evd transmission necessitates strengthened evd preventative and preparedness interventions greater crossborder collaboration and the flexibility to adapt to emerging needs 25 the government of rwanda through the rwanda biomedical centre launched the multisectorial risk communication and community engagement strategy for ebola virus disease preparedness and response in august 2018 25 the strategy seeks to contribute to the national preparedness and response plan to halt evd transmission in rwanda through effective evidence based social mobilization community engagement and public education that advocates for sociobehavioural changes although rwanda remains free of ebola its costeffective control strategy requires an uptodate understanding of peoples knowledge beliefs attitudes and behavioural patterns surrounding the virus apart from unpublished descriptive technical reports this survey is the first to assess evdrelated knowledge attitudes and practices at individual institutional and societal levels in rwanda methodology study design this mixedmethod crosssectional survey was conducted from may to july 2021 in five selected districts from rwanda these districts were purposely selected from the districts identified as highrisk zones given their geographical proximity or with direct air links to drc and uganda quantitative approach this research was carried out in the initial phase of the covid19 pandemic and due to the government of rwandas covid19 travel restrictions all interviews were conducted over the telephone by a trained member of the research team the research team consisted of two groups the first group was composed of data collectors who were stationed in all five study districts their role was to sample the study participants obtain informed consent and collect participants contact information the second group consisted of enumerators trained to administer the questionnaire later the enumerators called the participants to conduct the interviews participants were randomly selected from urban and rural sectors in each village the study participants were parents caregivers or household members of various backgrounds and occupations one participant was randomly selected from each household selected for the study vulnerable groups such as child headed familieshouseholds people living with disabilities and others were deliberately selected and added to the study cohort participants who could not communicate below 18 years old were excluded from the study the sampling frame in each village was developed with the help of community leaders assuming 50 of the target population have an attribute of interest a minimum sample of 1000 was found to be adequate at 95 confidence level 495 level of precision and considering a nonresponse rate of 15 26 in all five districts the research team contacted a total of 1010 participants using a structured questionnaire gasabo karongi rubavu rusizi and burera the questionnaire was originally designed in kinyarwanda and was later translated to english by two bilingual experts before the study team members validated the questionnaire in order to assess the convenience and interpretation of the questionnaire a pilot study was carried out on 35 participants from the general population and the questionnaire was modified accordingly the questionnaire was predominantly comprised of qualitative approach a purposive sampling strategy was used to select kiis and fgds participants from the list of contacts provided by the districtbased data collectors a total of 98 people participated through kiis and fgds the reasons for selecting these participants were mainly to ensure diversity in our cohort availability and accessibility of participants and willingness to openly express their opinions and experiences in each district kiis were completed with teachers early childhood development care givers community health workers and health workers in health centres at the national level kii participants were representatives from government institutions and their key collaborators all interviews were conducted over the telephone or via the zoom platform in each district fgds were conducted with community leaders parents caregivers and adolescents each fgd consisted of four people and were conducted through conference calls for the quantitative study the kiis and fgds guides were composed of questions related to knowledge and awareness surrounding the cause of evd signs and symptoms risk perceptions and beliefs behaviours and practices information communication channels and sources recommendations and vaccination issues data analysis quantitative data were collected using kobo collect software and then converted to an excel sheet analysis was carried out using statistical package for social sciences version 20 and python version 397 chisquared tests were used to determine the association between survey responses and district marital status and education level of the respondents a logistic regression model was used to assess the relationship between the question do you think rwanda is at risk of ebv an outbreak and the cofounder factors age gender at birth district level of education and marital status the minimum p value for significance was considered 005 qualitative data was managed using nvivo 8 software interview transcripts were imported into nvivo 8 for coding and subsequent analysis 27 to ensure intercoder reliability and agreement coding was performed by two researchers intercoder agreement remained above 90 throughout the analysis results quantitative findings characteristics of the study population out of 1010 respondents surveyed across the five districts 205 were in rubavu 203 in gasabo 2001 in karongi 200 in burera and 19 in rusizi in all surveyed districts 56 of respondents were male ranging from 492 527 579 591 to 604 for the total sample approximately 703 of participants were married 253 were never married and the most respondents reported that they had obtained a primary level of education assessment of knowledge and awareness on ebola the overall ebola knowledge levels disaggregated by district are shown in table 2 the analysis of these data suggests relatively high levels of awareness and knowledge pertaining to ebola across the five study districts albeit with variations in geographical proximity to affected regions of drc the study participants responded that they receive ebolarelated awareness and knowledge from multiple sources some of which are prevalent across the population subgroups the results are confirmed by the low p values obtained in a chisquared test comparing answers from different districts which indicates heterogenous answers across different places of the country for instance when people were asked if evd is caused by a virus the highest proportion of correct answers was found in rubavu whilst the lowest was found in burera this difference is computed by a low p value assessment of attitudes towards ebola infected and affected persons overall the respondents in all districts showed a positive attitude towards evd survivors for instance 88 of surveyed respondents reported that they would welcome back a neighbor who survived ebola with the highest proportion being in karongi and the lowest in burera the heterogeneity in the answer is captured by a low p value in the chisquared test however the proportion of respondents who would hug or touch a person who was previously infected with evd was lower with the highest proportion to answer yes being found in karongi and the lowest in rusizi this discrepancy in answers is reflected by a low p value assessing the risk perceptions and beliefs about ebola table 4 shows the respondent risk perceptions and beliefs related to evd first we report the drc to be the country with the highest proportion of risk assessment of ebola related behaviours and practices the respondents were also asked to indicate the action they would take for themselves and family members to avoid ebola table 5 presents the proportion of respondents with respect to various personal hygiene practices to avoid ebola the most common preventive measures which were mentioned in each of the locations were hand washing and limiting body contacts we also found that practicing handwashing and good personal hygiene was a common behavior to avoid ebola across districts with little variation while heterogeneously people reported changing their behavior or practices to avoid being infected with ebola with the lowest proportion of yes answers found in gasabo and the highest in rubavu when asked if people believe it is important to receive vaccination to prevent ebola 972 answered yes with nonsignificant variations across the districts however people from different districts showed variability in their answers regarding whether they believe vaccines against a wrong response evd are safe overall 901 of participants answered yes while the lowest proportion of yes answers were found in rusizi and the highest in gasabo the heterogeneity in the answers reflects a low p value for this question general perception to assess the impact of the variables age gender district of residence education level and marital status in people answering the question do you think rwanda is at risk of an evd outbreak we performed a logistic regression analysis we report significant effects on an answer for the question for the gender of the respondent and whether the respondent dwells in rubavu or rusizi qualitative findings assessment of knowledge and awareness on ebola analysis of qualitative data suggests that there are variations on overall ebolarelated knowledge among the subpopulation groups health workers community leaders adolescents and teachers for both ecd and secondary schools we have learned that ebola is caused by the virus which has its origin in animals fgd community leader rubavu i do not know the causes of ebola but i know its symptoms like vomiting bleeding and strong fever things like that kii teacher karongi i wish i had knowledge on ebola i could explain to students i do not have enough knowledge i am not ignorant completely i know little about it such as what we hear from radios on the nature of the epidemic teacher karongi although rwanda has not yet recorded an evd outbreak the study respondents were knowledgeable regarding the prevention of future outbreaks and the knowledge was almost uniform across the districts study population subgroups and geographical areas overall the respondents reported receiving knowledge on ebola mainly from their community leaders and community health workers during community work called umuganda health workers are invited to share information on ebola however since march 2020 there has not been any in rusizi there is a programme of vaccination against ebola so community leaders have information on ebola also doctors from kigali help people in the district on how to take measures to prevent ebola fgd community leader rusizi several districts have been organizing evd awareness campaigns to educate the public about how to better prevent the spread of the virus for instance community leaders in rubavu indicated that they had received formal ebola training from health workers at the district level as a part of the district awareness raising strategies all community leaders and opinion leaders have been trained and involved in ebola education the training was an alert in rubavu district we even did campaigns and the cars were driving around the town with loudspeakers with instructions on knowledge on ebola and preventive measures fgd community leader rubavu the analysis of the feedback from participants identifying as teachers across the study districts noted little to no formal ebolarelated dissemination of knowledge andor training for teachers for instance teachers in karongi reported limited exposure to educative activities on ebolarelated knowledge one of the teachers had this to say honestly i do not know much about ebola we simply just get some information from the radio but this is not comprehensive for the role we play as teachers who should impart such knowledge to the children who would in turn also share the information with their families at home kii teacher karongi assessment of attitudes towards ebola infected and affected persons responses from the fgds with parents and local leaders indicated that in general the community members have a positive attitude towards survivors the following is an excerpt from one of the participants sometimes the person can be quarantined however when he or she is sent to the hospital and the hospital discharges himher because heshe is cured then there is no reason to fear or quarantine himher we can welcome himher back fgd parentcaregiver karongi conversely the results also show that some respondents have negative attitudes towards ebola survivors should they affect the country these results are also supported by information gathered through fgds for instance some participants will need more time to personally assess the risk of eating hugging or shaking hands with a person who has recovered from ebola for the recovered member it takes time to go back into the community the population would like to be sure that he has fully recovered but there is no discrimination fgd local leaders rubavu parents and local leaders also reported a willingness to adhere to ebola burial guidelines and protocols when burying someone they suspect that he has died of ebola the following are excerpts from the fgds conducted with the parents for someone who died of ebola there is a burial team and because of fear of ebola no one can approach the dead body the community accept use of burial team even if families are psychologically affected by not paying the last respects to the dead fgd parentscaregivers gasabo in our customs we are used to make the last respect to the dead person so it is too hard to accept the burial team but it is a must sometimes one member of the family can wear the protective equipment and be part of the burial team fgd local leaders rubavu one national level kii noted the need to conduct a refresher on evd to raise awareness my immediate suggestion would be to conduct a refresher related to ebola especially when it comes to community sensitization approaches latest information latest science about ebola strengthen the knowledge of community health workers about the vaccine also because of turnover this refresher will be new information for new health workers we should also have a branded corner in health facilities where people can access ebola information we also need to engage teachers ecd caretakers young children to institutionalize knowledge about ebola plus we should constantly update to highlight the difference between covid19 and ebola we also need to have a refresher for religious leaders kii unicef gasabo assessing the risk perceptions and beliefs about ebola most of the respondents think that rwanda was at risk of an ebola outbreak this is reflected in the fdgkii findings with respondents citing both drc and uganda as the source of regional ebola cases yes the epidemic can come in rwanda because our neighbour drc is regularly suffering from the epidemics and we are at a risk since they can happen to a person from drc who can for instance enter and contaminate or spread the ebola kii teacher gasabo the fact that neighbouring countries such as drc and uganda had reported ebola cases put the rwandans at high risk the following excerpts suggest the potential risk of ebola as a result of illegal movement between boarders where we live there are people who come from drc to pick sand we need to avoid contact with these people they are picking sand at a place called kiraro fgd adolescent karongi with new drc one method of transport is boat many people come from goma and bukavu and there it is possible for rwandans to get ebola also here in karongi fishing is an important business the lake is between two countries but borders are not clear and there is constant movement between these people doing this business and other businesses which make the spread of ebola possible fgd community leader karongi it has been said ebola is coming from bats and in rwanda we have those bats so it can come also in addition movement from goma to rwanda can facilitate the spread of the virus fgd adolescents gasabo most of the respondents from the fgds and kiis perceive that everyone in rwanda takes ebola as a very serious disease that spreads however isolated responses from fgds with adolescents in burera and parents in gasabo karongi rubavu and burera mentioned that ebola was a political disease one that is madeup by politicians many people in the community know the seriousness of ebola before covid19 pandemic health workers from several hospitals were sent into different churches to teach them how to take measures against ebola virus fgd community leaders karongi once i heard traders talking about a political disease fgd adolescent burera people have different way of understanding some people have the misconceptions on ebola some said that ebola is a political disease it does not exist parent fgd gasabo the majority of myths and misconceptions were cited in kiis and fgds conducted in gasabo and the majority were captured in the kiis with health workers the persistence of myths and misconceptions also indicates a need for evd awareness campaigns the myths and misconception about evd it is said that the epidemic is caused by a virus made from laboratories and brought in africa kii health worker gasabo it is somehow said that it is an antichristian epidemic and aiming at imparting satanic stamp of 666 kii health worker gasabo assessment of ebola related behaviours and practices respondents were asked to indicate whether they had changed their behaviour or practices to avoid being infected with ebola this change in behaviour was attributed to the community meetingsumuganda that were held before the covid19 pandemic at these meetings the members of the community were trained and equipped with various methods to mitigate contracting the disease these training sessions were performed by health workers who gave speeches and handed out materials at these events during the community work also we were given the opportunity to talk to the people when you suspect a person you mention it on his transfer then you wait for the answer from the health centre to see if you were right kii health worker karongi in the event of onset of symptoms or confirmation of an ebola case within a family respondents across all the groups cited isolation as the recommended practice interestingly parents in gasabo went on to mention that isolation should be followed with testing of all family members to determine whether the disease had spread within the family in my opinion in case families suspect ebola we have to inform our community health workers in my village because i know they have more information on health issues usually we always seek help from community health workers because they are close to us and know how to behave in case of illness we trust them but in the meantime we have to isolate the suspect fgd parentcaregiver gasabo when we suspect one of member to be infected better to call the health workers while avoiding any contact and approach to that person fgd parentcaregiver rusizi some respondents indicated that they were previously vaccinated or willing to be vaccinated highlighting the importance of evd vaccines in preventing further infections and death the vaccinated participants attested to experiencing no sideeffects from taking the evd vaccine i saw many being injected especially those bordering democratic republic of congo and i was wondering when we will get the same vaccines too unfortunately we did not qualify for the first round but many are ready for the evd vaccines fgd community leader karongi i have already been vaccinated and my family if there are preventive measures they are not 100 percent tight the only way to be definite is to get vaccinated fgd community leader rubavu my family has been vaccinated for ebola we did not experience any problem we think the vaccine is safe because it is tested on those that received it fgd community leader rubavu most of the respondents were with the opinion that they saw no reason for communities to refuse vaccination a few participants however cited myths and rumours as the cause for hesitancy but also believed this could be overcome through awareness campaigns and community mobilisation nothing in my community can prevent people to get vaccinated sometimes rumours but with sensitization it was over fgd community leader rusizi the primary channel of communication that is most preferred by the respondents is radio and in some cases television but radio stands out across key informants and focus groups the radio is the principal means since almost everyone has it you can invite people in the community for a meeting and few will come but when it comes to the announcement made on the radio everyone will attend kii teacher karongi primarily they listen to the radio they watch television and also listen to cars going around with big speakers kii health worker rubavu pertaining to trusted sources of information the respondents collectively viewed the ministry of health and its personnel government institutions such as rwanda biomedical centre and local leaders as being more trustworthy in times of disease outbreaks those who do meetings like country leaders at the country level we cannot accept the information from the district unless we hear ourselves from high rank officials unless it comes from the cabinet otherwise we cant trust the rest kii teacher karongi regarding accurate dissemination of information some participants indicated that there is need to strengthen the flow of educational information regarding ebola one of the key informants said the following what is important is to reinforce the flow of information so that there is no cut in the communication to ensure that the right information is in the right place at the right moment we monitor this very closely also to make sure that there are no rumours kii who gasabo discussion this study sought to assess the knowledge attitudes and preventive practices concerning evd in five selected districts at high risk of crossborder spread given their geographical proximity or with direct air links to drc and uganda we observed relatively high ebolarelated knowledge and awareness levels across the five study districts albeit with variations by geographical proximity to affected regions of drc and by population subgroups such a high level of awareness is a good indication of the awareness raising efforts that have been previously undertaken by the ministry of health consultations with health workers across the five districts indicated that they had received formal training on ebola prior to the covid19 pandemic which had covered topics on general knowledge surrounding ebola such as what the causative agent is how it is spread how it can be prevented as well as the hallmark signs and symptoms the training is likely to have contributed to a relatively high level of knowledge on ebola apart from this training for health workers most respondents across the five districts reported that they mainly received the information on ebola through media sources including radio and tv another proportion of respondents reported receiving information on ebola from postersnotice boards at health facilities people who came from the drc were also a source of knowledge for the adolescents the channel of communication that is most preferred among respondents from all districts is radio which may be attributed to its increased accessibility this finding while not surprising underscores the importance of radio in the context of healthrelated communication especially in rural areas where other media sources are less accessible to the best of our knowledge this is the first comprehensive kap survey on evd in rwanda our findings indicated a heightened level of ebola risk perception in rwanda as a country because it shares a border with drc which is the evd epicentre in the east african region such a study is essential for developing preventive interventions for community members considering the increased risk of cross border evd spread between both countries previous reports and studies have also showed that the risk of cross border evd spread is exacerbated by the high volume of people traveling across the different borders between rwanda drc and uganda 2528 despite the generally high level of ebolarelated knowledge gaps remain in respondents knowledge and attitudes towards evd that were likely to impact preventive practices and behaviours this was observed in survey results where a large proportion of people were apprehensive about whether they should physically and or socially interact with evd survivors for example a small percentage indicated that they would not have a personal or close interaction with evd survivors our findings align with another previous study that has shown how evdrelated discrimination is largely based on community fear that evd survivors are still contagious 29 such discrimination has led to evd survivors being mocked by their communities being evicted from their homes by their property owners losing their former jobs and being divorced by their spouses 29 30 31 32 33 most of our study participants indicated that ones reacceptance into the community following an evd infection depends largely on being able to provide a certification of treatment and recovery from an ebola treatment centre similarly previous findings demonstrated that evd survivors were restricted from visiting public places such as public toilets and have experienced difficulty in trading commodities at their local market due to a community reluctance to physically handle their items or money 2932 these results demonstrate that comprehensive advocacy and awareness programs are still needed especially pertaining to preventative measures and treatment options ebola virus disease was historically perceived as a near certain killer in the absence of treatment however that is no longer the case supportive care rehydration with oral or intravenous fluids and treatment of specific symptoms are now used to improve the likelihood of survival in addition the provision of supportive medical care for evd infected patients combined with approved monoclonal antibody therapy leads to recovery for most infected individuals 734 variability in behavioural practices was observed by district where for instance residing in closer geographical proximity to affected areas resulted in residents being more alert in ensuring they protected their family members from contracting the virus our findings complement one prior study indicating that evdrelated fear can influence inhabitants to act with increased caution and to resort to preventive measures against the disease these changes in human behaviour resulting from fear of the virus may lead to a decreased human to human and human to pathogen contact rates 35 the majority of respondents consulted during the study felt that increased personal protection could be achieved via vaccination and that the evd vaccine was safe the government of rwanda in collaboration with the who and other partners have been implementing public health measures to protect its population against evd vaccination was one of the measures taken to protect health care and frontline workers in the districts at highest risk of evd in rwanda 636 raising awareness of the ebola virus educating people about appropriate prevention measures and vaccinating the frontline is of utmost importance for successful evd outbreak prevention and control efforts limitations and mitigation strategy the covid19 pandemic and the government of rwandas covid19 restrictions necessitated altering data collection methods from facetoface interviews to virtual interviews although contextually expedient conducting interviews virtually created unforeseen challenges where roughly 50 of selected respondents refused to provide informed consent this is probably because participants may be apprehensive about sharing sensitive information or being recorded during the virtual interviews consequently the research team was required to recruit more participants to replace those who had chosen not to participate in the study finally conducting interviews online might also introduce specific methodological limitations related to information bias for instance the absence of facetoface interaction may lead to misinterpretations or misunderstandings of questions potentially influencing the responses given by participants to address this the research team was requested to clearly communicate with study participants conclusion overall the study noted a relatively high knowledge level among the study respondents with 996 reporting having heard of ebola such high level of awareness is a strong indication of the effectiveness of the awareness raising efforts that have been previously implemented by the government of rwanda the results of this study also suggest that future communication and media efforts should be focused on knowledge dissemination in the public domain such as available treatment options case reporting and the importance of positively interacting with evd survivors these findings along with existing data and previous experience in communicating evdrelated information throughout the country should help guide other highrisk countries in creating an effective evidencebased framework for controlling evd abbreviations competing interests we declare no competing interests

background the overall goal of this survey was to understand the knowledge attitudes and practices related to the ebola virus disease evd in rwanda methods this mixedmethod crosssectional survey was conducted in five selected districts of rwanda quantitative data were collected from 1010 participants using kobo collect software and the analysis was performed using spss and python software qualitative data were specifically collected from 98 participants through key informant interviews kiis and focus group discussion fgds interview transcripts were imported into nvivo 8 for coding and subsequent analysisas per our quantitative findings we report that from the 1010 respondents 996 reported having previously heard of ebola 972 believed that vaccination is important in combatting the disease and 933 of individuals reported a willingness to receive vaccination should one become available around 54 of the respondents were correct in identifying that the disease is of a viral origin which originates from wild animals 421 when asked if they believed that rwanda is at risk of an evd outbreak 90 of the respondents believe that the country is at risk of an evd outbreak and the cofactors gender and whether people dwell in rubavurusizi were found to significantly impact their perception of threat as per our qualitative findings the respondents mentioned that both geographical proximity and relations with the democratic republic of congo place rwanda at risk of developing an internal outbreak although the respondents seemed to be aware of the ebola prevention behaviours it was noted that some of them will require significant time before reintegrating into the community an evd survivor as they will first need assurance that the patient has fully recovered therefore the qualitative findings reinforce what we originally reported in the quantitative approach to this studyour results show that there was high evdrelated knowledge and awareness among the general population in rwanda however for strong public health awareness preparedness and protection a massive investment †

introduction stillbirth has a longlasting impact on parents and families this study examined socioeconomic predictors associated with stillbirth in nepal for the year 2001 2006 and 2011 introduction stillbirth refers to the birth of a baby with no signs of life at or after 28 weeks gestation 1 globally stillbirth is a major public health problem with more than 27 million stillbirths occurring annually of these 98 are from developing countries 2 subsahara africa and south asia account for the highest numbers of stillbirth 3 the longlasting impact of stillbirth remains a large burden for parents families policy makers and public health practitioners 4 evidence has shown that stillbirth is associated with physical and psychological morbidity and remains a significant source of cost for the affected family and community 256 despite the huge burden of stillbirth on families and global health progress made in lowmiddleincome countries to reduce stillbirth is considerably slower than the decline in child mortality 3 stillbirth rates vary within and between countries with economically disadvantaged communities having higher rates compared to their economically welloff counterparts 37 in developing countries the major risk factors for stillbirth include advanced maternal age maternal educational status infections fetal development environmental hazards diabetes malaria and umbilical cord complications 8 9 10 11 recent studies from developed countries have also reported that psychological issues are associated with higher stillbirth rates 1213 the major causes and predictors of stillbirth in south asia are not well understood because of the huge variation in data availability and quality that underestimates the true number of stillbirths 5 recent casecontrol studies 1415 conducted in nepal found that stillbirth is associated with older maternal age lower level of maternal education coming from the poorest households inadequate antenatal care and antepartum haemorrhage similarly a verbal autopsy study conducted in nepal revealed that obstetric complications which included prolonged labour antepartum haemorrhage and pregnancy induced hypertension were associated with stillbirth 16 a communitybased study from a rural area of nepal found that a history of prior child loss maternal age above 30 years and low socioeconomic status were associated with higher stillbirth rates 17 the 2011 lancet series on stillbirths suggested that for better estimation and intervention the epidemiology of stillbirths should be at a country level instead of at the regional level because of the regional variations 4 a major limitation of these nepalese studies is that the findings cannot be used to inform initiatives and policy responses at the national level because the samples do not represent geographically diverse population across the country hence the aim of this study was to provide nationally representative evidence on the socioeconomic predictors associated with stillbirths in nepal using pooled data from the 2001 2006 and 2011 nepal demographic and health surveys findings from this study would enable public health professionals to inform different policies and programmes to reduce stillbirth with subsequent improvements in maternal and newborn outcomes in nepal methods data sources the ndhs is nationally representative collected by the nepalese ministry of health and population in collaboration with new era and icf international usa using a multistage cluster sampling design data on fertility mortality family planning and important aspects of nutrition health and health services were collected for the years 2001 2006 and 2011 using standard model questionnaires designed for and widely used in developing countries 18 19 20 for the 2001 ndhs 8726 women aged 1549 were interviewed of these 7089 pregnancies were 7 months gestation similarly in the 2006 ndhs 10793 women aged 1549 years were interviewed of these 5921 pregnancies were 7 months gestation in the 2011 ndhs 12674 women aged 1549 years were interviewed of which 5376 reported pregnancies 7 months gestation a total sample of 18386 pregnancies 7 months gestation five year prior each survey was included in the final analysis for the year 2006 and 2011 pregnancies were identified using calendar information such as pregnancy outcomes and duration of pregnancy whereas for the year 2001 pregnancies were identified using information such as pregnancy history index and outcome and duration of pregnancy further detail of the survey methodology sampling procedure and questionnaires are reported elsewhere 18 19 20 in all surveys the response was more than 98 study outcome the outcome variable was stillbirth defined as the birth of a baby with no signs of life at or after 28 weeks gestation 1 the outcome was recorded as a binary variable in the data set coded as 1 for stillbirth and 0 for alive at birth information on stillbirth was obtained using reproductive calendar and pregnancy history and outcome of pregnancies exploratory variables the exploratory variables selected for this study were based on previous studies from developing countries 81416 21 22 23 and the information available in the pooled data sets midwestern and farwestern and place of residence the socioeconomic level factors considered were maternal education literacy level occupation paternal education mothers current work status and household wealth index the household wealth index measures the economic status of the household as a measure of household wealth index we pooled the wealth index factor scores in each of the three original individual recode data files as calculated by original dhs the pooled original household wealth index factor scores were then categorised into three the bottom 40 of households was referred to as poor households the next 40 as the middle households and the top 20 as rich households 25 maternal factors encompass maternal age at first birth previous death of a baby mothers current age and maternal marital status we also considered environmental factors consisting of drinking water source and types of sanitation facility for each household classified based on the who and unicef joint monitoring program guidelines 26 based on jmp guidelines we categorized sources of drinking water as piped water on premises other improved drinking water sources unimproved water sources and surface drinking water sources similarly we categorized types of sanitation facility as improved and unimproved improved sanitation facilities included unimproved sanitation facilities were traditional pit toilet pit latrine without slab or open pit and bucket toilet and open defecation statistical analysis frequency tabulations were first conducted to describe the frequency and relative frequency of all potential confounding factors this was followed by calculating the stillbirth rate and 95 confidence interval using the number of stillbirths divided by the number of live births multiplied by 1000 generalized linear latent and mixed models with the log link and binomial family 27 that adjusted for cluster and survey weights were used to identify those socioeconomic predictors associated with stillbirth a staged modelling technique 28 was adopted communitylevel factors were first entered into the baseline multivariable model with manual backward elimination process to keep statistically significant variables with pvalue 005 second socioeconomic factors were added into communitylevel factors associated with outcome variable and those factors with pvalues 005 were retained after backward elimination process was conducted third maternal factors were added into model 2 after applying similar approach as above variables with pvalues 005 were retained in the next model in the final stage environmental factors were assessed with a list of significant variables from model 3 variables with pvalues 005 were retained in the final model only those factors significantly associated with stillbirth at a 5 significance level in the final model were reported in the study in the final model collinearity was tested and reported the analysis was restricted to five years preceding each of the survey a total of 57 missing values were excluded from the multivariate analysis and gllam estimates were translated to relative risk and 95 confidence interval all analyses were performed using stata statistical software version 141 with svy commands to allow for adjustments for sampling weights and cluster sampling design results basic characteristics of the study participants the majority of mothers who reported higher rates of stillbirth were from rural and mountainous areas poor households parents with low levels of education households with unimproved sources of drinking water and unimproved toilet facilities we also noted that mothers whose major occupation was agriculture had more stillbirths compared to those mothers who worked in nonagricultural sectors the prevalence of stillbirth across three ecological zones indicates that the rate was 28 per 1000 amongst mothers who resided in the mountains whereas this rate was 17 per 1000 in the terai and 19 per 1000 in the hills predictors of stillbirth the univariate analyses revealed that ecological zone religion mothers literacy parental level of education currently not working mothers mothers whose major occupation was agriculture mothers age types of drinking water source and types of sanitation facility were all significantly associated with higher stillbirth multivariable analysis revealed that factors associated with stillbirth were mothers in the age bracket mothers who lived in mountains or hills mothers whose religion was hindu muslim christian and others mothers who had no schooling or only primary level of education further we found that mothers whose major occupation was agriculture and those who used open defecation reported higher stillbirth in the final model we removed maternal education level and replaced it with fathers education level the result indicated that stillbirth increased significantly among fathers with no schooling discussion this study reports the predictors associated with stillbirths in nepal by using pooling the three most recent nepal demographic and health survey and found that maternal age low levels of education sanitation and ecological zones were predictors for stillbirth additionally when mother education was replaced by father education in the final model father with no education reported significantly higher stillbirth this current study provides an evidencebase that could be used to inform the design of effective interventions policies and programmes aimed at health professionals and individuals recognising stillbirths primiparity is an established risk factor for stillbirth in both high and low income countries 29 and our results also found this association this study demonstrated that mothers aged 25 years and above at the time of their first birth were more likely to experience stillbirth this finding was supported by casecontrol studies conducted in nepal bangladesh and canada which indicated that older mothers significantly reported higher stillbirth than younger mothers 142230 similarly a hospitalbased study conducted in nigeria also revealed that mothers aged 35 years or older were significantly more likely to report higher rate of stillbirths 31 studies conducted in highincome countries showed a significant relationship between stillbirth and maternal age 7 32 33 34 35 higher stillbirth rate in older women has been attributed to the increase likelihood of congenital anomalies chronic hypertension placenta praevia uterine rupture and breech deliveries in older mothers which may contribute to an increased fetal death 36 37 38 39 studies have also shown that advanced maternal age has been associated with an increased risk of abnormal chromosomes and or decreasing uterine and hormonal function 4041 parental education is considered as one of the important determinants of health previous studies from pakistan and bangladesh reported that education could increase the uptake of health service utilization 4243 with subsequent reduction in stillbirth this study found that women with only primary level of education or no schooling had higher risk of stillbirth compared to those who had secondary or higher levels of education there are very few studies from developing countries that have examined the relationship between maternal education and stillbirth a study conducted in a province of thailand revealed women who had low levels of education were at a higher risk of having stillbirths 44 this finding is also consistent with previous studies from canada and denmark which found that lower level of maternal education was associated with higher risk of stillbirths 45 46 47 plausible reasons for this finding may be that educated mothers are more likely to practice healthy behaviours including health seeking which may contribute to reducing their risk of stillbirth compared to mothers with no education likewise fathers with no schooling were also associated with higher risk of stillbirth our study demonstrated that the risk of stillbirth was significantly higher among women who worked in an agricultural sector similar to a finding from a hospitalbased casecontrol study conducted in the nguyen province of vietnam 44 our finding of higher risk of stillbirth among mothers residing in the high altitude mountains or hills was similar to a retrospective births record obtained from four regional centres in peru which indicated that after controlling for potential confounding factors mothers who lived in high altitude were significantly more likely to report higher stillbirths than those mothers that lived in low altitude 48 whether our finding is related to altitude or access to antenatal and birth service is unknown due to the limitations of the dhs data however literature has shown that management of pregnancy complications through quality antenatal care 49 and provision of skilled birth attendance around labour time 4 help to prevent stillbirth based on these evidences it can be argued that the focused antenatal care as well as targeted skilled birth attendance for women residing in the mountainous region would help to reduce the number of stillbirth our study also found an association between stillbirth and mothers religious affiliation mothers whose religion was hindu and others including muslim and christian reported significantly higher stillbirth compared to those mothers whose religion was buddhist analysis 50 conducted in india using the national family health survey reported differences in child mortality based on religious affiliation in nepal access and utilization of birthing services differs by religious affiliation and this may contribute to the increased stillbirth in some religious groups 51 unimproved water and sanitation contributes 09 to the global disability adjusted live years 52 it is not surprising that women who reported open defecation were at greater risk of stillbirth compared to mothers who reported improved sanitation facilities similar with the finding from a populationbased prospective cohort study conducted in india that revealed open defecation among pregnant women was associated with adverse pregnancy outcomes 53 the study has a number of strengths firstly the analysis was based on nationally representative data thus estimates from this study are generalizable to the nepalese population and can inform national policies and initiatives in nepal secondly the response to the surveys was high reducing a likely chance of selection bias from the observed findings thirdly measurement bias is unlikely to affect the observed results as the data were collected using a standardised questionnaire developed for developing countries including nepal 18 19 20 it is however retrospective data and there may be some bias in reporting stillbirth despite these advantages this study is limited in a number of ways firstly the diagnosis of stillbirth was based on selfreport from mother and is subject to recall and misclassification bias secondly formal verbal autopsies were not conducted on stillbirths finally no information on health services factors or other factors such as tobacco gestational diabetes and genetic abnormality that may have been associated with stillbirth were included in the ndhs data policy implications to close the equity gaps communitybased interventions need to be formulated and implemented in order to improve maternal and child health in nepal at the individual level intervention uptake and quality of antenatal care should be encouraged among mothers from low socioeconomic group and those mothers from hilly and mountainous ecological zones at the community level intervention increase awareness and access to basic and emergency obstetric care to women from hilly and mountainous ecological zones these interventions will improve prevention strategies that could have massive and farreaching improvement on nepalese mothers and children in order for the country to accelerate progress towards achievement of ending preventable stillbirths by 2035 54 conclusions our findings suggest that antenatal care service should be targeted to women from low socioeconomic status and those who lived in the mountainous ecological zone in order for nepal to further reduce the rate of stillbirth to a target of 12 stillbirths per 1000 births by the year 2030 the data was obtained from availabledatasetscfm ethics the dhs project obtained ethical approval from the nepal health research councilkathmandu the first author communicated with measure dhs icf international and permission was granted to download and use the data for his doctoral dissertation with the school of science and health at western sydney university australia and mkn is supported by early career researcher postgraduate scholarship sydney medical school the first author gratefully acknowledges the comments made on first draft by dr amit arora from western sydney university

the nepalese demographic and health survey ndhs data for the period 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 were pooled to estimate socioeconomic predictors associated with stillbirths in nepal using binomial logistic regression while taking clustering and sampling weights into accounta total of 18386 pregnancies of at least 28 weeks gestation were identified of these pregnancies 335 stillbirths were reported stillbirth increased significantly among women that lived in the hills ecological zones arr 138 95 ci 102 187 or in the mountains ecological zones arr 171 95 ci 110 266 women with no schooling arr 172 95 ci 110 269 women with primary education arr 181 95 ci 111 297 open defecation arr 148 95 ci 100 218 and those whose major occupation was agriculture arr 180 95 ci 116 278 are more likely to report higher stillbirthlow levels of education ecological zones and open defecation were found to be strong predictors of stillbirth access to antenatal care services and skilled birth attendants for women in the mountainous and hilly ecological zones of nepal is needed to further reduce stillbirth and improved services should also focus on women with low levels of education

introduction prs 100year anniversary4 passed quietly amid the health crisis caused by the covid19 pandemic and potentially overwhelmed by both the visibility and impact of their work prs first century has brought variety of paradigms theories and themes present as well as in the increase of publications dedicated to the profession whether national regional at times bior trilingual international and interdisciplinary this confirms that pr not only needs constant revisiting revising and reconsideration but does so with consideration to the past present and future the profession too grew tremendously and is expected to continue doing so the size of pr market being projected to reach an estimated 133 billion us dollars by 2027 more than 6 compared to its current revenues the last estimates of the number of people working in pr are from 2006 such expected growth in the current context shaken by crises of many kinds that are increasingly complex and wicked is due to pose new challenges to communication practitioners an online survey carried out by the cipr among uk based professionals in 2021 during the height of coronavirus restrictions found an overhelming number of respondentes to suggest that the pandemic has increased the value and reputation of public relations german practioners seem to agree as they observe an increasing importance of prcomms within their organisations comparing a set of indicators used to measure the internal value of the communication function over 14 years seidenglanz fechner conclude that the crisis caused by the global pandemic has strenghtend prcomms claim for leadership additionally developments in technology work and society will also play a role in shaping the demands and expectations of and towards individual practitioners and the profession itself as a result research and practice have focused more recently on the future of prcomms as well as on the potential differences in expectations perceptions and projections formulated by different age groups considering the long way the profession has come the present study embedded in the german market pursues similar goals theoretical framework the future of pr the concern for the future and development of prcomms has emerged in the 1990s with renewed and more intense interest emerging in the mid2000s it might have been initially linked with efforts to establish pr as an independent profession or as a natural development to the descriptive research documenting the rise of pr degrees this has led on the one hand to the review to educational offers and on the other hand to reflections and assessments of emerging trends this latter focus aimed to provide suggestions and solutions for how to address emerging trends business demands and university degree offerings all aiming to secure the longevity and success of prcomms following her literature review and analysis of 580 departments listing pr courses neff suggested that future program development in public relations curriculum will be most likely led by the communication departments the concept of a management orientation as being the ideal focus for the public relations professional not being satisfactorily established in the literature of the time later studies reviewing the perceived relevance of pr education and its content consistenly pointed out to the need to focus more on research ethics reflecting more on their increasingly strategic role and the continuous globalziation of the profession what research also pointed out at the time were contradictory views especially among practitioners regarding pr education and its role in shaping the profession for example on the one hand employers perceive public relations education as over theoretical and lacking practical application on the other it is blamed for failing to instill the analytical flexibility found in nonpr graduates this has thus resulted in industry led initiatives aiming to establish benchmarks for the practice it is in this context that global alliance commissioned the global body of knowledge project aiming to identify the knowledge skills and abilities of pr practitioners depending on their role and career level an international project in its nature what the gbok also implied is that professionalization of pr remained a concern from here two different areas have emerged both future related one aims to ensure the professional status of pr is attained and maintained the first includes capturing the reflections of practitioners themselves about their own field and practice while the second investigates the context in which pr exists and the trends influencing its application here too some common areas of concern emerge vuca superwicked problems trust in the profession and in organizations polarization of society and technological developments more particularly digitalization social media and artificial intelligence each of these topics is then reconsidered within the context of communications practice in 2023 the edelman barometers main finding is that distrust breeds polarization usc annenberg center for public relations report shares similar findings 77 of the respondents agreed with the statement polarization is bad for the country which is bad for our company with 61 of the respondents attributing polarization to partisan media outlets communicators predict that organizations will increase their public engagement in dialogue around one or more social issues with 83 of them agreeing or somewhat agreeing that business has a powerful platform it can use to speak from on important issues thus the report suggests that professional communicators are the pioneers in this unfamiliar territory 93 are spending more time navigating a growing list of complex societal topics based on examples like procter gambles likeagirl campaign in 2014 patagonias documentary damnation and paypals and deutsche banks decisions to cancel plans involving business operations in charlotte north carolina after the state passed an antilgbtq law known as house bill 2 in 2017 one can expect businesses to become more vocal and visible in social issues both reports agree on the future directions of concern and potential focus for communicators and maintain the same points made by research into pr education twothree decades earlier trust ethics research measurement and evaluation all on an increasing background of volatility and complexity and a higher expectation of responsible involvement from businesses adi s pr2025 study took the questions about the future of prcomms further inviting participants to reflect on how they perceived their role as communicators and then to identify the trends that they considered influential for the profession in doing so participants were then invited to focus on the solutions in this case competences attributes responsibilities and frameworks to ensure appropriate preparation and response in identifying that technological and digital changes are of concern for the near future prcomms practitioners agreed that it is digital literacies and associated ethics that are of more value as learning focus in the future rather than specific platforms equally guaranteeing both time and budgets for learning is what it was suggested it was needed the most to ensure success demographics and generational divides the multiple crises of our time are likely to create shared experience that could be defining for the current adolescents the same was true for the old generation adolescents as baby boomers were shaped by the postwwii prosperity generation y by the invention of the internet and generation z by the ubiquity of the digital world as a result of the same historical political technological cultural and social conditions under which they grew up age cohorts developed similar characteristics in which they differ from other age cohorts that exactly is the main idea behind the social generation concept empirically speaking the generation is a nondisputed variable identified and coded based on selfreported age groups andor year of birth the distinctions between digital natives and digital immigrants those who grew up with internet and digital technology and those who did not respectively have been widely recognized several studies have suggested that there are similarities between different generations within the digital natives group nonetheless generation z differs considerably from its predecessor generation x more than it does from generation y members of generation x tend to be more individualistic sophisticated and hedonistic than previous groups and they seek engagement in tasks they find meaningful interesting and varied these characteristics have implications for their perceptions of their profession and its organizational and societal role as well as for their work expectations and desire for recognition consequently generation x represents a highmaintenance workforce requiring a leadership style that klein has characterized as helicopter management while some researchers view these generational categorizations with skepticism and others even reject the concept in pr research they are rarely questioned or critically considered in fact even when focusing on generational research and differences the focus stems either from generational bashing and interactional frustrations with one particular group the millennials the present study aims to address the frustrations in the field of pr by critically examining a specific agedefined group the likely next generation of pr leaders specifically this study focuses on germanspeaking pr and communications practitioners aged up to 35 who will potentially assume leadership roles and shape the profession in the upcoming years hence the focus on the near future but also on future as in desirable and ideal to investigate their professional attitudes behavior and opinions the research question reads as follows how do young prcomms professionals in germany view their profession today and in the future research framework the study draws upon occupational area research such as the latest editions of seidenglanz and fechner and zerfass et al as well as the tradition established by pr2025 the study explores four aspects of how the next generation of prcomms professionals act think about and reflect on their profession the study presented here aims to explore and build upon the concerns surrounding the pr profession by critically approaching a specific agedefined group within the industry the likely next leadership generation the population under investigation consists of all germanspeaking prcomms practitioners aged up to 35 to explore their professional attitudes behavior and opinions the study draws upon occupational area research and the tradition established by the pr2025 study in doing so it formulates 4 research theses guiding the analysis aimed to facilitate the understanding of the views and expectations of young germanspeaking professionals • research thesis 1 practitioners aged 35 and younger will consider vuca and its postpandemic version bani as shaping their work and the future profession both vuca and its postpandemic version bani were identified in previous studies as shaping and influencing the profession • research thesis 2 building and maintaining trust will be considered a major challenge by young prcomms professionals who recognize the influence of vuca and bani on their work • research thesis 3 young professionals perceive their current occupational practices to be lacking in social focus and they envision for the future a higher focus for such issues this is thesis links and explores argument about prcomms still not meeting all the requirements a professional status • research thesis 4 young prcomms experts will consider flexibility and a balance between work and private life as the most important factors when choosing an employer further details about their respective family status will be inquired to check the appropriateness of generational generalizations methodology the current study was part of a much wider research project study a standardized questionnaire was used to explore the research questions and looking more closely at the appropriateness of research theses a listbased online survey was thus implemented data collection took place between the 17th of may and the 10th of july 2022 and produced 160 completed answers the sampling for this research was purposive the databases used to recruit the participants were provided by the german prcomms association quadriga university of applied sciences and quadriga media all invited participants indicated previously that they would be interested and willing to support any research carried out by either organization having cleared the ethics disclaimers and demographic questions all participants indicating that they were 35 years of age and younger proceeded with questions about their employment expectations challenges facing prcomms the purpose and role of the profession 111 of 160 respondents identified as female 37 as male and one as diverse 5 most of them exactly two thirds work for companies with an average age of 31 years at least two of three live in a relationship but only a few already raise children overall there is no indication that the characteristics of the sample vary considerably from the population that is young prcomms professionals aged no more than 35 years due to the nature of the sample which is outlined above no claim of representativeness can be made consequently the means of inferential statistics cannot be applied instead the benefit of this study lies in its focus on a younger demographic which is likely to take over leadership roles in the profession in the upcoming years and critique the variables so far taken for granted in previous studies including their assessment of desirable and ideal practices like with the pr2025 study the projection of upcoming trends and portrayal of the ideal future is seen as a proxy to desirable behavior the use of descriptive statistics to evaluate the data is thus the most appropriate in this case results rt1 vucabani all participants of the study have been confronted with eight descriptive statements operationalizing if and to which extent phenomena associated with vuca and bani are visible specifically within their own prcomms practice the task given was to indicate their level of agreement considering the current status quo on the one hand and the future situation on the other the mean scores for agreement are higher for the vuca dimensions this means that despite the impact the pandemic and global health crisis bani items have received less agreement stakeholder relationships are still considered stable and not brittle causes and interdependencies in public communication are generally comprehended and the impact of communication measures can still be predicted albeit a few uncertainties only a considerable degree of anxiousness among stakeholders operationalized by the baniitem the complexity of public communication has made stakeholders increasingly uneasy is identified as a more serious issue participants consider the accelerating change of public communication that means volatility of societal developments as most pertinent trend and thus potential threat other development typically associated with vuca that is more complexity uncertainty and ambiguity are also considered relevant moreover nearly identical mean values for uncertainty ambiguity and anxious could be related to the increasing complexity of prcomms work source own elaboration finally mean differences between the status quo and the expected situation after five years are not major all items record a higher agreement for the forwardlooking statements indicating that participants expect all aspects of vuca and bani to be exacerbated in the future both the average vuca and bani scores confirm vucabani as current and future phenomena and thus relevant for the prcomms profession however the next generation of practitioners does not predict a change from vuca to bani as the average vuca mean score remains well above its bani counterpart specific challenges participants were asked to rank the most crucial challenges in the prcomms field the results showed that most practitioners considered establishing and maintaining trust as the top challenge with an average rank of 28 this was followed by communicating the environmental responsibility of organizations in social economic and environmental contexts and creating transparency with regard to organizational actions and explaining the respective contexts the challenge related to fast and flexible adaptation of stakeholder communication to constantly changing circumstances ranked fourth source own elaboration rt3 objective and purpose of prcomms participants were asked to assess the current status quo and their possibly idealisticexpectations for the objectives and purpose of prcomms the results revealed that building public trust was seen as the second most soughtafter task of the profession with a mean score of 44 out of 50 the predominant objective identified was providing public information which scored slightly higher notably young practitioners believed that the prcomms industry is currently doing too little to bring society together as reflected in their desire to promote social cohesion the mean values for public information building public trust establishing transparency and promoting social cohesion increased between 02 and 09 when considering the ideal state in the future these findings indicate that young german practitioners view prcomms as having a crucial role in creating a more cohesive society while the relevance of organizational objectives might decrease in the future they still hold value building organizational reputation and trust scores 45 on first question but only 43 on second same goes for avoiding negative organizational publicity and persuasion in the organizational interest other items such as balancing the organisations and external stakeholders interest and creating dialogue opportunities for external stakeholders on the other hand gain significance for the next generation between the desire for intrinsic values and the extrinsic motivation of a wellpaid job the next generation of pr professionals demonstrated both a progressive and a hedonistic approach when selecting an employer they valued employerprovided training for skill development flexible working hours career opportunities and sufficient free time the compatibility of family and career was more important for practitioners with children compared to those without children table 4 relevance of criteria for choosing an employer question what criteria were decisive for you personally when choosing your current employer assessments measured on a scale from for not relevant at all to crucially relevant in summary young practitioners in prcomms prioritize intrinsic values and seek a pleasant work environment they also value a balance between work and personal life while organizational objectives still hold relevance the next generation intends to bring a more societal focus to the profession discussion the current study confirms that vuca dimensions explored in studies like pr2025 remain of concern even for younger pr practitioners more specifically the comparison with a study conducted four years earlier by bentele seidenglanz fechner shows some interesting developments although it has to be noted that the latter sample represents prcomms professionals of all ages taking this potential bias into account all vuca items are deemed more relevant today as they have been back then this confirms the pertinence of the associated phenomena moreover volatility became by far the most relevant aspect of the theory indicating a steady acceleration of communication finally this highlights the need for practitioners their departments and organizations to pay more attention to wellbeing to cope and address potentially higher stress levels a change in mindset is also noted among the sample of this study while trust and transparency are topofmind topics that younger practitioners share with their more senior colleagues it is their focus on and concern with sustainability that sets them apart which corresponds with the findings of various nonprcomms related studies investigating generations y and particulary z such as beckers et al or first insight clearly progressive attitudes affect how young practitioners see the purpose and mission of the pr profession as well nevertheless the intent is not to reinvent but to change the focus of the profession in the direction of more societal contribution is obvious in fact the reported status quo for prcomms objectives very much aligns with a previous study which evaluated the whole profession regardless of age young german practitioners do not dismiss prs organized persuasive work but strongly believe that social cohesion and transparency should have more weight within the professions work which justifies making stakeholders a priority this also echoes both bleiles projections of prcomms becoming a tool at the publics disposal with the best communicators working for the public to provide value and legitimacy and adi and stoeckles call for a more accountable and responsible pr practice the potential change young communicators might bring to the profession has to be viewed at in the context of another observation typically for generations y and especially z the personal pursuit of happiness becomes a central issue when deciding for a job and choosing an employer although idealistic values certainly do matter the hedonistic attitude makes them look for a pleasant work occupation where they can do their own thing are getting paid well and still enjoy a beneficial balance between work and private life a contradictory situation which plastino generally observes within that particular age group interestingly life situations also seem to also play a role here as priorities seem to change once pr practitioners become parents hence it is not impossible that other factors as well may result in a change of attitudes overall although this study is able to identify a few clearcut trends there is still a lot of riding on the future of prcomms conclusions this study offers insights into the future developments and trends of the prcomms profession in germany as perceived by 160 young professionals who represent the potential next generation of prcomms leaders the findings show notable difeerences between the current state of the profession and its desired state particularly in relation the purpose and organization of the profession the participants have demonstrated an idealistic mindset driven by the pursuit of personal fulfillment worklife balance and financial stability however family circumstances can potentially influence this approach the study also confirms the relevance of vuca characteristics in the profession while participants acknowledge that the field has not fully entered the bani territory characterized by complex and unpredictable public communication they anticipate increased challenges in the future limitations the nature of the sample and sampling method obviously limit the degree to which the presented results can be generalized statistical representativeness thus cannot be claimed which is a limitation faced by much of the current prcommsrelated surveys research fatigue increased workloads and difficulty maintaining respondent databases that are gdpr compliant being contributing factors despite this the study offers a unique opportunity for research on a specific subgroup within the prcomms profession moreover the results do echo the findings from other studies indicating to a developing mood and a set of common concerns shared by young communicators looking in the crystal ball is always problematic this is especially true for surveys with forward looking questions it is just not within the capacity of the human brain to predict future behavior precisely and reliably complicating the situation some of the questions trigger a social desirability bias so what is measured are intentions based on limited sample which only allow conclusions for likely tendencies moreover the hedonistic attitude which became apparent while exploring the deciding factors when choosing an employer cannot be underestimated and may lead to a more pragmatic and less progressive approach to prcomms among some practitioners nevertheless since advocacy for more reflective transparent accountable prcomms practice is shared widely the assumption that idealistic values among the next leadership generation prcomms will lead to a change of the profession within the foreseeable future seems realistic but the degree of change probably will be less obvious as todays data suggest further research having reflected the limitations future research should continue to challenge and explore these generational aspects while also integrating other variables first language country of birth vs country of residence personal values preferences additionally more regional and national data including more european data is still highly needed methodologically it would make sense to explore the attitudes behavior and opinions of the next prcomms generation more deeply using qualitative techniques such as single indepthinterviews focus groups or delphi designs source own elaboration rt4 decisive factors choosing an employer to understand the factors influencing the choice of an employer participants were asked about the criteria that were decisive for their current employer the results indicated that intrinsic values were prioritized with a high importance placed on a pleasant work atmosphere and assuming responsibility and decisionmaking freedom the compatibility of the organizations purpose with personal values was also deemed important however there was a conflict

this study investigates the perceptions of young prcomms professionals in germany regarding the professions current and future state amidst the significant impact of the covid19 pandemic on the job market the research builds on previous studies exploring the future of work and the pr industry aiming to address gaps in literature regarding generational differences in attitudes and a critical reflective approach the study used a standardized survey and purposeful and snowball sampling methods to select 160 pr practitioners under the age of 36 the results reveal that the next generation of prcommunications professionals values intrinsic and idealistic factors when choosing an employer but those without children pursue a more hedonistic agenda respondents perceive themselves as dealing with the ramifications of a vuca volatile uncertain complex ambiguous world and consider trust as the most significant challenge within the next five years the study highlights a significant gap between the societal and internal dimensions of prcommunications and its actual implementation the implications of the study suggest a need to address contentious questions surrounding the role and mission of prcomms in society focusing on social impact and social value and advocating for more collaborative and interdisciplinary approaches in training and learning practices

introduction during the last 15 years adolescent birth rates have decreased dramatically in the united states despite declines since the mid1990s latina teens have maintained higher birth rates than black and white teens in 2009 although californias latina teen birth rate was below the national average for latina teens it was nearly two times higher than the average teen birth rate in the state that same year 72 percent of all teen births in california were to latina adolescents numerous factors have been identified as influences on adolescent childbearing including contraceptive access and method choice sexual partnership characteristics social and cultural norms regarding teen childbearing and parentchild communication and parental monitoring socioeconomic disparities and poverty at the individual household and neighborhood levels consistently have been found to be associated with teen pregnancy and sexual decisionmaking the weathering hypothesis which attributes adverse health outcomes to cumulative exposure to socioeconomic and political inequities offers one theoretical explanation that may underlie these associations adolescents future discount rates affected by perceived life chances has been hypothesized an alternative explanation of health behaviors likewise acculturation the process whereby immigrants and children of immigrants adapt to multiple cultural and social norms in their home and community environments may be a particularly influential factor for latina youth such findings suggest the potential importance of addressing structural factors that shape the environment in which youth make decisions about their futures including decisions around childbearing socioeconomic opportunities measured as educational and career aspirations and expectations as well as by poverty indicators have been shown to affect the reproductive health of us adolescents adolescent girls with low educational expectations are more likely to become pregnant and to give birth than girls with high expectations youth with aspirations for the future are more likely to abstain from or delay intercourse and to use contraception if sexually active parents educational expectations for their daughters are associated with adolescent sexual behavior and pregnancy occurrence with national data documenting that low parental expectations are tied to higher likelihood of teen pregnancy and childbearing one qualitative study conducted with latino parents concluded that although parents preferred that their children defer childbearing to permit greater educational opportunities the value placed on the role of motherhood and the attention given to teen mothers sent conflicting messages to their daughters other research suggests that latina teens may view childbearing as motivation to achieve educational and occupational success or as a way to develop in a social environment that offers few alternative opportunities for the transition to adulthood however few studies have focused on how socioeconomic opportunities influence latino teen childbearing a relationship that may be uniquely shaped by immigration and acculturation family environment and cultural norms in response to the persistently high rates of teen births among latinas and a need for improved understanding of socioeconomic and racialethnic disparities in teen childbearing we conducted a qualitative study examining contextual influences on pregnancy and childbearing among pregnant foreignand usborn latina adolescents in two california counties we included a comparison group of young latina adult women in the same communities who had delayed childbearing until adulthood our primary objective was to explore how individual and family educational and employment aspirations and expectations affected teen childbearing among young latina women further we assessed how contextual factors family immigration and subsequent acculturation shaped these relationships methods sixtyfive pregnant foreignand usborn latina women ages 15 to 19 or 22 to 35 were recruited at eleven communitybased clinics or health education programs in los angeles and fresno two california counties with high teen birth rates all participants were pregnant with the first child they planned to carry to term and were in their second or third trimester of pregnancy all research activities were approved by the california health and human services agency committee for the protection of human subjects and by the committee for human research at the university of california san francisco a detailed description of the studys methodology and analytic approach has been published elsewhere and entered into qsr nvivo software the qualitative analytic work was organized first by structural codes corresponding to study questions subsequently a list of emerging thematic codes was identified and refined through iterative reviews of study transcripts structural coded sections and memos produced by the research team for this paper the research team analyzed text corresponding to two thematic codes 1 educational and employment aspirations and expectations including subthemes related to school commitment and participation childbearing and socioeconomic aspirations and expectations and barriers to education and 2 influences on aspirations and expectations results study population characteristics the 65 study participants were evenly distributed between fresno and los angeles and between usand foreignborn women expectations for education and employment influences on teen childbearing nearly half of teen respondents experienced a common trajectory during their early teenage years that involved a gradual disengagement from and disinterest in school prior to their pregnancy a handful of teens had already left high school to complete educational requirements through home study or continuation school for usborn teens and youth who immigrated to the us prior to adolescence this trajectory was influenced by environments largely void of economic opportunities a number of teens described pregnancy as a motivation to focus on education and career and as presenting them with an opportunity for maturation one teen described her pregnancy as a positive influence on her development i feel that ill actually have a life now cause before it was just fun and games now ill have a responsibility adult respondents in contrast were more likely to describe high school as an enjoyable place where their ability and intelligence were recognized and as a critical step in achieving future educational goals furthermore they tended to describe teen pregnancy as an event that would have interfered with their educational and career development i had goals way before i was even thinking about kids…i would think if i had a kid right now i wouldnt be able to go to school i wont be able to become a doctor that i wanted to be some adults recognized that as teens childbearing constituted an important goal however they noted that their own education was critical to their success as a mother as one respondent stated my main goal was the family but i thought if i didnt educate myself first how was i going to educate my children future aspirations of several recent immigrant teens were shaped by traditional gender norms that aligned their education and childbearing trajectories with those of teens in their communities of origin these respondents articulated low employment expectations resulting in reduced emphasis on schooling this was sometimes directed by their male partners who supported them in completing high school but had stated clearly that they could not work and develop professionally furthermore for some recent immigrant youth early childbearing was regarded as typical in their home country and the later teen years ages 17 18 19 were considered an appropriate life stage for pregnancy educational goals as a consequence were sidelined family expectations for education and employment influences on teen childbearing most respondents stated that education was important to their families however expectations for the level of educational attainment and the support provided by parents varied between teen and adult respondents whereas about half of teens noted that their parents expected them to complete high school adults commonly reported that high school graduation was considered by their parents to be a given rather than a goal and most families supported education beyond high school adult respondents generally reported they had more familial support available to them during their teenage years then did teen respondents and related specific examples of how their parents provided emotional and tangible support in school emotional support included encouraging school attendance vocalizing the desire to see their child succeed and warning teenage daughters about the challenges of finding employment without a good education tangible support included assistance with homework meeting with teachers and school staff and helping with school paperwork and applications one usborn adult commented how her father contributed quite substantively to her learning i remember my father always showing interest in my schoolwork he always wanted to read my writing assignments…he looked so forward to when it was time to do projects because it got his creative mind going…hed sit down with me and wed come up with incredible ideas though some teens remarked that their parents advocated education my mom and dad always push me to go to school and tell me that if i want to have a good life that i will have to go to school others all usborn commented explicitly that their parents expressed little interest in their life or future as stated by one usborn teen my dad was abusive…he couldnt take care of us cause he had like three or four other jobs he was never there for us i was basically taking care of my brothers and sisters he would be out in the streets until one 200 in the morning foreignborn adult and teen respondents particularly those who had immigrated to the us prior to adolescence articulated a strong influence from parents to attain a college education and to take advantage of opportunities presented to them by their having immigrated to the us among teens for example nearly twothirds of foreignborn compared with onethird of usborn respondents indicated expectations from their parents to obtain higher education a foreignborn adult reflected on how her parents encouraged education as a way to achieve a more secure future when i was a teenager my parents took me to the fields to see how you earn money…to work in the fields i didnt like it and that kind of encouraged me more to go to school and have a better future however having a parent place tremendous value on education was insufficient alone in ensuring teens achieved their educational goals and delayed childbearing immigrationand acculturationrelated barriers presented obstacles for some to actualize these goals which ultimately affected childbearing immigration influences on education effects on childbearing legal and linguistic barriers were cited by many pregnant foreignborn teens as inhibiting educational attainment and perceived professional opportunities for teens who immigrated during adolescence immigrationrelated factors constituted a primary influence on shifts in educational expectations and attitudes toward school motherhood therefore constituted a viable alternative immigration laws that limit access to financial aid and higher education also presented constraints as one foreignborn teen who had lived in the us since childhood stated it is really hard…for latinos…especially people that dont have papers you know you do want to finish high school but going to university or college…its difficult cause you don got papers you dont got money to pay the college language barriers constituted a second challenge for participants who immigrated to the us during their teenage years an 18yearold participant who moved to the us at age 15 highlighted the challenge presented by linguistic barriers i didnt want to go to school anymore i was embarrassed because im an adult already and i didnt speak any english for some youth who immigrated as teens immigration itself disrupted their schooling these youth described difficulties in acculturating to a new social environment coupled with lack of english comprehension and language skills in the classroom ultimately limiting their ability to sustain previously high educational performance finally reasons for immigration were noted by several teen participants as contributing to low educational expectations upon arrival in the us and likely affected early childbearing family influences on education effects on childbearing economic instability within the family household disruption due to parental separation or divorce and family care taking responsibilities presented great stressors on teens foreignborn teens in particular these barriers were prompted frequently by immigration itself or by movement between relatives households after arriving in the us as one foreignborn teen commented after her move it was just my mom and myself and when we got there she couldnt find a job and we didnt have anyone else there who could help us out and i tried to find a way to help her too in that way so i looked for temporary jobs as a way to earn money family reunification of adolescent children and their parents highlighted by one teen who had been raised by her grandmother in mexico and then moved to the us to live with her mother at age 13 highlighted the potential complexity of reconciling a parentchild relationship alongside adapting to a new country of residence other immigrant teens had to assume substantial childcare responsibilities for extended family members which interfered with their ability to stay in school as an immigrant teen whose cousin had two children reported my cousin would watch one of the kids and i would watch the other one this directly inhibited her ability to attend school regularly in contrast family instability due to illness neglect substance use and incarceration presented substantial challenges for usborn teens in attaining their educational goals these issues rarely surfaced as major educational barriers for adults one usborn teen commented on why her mothers illness prompted her to drop out of high school i guess because my mom needed somebody to be with her at the house and she wouldnt have nobody and i would be like the only one that will help her around like to cook and stuff another statement underscores the level of familial disruption faced by some usborn teen respondents well my dad…he used drugs a lot hes in prison hes in there for life my mom…we never got fed and she always had different guys over and just she wasnt really a good mother discussion pregnant latina teens in this study described few tangible socioeconomic opportunities thus for many teens pregnancy even when unintended offered an opportunity for a meaningful transition from adolescence to adulthood despite general family support for education teens faced substantial socioeconomic and family barriers to achieving their educational goals for foreignborn teens legal and linguistic barriers predominated with immigration itself prompting disruption in household and socioeconomic stability for usborn teens lack of emotional andor tangible support from family as well as instability within the household presented substantial challenges to educational attainment many of these factors reflect underlying household and neighborhood poverty that shaped the more proximal determinants of early childbearing including pregnancy intentions and ambivalence and patterns of contraceptive use many teens felt that while their family members generally supported their educational and career goals they lacked the knowledge and skills to help them realize their goals in contrast relationships with engaged and communicative parents during the teen years helped many adult latinas defer childbearing until adulthood previous literature underscores the importance of engaging parents in their childs education throughout adolescence yet this study highlighted distinct barriers to achieving this goal for usborn teens in particular such an approach would require consideration of family structure and neighborhood instability due to economic insecurity substance use and community violence and the effects these environmental factors have on childbearing perceptions and desires within the life course for foreignborn teens such efforts would need to address linguistic and legal barriers to education we found variability in the factors affecting educational attainment and childbearing outcomes within the foreignborn population represented in this study different acculturation trajectories appeared to account for some of this variation participants who had immigrated as young children tended to report receiving strong family support for their education often because their families migration to the us was motivated by their parents desire to improve their childrens socioeconomic opportunities in contrast gender norms expressed by some more recent immigrants favored childbearing over education and career particularly among teens and young women who were already married other recent immigrants articulated strong values for education but noted financial and linguistic barriers that inhibited their ability to attend high school andor continue career training they might have begun in mexico these findings highlight the importance of tailoring pregnancy prevention programs including those that address socioeconomic opportunities to the diverse range of norms and experiences reflected in the population of foreignborn adolescents us immigration policy also has an important effect on the educational experiences of latinos residing in the us the federal dream act which would permit states to provide instate college tuition for students without regard to immigration status grant conditional permanent residency and permit later naturalization addresses a structural barrier to educational opportunities faced by immigrants without permanent resident status several study limitations should be noted first adult respondents were asked to report retrospectively on their educational experiences and parental attitudesresources during their teenage years thus we focused comparisons on issues that would be less subject to recall bias second to protect participant confidentiality we collected little information on the circumstances of migration and the reasons for immigrating to the united states which likely influenced individual acculturation as well as family structure and its effects on setting educational and career expectations third study participants were volunteers from a clinic population predominantly and we were not able to assess the representativeness of study participants compared to all pregnant women seeking prenatal services at the study sites therefore results of this qualitative study should be considered descriptive and exploratory this study offers an indepth examination of contextual factors that affected perceived socioeconomic opportunities and childbearing among latina teens in two california counties the studys results support a need to provide tangible future opportunities for latina youth by promoting youth development strategies strengthening educational resources for youth and their families and encouraging youths educational and career development as a strategy for reducing teen childbearing though immigration presented distinct structural and cultural barriers to education that appeared to influence teen childbearing the fundamental lack of hope for educational achievement and professional development was profound comprehensive pregnancy prevention efforts that address youths socioeconomic and family environments including factors affecting immigrant adaptation and acculturation constitute a critical area for intervention b parental educational attainment when the participant was 1314 years olddoes not sum to 100 owing to participants who reported not knowing their parent educational attainment

backgroundthe decrease in adolescent birth rates in the united states has been slower among latinas than among other ethnicracial groups limited research has explored how socioeconomic opportunities influence childbearing among latina adolescents methodswe conducted indepth interviews with 65 pregnant foreignand usborn latina women 31 adolescents 34 adults in two california counties we assessed perceived socioeconomic opportunities and examined how family immigration and acculturation affected the relationships between socioeconomic opportunities and adolescent childbearing resultscompared with women who delayed childbearing into adulthood pregnant adolescents described having few resources for educational and career development and experiencing numerous socioeconomic and social barriers to achieving their goals socioeconomic instability and policies limiting access to education influenced childbearing for immigrant adolescents in contrast family disintegration tied to poverty figured prominently in usborn adolescents childbearing conclusionlimited socioeconomic opportunities may play a large role in persistently high pregnancy rates among latina adolescents

introduction more than 10 million prisoners are available worldwide and approximately 30 million prisoners are released annually more than 7 million prisoners are living in lowincome and middleincome countries comprising about 70 of the worlds total prison population many of whom are imprisoned due to drugrelated crimes about 225000 iranian prisoners are above 18 years old with 391 of them being female while under18 yearsold prisoners are kept in the juvenile correctional and rehabilitation center the number of prisoners differs from one country to another and it is difficult to compare the number of criminals in different societies because police and judicial institutions in every country have different rules for imprisoning criminals and their rules may change with the passage of time the number of male prisoners is much higher than that of females all over the world moreover the pathways to prison differ between male and female and sociopsychological problems hiv prevalence and related risk behaviors such as drug injection among male prisoners is higher than that in female prisoners therefore it is important to study male prisoners prisoners are vulnerable to multiple problems with many restrictions and deprivations in prison adding to these problems they suffer from poor relationships and social rejection because of the norms and subcultures in prison and separation from the family such problems decrease their personal and social adjustment as well as their mental health and safety but some prisoners are efficient and young and must return to social environment after their release prison is a potentially important stressor in either the formation or exacerbation of prisoners psychological problems such as low level of psychological wellbeing psychological wellbeing is among the most important determinant of global wellbeing and health of prisoners the pwb is defined as an attempt to realize ones potential capabilities and includes six characteristics of positive relationships with others selfacceptance personal growth purpose in life environmental mastery and autonomy which indicate ones mental balance and health wellbeing generally predicts a variety of vital outcomes including a sense of life satisfaction and greater success in job and relationships studies have shown prisoners low level of pwb so its assessment in prisoners is important because they are vulnerable poor family cohesion contributes to ones diversion and criminal behavior delinquency and consequently imprisonment upon entering prison this problem has destructive effects on family relationships family cohesion a determining factor for pwb is defined as the emotional bond between family members fc is associated with adolescents internal and external problems and predicts their future behaviors external psychological symptoms such as academic failure isolation violence and hyperactivity and internal symptoms such as anxiety and depression may also transmit to adulthood imprisonment seriously disrupts planning and purpose in life pl is a positive structure that can better predict and promote wellbeing pl is an important religious philosophical and psychological topic and has various definitions in different fields however it is usually defined as ones sense of function and meaning in life purpose in life and meaning in life are often used interchangeably a review of the literature showed that pl was an important and positive personality trait and predicted health outcomes as well as a higher level of pwb in present and future goodman et al showed a significant positive relationship between family attachment and pl in men and women alhussain et al reported a significant relationship between pwb and fc in young people another study on students showed that the higher the fc the higher the pwb problems of prisoners are usually ignored and neglected by community health nurses and social workers who can render professional services to prisoners and their families by assessing the pwb fc pl and their interrelationships they also can design social work interventions and educational programs to increase the pwb fc and pl given the cultural and contextual nature of these factors studies are required in different communities to design comprehensive educational interventions no study has simultaneously examined the three variables of pl fc and pwb in prisoners most of the studies mentioned above were conducted on nonprisoners and those who had clear differences with prisoners so the current study aimed to evaluate pwb fc pl and their correlations in male prisoners in iran materials and methods design and settings this crosssectional study was conducted on male prisoners in a large prison in southeastern iran sampling the target population of this study included all prisoners aged above 18 years old who were available at the time of the study according to cochrans formula the sample size was 252 people with about a 5 probability of dropout 265 male prisoners were selected using simple random sampling inclusion criteria included prisoners who could read and write to complete and understand the concepts of the questionnaires were imprisoned for at least 6 months had at least one member family and declared no acute mental and physical illnesses at the time of data collection the first researcher selected samples using simple random so he prepared the list of prisoners and recruited the samples using random number table data collection and instruments data were collected using anonymous selfreported and paper questionnaires from march to may 2021 to collect data the first researcher referred to the study setting distributed the questionnaires among the eligible participants and explained the study objectives he also trained prisoners on how to fill out the questionnaires finally 259 prisoners completed the questionnaires and six prisoners did not complete questionnaires four tools were used in the current study demographic information questionnaire it includes age education nationality occupation number of marriages length of stay in prison history of imprisonment history of drug abuse and its type history of mental illness psychiatric drugs and smoking and type of crime ryff psychological wellbeing scale ryff developed this selfreport scale in 1989 the short 18item pwbs with six subscales was used in this study selfacceptance autonomy positive relationships with others purpose in life personal growth and environmental mastery ryff confirmed the reliability of the original version of pwbs using cronbachs alpha coefficient as well as its validity through content validity researchers confirmed the reliability of the persian version of this questionnaire using cronbachs alpha coefficient and experts confirmed its validity the pwbs is scored based on a sixpoint likert scale including strongly agree somewhat agree a little agree a little disagree somewhat disagree and strongly disagree the total score in this questionnaire is between 18 and 108 with scores of 1848 4978 and above 79 considering as poor moderate and favorable pwb respectively family standardized cohesion questionnaire fischer et al developed this questionnaire as part of the california family health project the questionnaire has 13 items and four dimensions including cohesion cooperation clarity of rules and leadership in the family the questionnaire is scored based on a sixpoint likert scale ranging from strongly agree somewhat agree a little agree a little disagree somewhat disagree and strongly disagree fischer et al reported the internal consistency of the original version to be 078 using cronbachs alpha experts confirmed the validity of the persian version of this questionnaire and its reliability was above 070 using cronbachs alpha method in this study scores of 02 24 and 46 were considered as poor moderate and favorable fc respectively purpose in life questionnaire krombugh and maholick developed this scale in 1969 to measure individuals sense of purpose or meaning in life the questionnaire consisted of 20 items and participants chose one answer between one and seven scoring type and content of the items in this questionnaire are different with the subscale of purpose in life of pwb in this questionnaire the minimum and maximum scores are 20 and 140 with scores of 2060 60100 and 100140 considering as poor moderate and high pl respectively the reliability coefficient of the original version of pil was 088 using cronbachs alpha coefficient the questionnaire has content validity based on frankls logotherapy theory a study on 250 iranians reported that the reliability coefficient of the persian version of the pil questionnaire was 092 using cronbach alpha the validity of the persian version was confirmed by studying the correlation of its scores with life satisfaction vitality and positivenegative affection data analysis the data were analyzed by spss 21 first data normality was determined by the kolmogorovsmirnov test regarding the normality of quantitative data the pearson test and multivariate linear regression were used the significance level was considered 005 results demographic information majority of the participants were 2040 years old married iranian and had diploma table 1 shows all demographic information of the male prisoners description of pwb fc and pl the results showed that the total mean pwb score of the male prisoners was moderate with purpose in life subscale and environmental mastery subscale receiving the highest and lowest mean scores respectively the total mean fc score of male prisoners was moderate with the clarity of rules and cohesion subscales receiving the highest and lowest mean scores respectively the total mean pl score was moderate in male prisoners the item i wasted the rest of my life after retirement i did the most exciting things i ever wanted to do received the highest mean score while the item i am very responsible i am very irresponsible received the lowest mean score correlation between variables the results of this study showed a direct correlation between male prisoners pwb and fc scores but pwb had no significant correlation with pl score in addition fc score was not significantly correlated with the pl score all dimensions of pwb had a direct correlation with fc except for positive relationships with others in addition all dimensions of fc had direct correlation with pwb none of the pwb and fc dimensions were related to pl regression analyses the multivariate linear regression showed that fc marital status and length of imprisonment were the significant predictors of pwb therefore married prisoners with a higher level of fc and imprisoned between 6 months and 2 years had higher scores in pwb discussion the current study showed moderate pwb fc and pl as well as a direct correlation between pwb and fc in male prisoners one study on young prisoners in iran supported our results and reported moderate pwb of the male prisoners modarres et al indicated that counseling and training were effective in promoting mental health indicators among prisoners they believed that prisons were not closed and passive environments and do not merely seek to punish individuals rather they considered other aspects of their lives such results may be due to the organizational goals of prisons including therapeutic psychiatric social work rehabilitation and correctional activities in prisons therefore relevant experts perform a wide range of activities such as cultural religious artistic scientific and vocational programs which can be effective in improving the pwb of prisoners in addition the factors and conditions that prisoners deal with before imprisonment may affect their pwb as pwb develops over time it can be concluded that prisoners have suffered psychologically before their imprisonment moreover depending on the psychological and personality characteristics of prisoners they might have had various exciting experiences in their past lives purpose in life the pwb subscale received the highest mean score which may be due to the type and content of the items in this subscale for example sometimes i feel i have done everything in my life indicates that the prisoners are constantly worried about employment family financial status and other important issues of postrelease life so they have the opportunity to think about their lives as well as learn the psychological training provided in prison environmental mastery received the lowest score which was expectable because of prisoners conditions and limitations prisoners are in a limited environment have no choice in sleeping waking up exercising training or other programs and must perform all their daily activities collectively and systematically the results revealed moderate fc of the male prisoners social work and cultural activities in prison may have contributed to improving outcomes the social work sector in prison attempts to improve conditions by strengthening prisoners family relationships and interests through phone calls inperson visits and temporary release from prison datchi et al confirmed the role of family support and family centered programs in bringing prisoners back to society with favorable wellbeing and family conditions hall et al concluded that identifying prisoners skills and strengths strengthened their cooperation and involvement with their family members but a study on family members of individuals with substance use disorder reported a poor level of fc our results showed that the male prisoners pl was moderate various factors may affect prisoners pl such as socially adverse conditions poverty mental health problems and lack of awareness of the pl skills before imprisonment and disruptions in the process of living and planning due to imprisonment when people are imprisoned their planning and pl are disrupted the highest mean score was related to item i wasted the rest of my life after retirement i did the most exciting things i ever wanted to do this result can be explained by prisoners environmental and psychological conditions due to the physical and social constraints during their imprisonment prisoners feel sad about exciting recreation that cannot be done in prison therefore doing something exciting has become a wish for someone who has been in prison for several years the lowest score was related to item i am a very responsible person i am an irresponsible person prison limitations made prisoners not feel good about responsibility so they did not get good scores the results of this study showed that pwb scores of male prisoners were significantly and directly correlated with their fc scores and fc was a predictor of pwb these results are consistent with those of other studies one reason for this similarity may be related to the important role of the family in different aspects of life including mental health boyraz and sayger emphasized that increasing parental fc and wellbeing might contribute to the health and wellbeing of children farajzadegan et al found that family functioning had a direct and indirect impact on quality of life and wellbeing and that family was important in improving wellbeing our results showed no significant correlation between pwb and pl in male prisoners these results were not consistent with previous studies indicating that pwb was significantly correlated with pl score one reason why these studies are inconsistent with the present study may be that the studies were conducted on normal groups while prisoners are vulnerable with special circumstances the results of this study showed that the fc score in male prisoners had no significant correlation with their pl score this result was not consistent with two studies which reported an important role of the family function in identifying and finding meaning in life another study emphasized the impact of family on pl with the mediating role of sense of belonging the reasons for this discrepancy may include the type of training and social work provided in prison as well as the conditions of prisoners in addition several factors may affect the correlation between these variables which have not been examined in this study for example pl is based on the time and environment of the individual and prisoners environment and decision making are limited limitations the study population was male prisoners in a prison in southeastern iran therefore generalization of the results to other communities should be performed with caution it is suggested that longitudinal studies be conducted to provide more detailed information about the changes in the studied variables from prisoners imprisonment to their release in different cultures and contexts conclusion the results showed that male prisoners pwb fc and pl were moderate and the prisoners pwb had a direct correlation with their fc the results highlighted some important practical implications for the healthcare providers in particular community health nurses and social workers they are recommended to design specific interventions such as rehabilitative supportive cultural and educational programs for prisoners researchers should explore the effectiveness of these interventions to improve prisoners pwb fc and pl and determine factors affecting these variables as well as the investigative needs of vulnerable groups such as prisoners data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation variables family cohesion purposeful life cohesion cooperation clarity of rules leadership total family cohesion ethics statement the studies involving human participants were reviewed and approved by this manuscript derived from a masters thesis in nursing was approved by the ethics committee of kerman university of medical sciences at the request of the ethics committee the present study was conducted in accordance with the declaration of helsinki and ethics publication on committee the researcher presented the letter of introduction to collect data and received permission from the administrative division of prison he explained the research and its goals to the participants and obtained their consent the confidentiality of information was respected and the results of the research were reported to the relevant setting the patientsparticipants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

background psychological wellbeing family cohesion and purposeful life are important determinants of the prisoners overall wellbeing and health therefore their evaluation is extremely important in prisoners as a vulnerable group objective this study evaluated psychological wellbeing family cohesion purposeful life and their correlations in male prisoners methods this crosssectional study used simple random sampling to select 259 male prisoners data were collected using questionnaires of ryff psychological wellbeing fischer family cohesion and crumbaugh and maholick purpose in life results majority of 78 the participants were 2040 years old and married 59 the mean scores of psychological wellbeing family cohesion and purposeful life of the male prisoners were moderate psychological wellbeing was directly correlated to family cohesion in male prisoners but it had no significant correlation with a purposeful life family cohesion was not significantly correlated to a purposeful liferegarding the moderate level of psychological wellbeing in prisoners it is suggested to pay more attention to educational and supportive programs in prisons for promoting such indicators in prisoners

in governments review of waste policy in england it pledges to work in partnership with local authorities and businesses to facilitate the uptake of best practice in waste prevention and resource management amongst other ways through reducing barriers to innovation and wherever possible the burden of regulation on compliant businesses supporting capacity building in local communities and giving them freedom to take initiatives in service design and provision the review also includes reference to using the localism act 2011 and big society concepts to empower local communities it promotes a partnership between local communities and allows community stakeholders to participate in the decision making processes with regard to how the community deals with environmental issues including waste management this approach builds on the recommendations of the sustainable development commission that concluded that government policy should prepare the ground for communities to deliver sustainable actions coordinate support and provide access to funding within the context outlined above the role of voluntary and community sector organisations have been viewed as the agents of change at the local level to deliver and facilitate more sustainable strategies however while there has been much research on community level initiatives to promote sustainability there is limited practical evidence to guide policy or indeed to inform successful public engagement with such initiatives according to weerawardena et al the issue of building longterm sustainability within the third sector is fragmented and relatively under developed using three towns in the east midlands of england as case studies this study aimed to examine and understand the levels of public engagement with vcs organisations and the factors that influenced this engagement vcs organisations and the sustainability agenda vcs organisations are groups within which individual members associate of their own volition with others in the pursuit of common objectives the term voluntary and community sector is generally applied to entities that are value driven and which principally reinvest their surpluses to further social environmental or cultural objectives the sector ranges in scale from small local charities to nationally important bodies due to its range and diversity segmenting it by type of organisation can be helpful particularly for sharing best practice and maximising the impact of sector activities voluntary organisations working internationally are sometimes referred to as nongovernmental organisations community groups may be differentiated from voluntary organisations these entities are collectively referred to as voluntary and community organisations or the voluntary and community sector various vcs organisations form a cornerstone of civic society and an institutional basis of societys third sector in many countries they have grown considerably in scope and scale within recent decades and play a key role in engaging with and empowering society in a manner in which top down approaches are unable to for example it is at the community level that notions of climate change adaptation and mitigation and wider sustainability should best be developed and implemented at the local levels in this way opportunities to embed these concepts into existing mandates budgets and governance structures at the local and regional levels can best be realised there are also emerging narratives around the significance of community structures as means of maintaining the fabric of the community by embedding and facilitating notions of urban resilience thus community governance structures such as third sector bodies and engagement with these structures play a vital role not only in promoting sustainability but also in enabling the capacity for change within communities and the society at large 2methods two main approaches were employed in the project namely a metaanalysis and questionnaire surveys the metaanalysis utilised both academic and grey literature to examine the nature and key operations of vcs organisations in the uk and beyond the selected papers were obtained mainly from the science direct database as well as key uk government agencies such as the waste and resources action programme department of the environment food and rural affairs the audit commission the office of the third sector and publically available environmental consultancy reports the questionnaire surveys were undertaken in three adjacent towns in the east midlands region of england namely luton milton keynes and northampton the aim wasnt to be undertake a statistically significant sample from each town but rather to capture a snap shot in terms of the socioeconomic profile of the population as well as the main activities of the organisations operating in the three towns the surveys were conducted during the first three weeks of april 2013 with milton keynes being first followed by northampton and lastly luton each of the three surveys employed 50 questionnaires with respondents randomly selected from people walking in the streets usually the high street respondents were handed the questionnaire and it was collected back on completion a total of 149 questionnaires were completed and returned the main purpose of the questionnaire was to determine public perceptions attitudes to and use of the organisations in the case study areas the questionnaire a four page document with an introduction and contact information for reference and feedback purposes was divided into four sections namely generic questions on recycling and shopping from charity shops evaluation of shopping practices at furniture reuse shops examination of general environmental attitudes and beliefs and sociodemographic information the majority of the responses utilised tick boxes and likert scales ranging from 1 5 with 5 indicating agreement and 1 nonagreement there were also spaces for open questions provided to facilitate the analysis all questions were coded likert scales ranging from 15 were used to code the questionnaires the coded information was initially entered into ms exel and these data were then transferred into spss for analysis the normality of the data was first ascertained using the shapirowilk test as p 005 the data were assumed to be parametric descriptive analyses were first performed to determine frequencies bivariate analyses using pearsons correlation were then undertaken to examine and evaluate the nature of the key antecedents to the perceptions and attitudes of the participants towards the organisations and their use of the shops results metaanalysis reported numbers of the organisations in the uk vary for example according to curran and williams there have been approximately 400 such agencies set up in the uk since 1970 however defra note that there are about 1000 such entities in england alone while lr solutions and london crn state that there were 693 third sector reuse organisations and initiatives in london divided into six main categories namely • domestic furniture and appliance reuse organisations • computer and other it reuse organisations • charity shops • other reuse organisations • internetbased exchange forums • locally organised swap forums give or take days despite the discrepancy in numbers it is generally agreed that most are small and localised with income of less than £250000annum however there are around 7 which have an income of over £1m and 20 operate regionally and nationally for example half of the principal reuse organisations in london serve one to three boroughs with only 11 serving seven to ten boroughs they have diverse scales of operation activities and objectives for example they deliver public services including waste management and in particular reuse bulky waste services community composting and waste minimisation activities in 2009 nationally the sector was diverting around on average 500000 tonnes of waste from landfill per annum for example featherstone states that reuse operations in london collect around 12000 tonnes the types of materials managed by the sector varies with only 4 of items donated to charity shops ending up in landfill according to defra textiles recycled through charity shops added up to 20 of the tonnages of material handled by other community organisations by 2013 some 96 of materials were recycled or sold on for reuse approximately 20 of furniture collected at the kerbside is reusable and around 40 of the materials at household waste recycling centres are reusable they also undertake a significant social role for example they redistribute the furniture and electrical appliances to vulnerable households thus alleviating poverty and combating social exclusion indeed as illustrated in fig 1 poverty alleviation is key factor in their objectives featherstone argues that reuse organisations play a vital role in social housing by facilitating the sustainable management of housing stock in the uk there is an increasing demand for reuse furniture with child poverty a pressing problem with two in five households having no working adult thus their benefits to society include the ability to deliver services in response to local demand particularly with respect to niche materials andor particular social needs making goods and materials available that would otherwise be unaffordable for those on a low income an emphasis on and ability to meet the specific needs of service users and the local community questionnaire survey over half of the sample was female there were more females 64 interviewed in luton than any other town however according to the ons the 2011 population census shows that the number of males and females in luton is almost similar the high percentage of female respondents could be attributed to reluctance to participate by men the majority of the respondents for the three towns were in the 1630 years age group followed by the 3145years age group some 503 of the population was in some form of employment with northampton having the highest part time employed and milton keynes the lowest however the figures show that there are far less people in full time employment than part time across the three towns luton had the highest number of students some 577 of the sample had an annual income of less than £20000 all three towns showed similar levels of income except in the £3050000 range where northampton had a significantly higher figure than luton over 50 of the individuals in all three towns resided in rented houses with luton having the highest rentals at 65 the most common houses were semidetached and flats house ownership was highest in northampton at 58 recycling and use of charity shops eightyone percent of all the respondents said that they recycled table 2 indicates that residents of northampton were the most likely to use charity shops followed by milton keynes and luton however on buying or taking items to furniture reuse shops luton had the least respondents milton keynes had 62 and northampton was highest at 80 as shown in fig 2 clothes were the most donated item at a combined percentage of 31 for all the three towns while furniture donation was 67 other items included books and toys over 34 of the respondents said they made monthly donations and 28 donated on an annual basis fig 2 items donated and bought across the three towns awareness of the existence of furniture reuse shops an overwhelming majority of respondents were aware of the existence of furniture reuse shops in their area and had shopped in them residents in luton had the highest lack of awareness about them overall 34 only came to know of the existence of the shops either by walking or driving by as demonstrated in 2 about 50 of the individuals stated that they would take their unwanted sofa to a charity while 40 said they would take it to the tip or throw it away environmental attitudes and beliefs the main reasons why individuals used the shops were because of the value offered and quality as demonstrated by these correlation factors being highest there was also some correlation with gender with women expressing a greater engagement compared to men however this may relate to the larger percentage of women surveyed perceptions about helping the environment and also living in close proximity to furniture reuse shops were also key deciding factors alternatively of those that said they did not buy from the shops 30 preferred to buy new items however they could not unequivocally say whether items from the shops were of good quality or not most reported strong beliefs on the positive role of recycling on the environment an overwhelming 78 thought that their consumption patterns had an impact on the environment and 88 agreed that it was their personal responsibility to look after the environment asked what would encourage them to use furniture reuse shops 81 suggested quality of items while 63 thought awareness of the existence of a shop within their local area might have an effect on their shopping habits 4discussion while accurate numbers of vcs organisations working in waste management across the uk vary they evidently play a significant role in society this is evidenced both in terms of their environmental role of collecting reusing minimising waste but significantly also their social role helping vulnerable households across each of the three towns there was high awareness of furniture reuse shops and most used them to either buy or sell items clothes were found to be the most donated item for all three towns with just over a third of residents stating that they donated items at least once a month this confirms the importance of textiles as found in other studies and suggests the key role played by textiles in achieving reuse targets the socioeconomic composition of the population appeared to have had some impact on engagement with the shops indeed most residents across the three towns were in pt employment earning less than £20000annum and within the age range of 16 30 years old these factors would have had a bearing on disposable income thus affecting lifestyles as well as behaviour and attitudes towards resource consumption its important to note though that use of charity shops was highest in northampton where incomes were highest this perhaps could be related to the higher quality of items in the shops it would be interesting therefore to extend the study into areas where disposable incomes are higher an overwhelming majority of the respondents were aware of charity shops in their towns primarily via either walking or driving by this would suggest the importance of location to such shops to ensure good public engagement the perceived value offered in shopping at these stores would also suggest that price is a significant contributing factor in public engagement interesting perceived benefits to the environment were also reported as a key reason why residents used the shops presumably this relates to perceived minimisation of waste through reuse and recycling of items which if they had not been donatedsoughtbought from the shops would have been disposed to landfill at the same time it may simply be respondents telling the researchers what they believed they wanted to hear nevertheless the findings suggest that notions of value quality and environmentalism should form keycomponents in the marketing strategies of these entities at the same time the results showed that costs and good quality were key influencing factors with 30 of the respondents preferring to buy new items this raises two key issues with regard to continued and future public engagement first there exists a dichotomy between price and quality if the quality of items donated to these entities continues to fall then regardless of the low price residents may decide not to engage with them and not use the shops second these organisations need cash flow to sustain operating costs and if there is no one to buy and no items to sell they will struggle to fund their operating costs and remain viable thus while the study suggests that there was generally good awareness of the organisations in the three towns and they were fulfilling a need for individuals seeking value there are a number of issues that need to be addressed to further improve public engagement conclusions vcs organisations working in the waste management sector have a key role to play in maintaining the environmental and social fabric of communities and the society while there was strong public awareness and engagement with the furniture reuse shops across the three towns there were also a number of challenges identified that impacted upon public engagement key amongst these included overcoming perceptions of the quality of items value and the locationvisibility of shops it is vital that they not only offer value but also good quality items a good location to ensure visibility is evidently also crucial greater awareness building and perhaps even a rebranding exercise to move away from public perceptions of the organisations offering primarily poor quality items may very well be required faced with competition from entities such as ebay and low cost retailers these are issues that need to be urgently addressed if the public is to be better engaged and ultimately the longterm viability of these organisations assured crucially outside of their role in waste management these organisations evidently also play a key role in addressing the social needs of society indeed the metaanalysis illustrated that poverty alleviation was a more important issue than waste management indeed glimpses of this are also seen from the survey in that value was a key contributing factor for why individuals engaged with the organisations in addition income levels in the three towns were low thus the shops were a manifestation of the lifestyle choices of residents it is possible that the timing of the study during the economic down turn in the uk may have impacted upon perceptions and public engagement an understanding of whether this is indeed the case would require a follow up study given their environmental and social roles it is vitally important that the sector remains relevant in tune with the needs of the public and ultimately therefore resilient

within the context of shifts towards the concepts of resource efficiency and circular economy voluntary and community sector organisations are increasingly being viewed as agents of change in this process using questionnaire surveys across three towns in england namely northampton milton keynes and luton this study aimed to understand public engagement with these organisations the findings suggest that there were generally high levels of awareness of the organisations and strong engagement with them clothes were the items most donated key reasons for engagement included the financial value offered and the perception that it helped the environment however potential limitations in future public engagement were also determined and recommendations for addressing these suggestedrecent european union eu and uk government policy and legislation have sought to encourage a more sustainable approach to the management of resources ec 2008 defra 2011williams et al 2012 the revised eu waste framework directive rwfd ec 2008 transposed via the waste england and wales regulations 2011 identifies waste as a resource giving greater priority to waste prevention and preparation for reuse indeed for some time government has sought to implement policies and to encourage enhanced efficiency and recovery measures defra 200520072011

introduction in the context of our countrys long history of social injustice the issue of systemic racism in higher education has recently gained a lot of attention constantly african american students have suffered injustice that has reach a tipping point the call to action for combating systemic racism has sparked a cultural phenomenon that has made inroads in all walks of life consequently this study seek ways to explore compare and contrast the factors or reasons linked to the systemic racism that influences african american students decisionmaking when deciding to join an institution of higher education the african american students experiences in the us are unique most importantly there are many factors that are beyond students control that have shaped it such as historical and economic issues however this is a top priority in respect to students college choice historically the academic journey from early school for african american students has not been straightforward in schools african american students are more likely to be labeled mentally challenged or learning disabled and overrepresented in special education programs in addition they are less likely to appear in talented or gifted programs such as honors classes or advanced placement courses furthermore they are subjected to expulsions and suspensions and the retaining rate is alarming one out of five african american students received an outofschool suspension and they are 35 times more likely than their caucasian peers to be suspended or expelled consequently many african american students lack adequate opportunities to develop positive classroom experiences they are often berated for minor classroom behavioral issues that become magnified by teachers and administrators over the years researchers have identified three major problems that have emanated for african american men before they enter into higher education such as lack of quality teachers in k12 education overrepresentation of african american male students in special education programs and a lack of african american male students as well as other students of color in advanced placement courses at the secondary education level according to bottiani bradshaw and mendelson students perceptions of differential treatment exclusion and discrimination by teachers and other adults in school appear to play a significant role in the poor outcomes among youth of color however there are lot of barriers when it comes to admitting more black students to the nations selective universities the climate change surrounding racial issues and the us economic downturn have had a significant impact on the commitment of students of color in respect to higher education historically black colleges and universities have played a significant role in expanding educational opportunities in the united states this study attempts to answer the overarching research question how does systemic racism play a role in african american students college choice decisions and the factors affecting the decision theoretical framework to lead this study this study is grounded in critical race theory and college choicedecision theory the conceptual framework for this study was provided by the critical race theory this is because crt explores and analyzes the experiences of students of color which can inform crosscultural inclusivity practices in a number of ways however crt was appropriate for this study because it presents practical techniques that can be used by academic advisors and other higher education administrators when working with students of color crt can also serve as a theoretical framework through which a person can understand various ways on advising interactions and practices with students of color in order to offer help or exert harm this study applied crt because it challenges the status quo and examines racial difrences in myriad contexts such as the many ideologies and norms embedded in educational institutions furthermore crt has been used to normalize and analyze racialized experiences in research and practice by challenging traditional paradigms methods texts and discourses on race gender and class based on the different models within each of the college choice and decision theories there is an understanding on why african american students might choose to attend an hbcu or predominantly white institutions models by iloh glasser hasen and litten and freeman provide an explanation of college selection and decisionmaking aspects within each example to support the study objectives methodology the present study is a nonexperimental qualitative comparative case study analysis this study will use qualitative research which entails collecting and analyzing nonnumerical secondary data in order to understand concepts opinions experiences and phenomena the aim is to gain indepth insights into the problem answer the research question or generate new ideas for future research qualitative researchers engage in naturalistic inquiry and explore realworld settings by inductively developing rich narrative descriptions of the cases they are investigating inductive analysis across case studies yield patterns and themes which is the fruit of qualitative research the purpose of this study is to analyze data for insights within across and between cases therefore this comparative case study design involves comparing contrasting analyzing and synthesizing the similarities differences and patterns across three selected case studies that share a common focus goal or phenomenon this study also used secondary data sources from all three cases which includes documentation archival records interviews physical artifacts direct observations and participant observation the researcher has collected and integrated data within the case study research which is unique to other qualitative approaches this has help in facilitating a holistic understanding of the phenomenon being studied data collection this qualitative research is designed to reveal the meaning that informs the action practices or outcomes using rigorous and systematic transcribing coding comparing analyzing and interpreting the trends and themes with a focus on retaining the true meaning however such research is used to understand how people experience the world qualitative researchers often consider themselves instruments in research because all observations interpretations and analysis are filtered through their own personal lens this case study analysis involves intensive analysis of the following three selected case studies to understand and gain an indepth holistic view of the research problem i consequently these three research studies conducted within ten years were selected through extensive database searches using specific words the titles and research questions from the selected case studies were extracted and compared using a colorcoding method to show internal consistency data analysis procedure the researcher extracted the relevant data from the selected case studies and utilized this data for secondary data analysis the selected case studies were semantically coded to assess their interrelatedness understand the text data label the emerging sections with codes examine the codes for similarities and then combine the codes into broad themes to initiate the data analysis the following preliminary themes were developed student college university african american black racism and identity the selected studies were uploaded to atlas ti9 to arrange and code the major themes a word cloud was assembled by ordering the importance of the phrases from all three case studies next a hierarchical network was constructed where the coding revealed an emerging themes furthermore the codes were arranged into themes or categories to create a database of topics that were widely discussed in the case studies this process give room for the researcher to observe the density comprehend indepth understanding to answer the research questions and ensure the credibility of the data analysis subsequently themes were developed by utilizing the sixstep processes suggested by caulfield results findings on theme one systemic racism in higher education in analyzing the three case studies the first theme that emerged was systemic racism in higher education in case studies 1 and 2 the findings of these research studies displayed an acknowledgment of racism as a factor in african american students choosing to attend an hbcu or a pwi findings on theme two african american students decision making in case studies 1 and 3 the process of choosing a college to attend was another theme that emerged the decisionmaking factors of african american students are prominent themes in each case study in this theme three small subthemes have been discovered college choice and decision factors reasons for choosing hbcus and reasons for choosing pwis findings on theme three experiences of african american students in hbcus and pwis in study 1 recent high school graduates from hbcu and pwibound have a high expectations of college life that are typical of experiences that will duplicate high school in a larger community in study 2 the students at the historically black colleges and universities reported a better psychological and functional faculty support levels than their pwi counterparts findings on theme four minority students stress and anxiety in hbcus and pwis in case study 2 the report from african american students at pwis were more stress related and exposure to racial discrimination are being underrepresented on these campuses as codes emerged the researcher could see linkages between the factors influencing college choice and the selected theoretical frameworks of college choice decision and critical race theory in this study crt was used in analyzing how race and privilege play a major role in society and also how it plays a role in higher education specifically in this study college choice and decision theories were used in addition several college choice and decision theories were used to analyze how college students think and arrive at their decisions to attend a college or university however the findings in case study 1 helped the researcher to connect the case findings to other cases utilized in this study in case study 1 the theme of systemic racism in higher education was also discovered this is connected to the findings and other themes from other case studies in case 1 african american students use racial climate and the significant presence of a diverse or samerace student body to validate their final selection in case study 2 there were discussions about how african american students have more positive perceptions at an hbcu and also how the experiences of black students at pwis were negative these findings have helped in discovering minority students stress and anxiety at hbcus and pwis as a key theme emerging from the analysis of case study 2 african american students on an hbcu campus would report lower minority status stress levels than their counterparts on a pwi campus collectively the current analysis suggests that institutional racism affects african american students college choices conclusion while answering the research question the findings of this study have revealed that the role that systemic racism plays in college choice decisions of african american students is displayed in critical race theory this is because it is a crucial factor in the analysis of choice theory in the context of systemic racism the critical race theoretical lens that affects the college choice decisions of african american students shows that race is an embedded factor in college choice decisions because of a deeply rooted and racist normalized traditions the crossanalysis of the studies confirms that african american students use racial climate and the significant presence of a diverse or samerace student body to validate their final selection this research confirms that racism and many other factors play a crucial role in the college choice decisions of african american students in attending predominately white institutions of higher education it is apparent from this studys findings to note that racism is an issue for african americans in their college choice decisions consequently the students decisionmaking for higher studies or deciding on their careers is a complex process however there is still much to learn about how african american students choose a college education for themselves it is instructive to engage in a racial analysis of the access and choice processes to better understand the oppressive structures encountered by collegebound african american students contrarily the college enrollment decisionmaking process for students can on the surface appear fair and inclusive across racial lines although this is not the case conflict of interest the author reported no conflict of interest data availability all of the data are included in the content of the paper funding statement the author did not obtain any funding for this research

a lot of attention has been given to the problem of institutionalized racism in academia lately from a young age the road to success in school has not always been an easy route for african american students according to bottiani bradshaw and mendelson 2016 students perceptions of differential treatment exclusion and discrimination by teachers and adults in school appear to play a significant role in the poor outcomes among the youth of color the climate change surrounding racial issues and us economic downturn have had a significant impact on students of color as regards to their commitment to higher education karkouti 2016 this paper attempts to answer the overarching research question such as how does systemic racism play a role in african american students college choice decisions the results from this paper are displayed in critical race theory as it is a crucial factor in the analysis of choice theory

introduction in the past decade the struggle for water and sanitation justice has been linked with alliances deploying informal strategies and campaigns for formal recognition of the human right to water and sanitation the focus of this paper is on the struggle discourses and politics in spain departing from the european citizens initiative right2water and examining links and similarities between the european right2water movement and spanish water movement the european citizens initiative right2water ran and collected 19 million signatures across europe in 20122013 uniting cities villages and civil society organizations against water privatization with that result it became the first successful eci simultaneously building a europewide movement and putting the water issue high on the european political agenda right2water proposed to implement the human right to water and sanitation in european legislation as a strategicpolitical tool to fight privatization of public water utilities implementing such water justice notion is part of an ongoing sociopolitical struggle this struggle had been going on in spain before the start of the eci and it has continued afterwards deploying a political ecology lens this paper examines how right2water influenced and impacted ongoing struggles for access to and control over water in spain how it fuelled the debate on privatization of water services and what heritage it has left in spain moreover it looks at how social movements developed reinforced or complemented each other in their struggles for social justice and against austerity measures that have marked the second decade of this century rise of the indignados movement coincided with the rise of a water movement like the red agua publica in the past decade a growing number of cities and regions have decided to remunicipalize water supply the human right to water and sanitation framework was instrumental in this process as we will show in a few cases the right2water movement changed water policy discourse in europe and proved to be a support to the spanish water movement that continues to fight for a more participatory and democratic water governance and policy in section 2 we describe our research framework and methodology in section 3 we will look at the history of water policy and privatization in spain in section 4 we will look at the rise of social movements and in section 5 we will highlight a few cases of water struggles in spain in section 6 we examine the stakes and stakeholders that for the time being have won and lost in these struggles and the overall outcomes of the water policy and politics battles over the past decade we draw our conclusions in section 7 conceptual framework and research methodology the conceptual base of this research is political ecology which is a political approach toward the study of natural resources management ecological problems are seen as deeply interwoven with and produced by the sociopolitical and economic context this paper will analyse historical and political processes of water management in spain looking for underlying power relations directly connected to this the notions of environmental justice and contestationsnoncontestations are central in academic and activist debates environmental justice is defined in multiple waysfor instance by integrating and balancing or contrasting the arenas of distributive justice cultural justice representational justice and socioecological justice for human and nonhuman communities and agents in this research we concentrate on three of its conceptual dimensions recognition redistribution and representation we focus therefore not just on the distribution of access to water but also about who participates in political decisionmaking processes and whose values and interests are recognized by for example social norms languages and institutions with regards to public water services this means that citizens must be recognized as political actors and therefore codecide and cogovern in water services management all dimensions are distinct but interlinked and overlapping hydrotechnological modernization processes and legalinstitutional policy reforms coalescing in diverse forms of neoliberal water governance provide the background to these last decades powerful trends toward europes water governance model understanding neoliberal water governance conceptualization is key in brief neoliberal thinkers and policymakers advocate treating water as an economic good water resources service andor property therefore need to be private transferable and pricedcommodified according to neoliberal logic policy measures such as privatizing water service provision granting concessions to operate distribution networks and implementing fullcost recovery in water service pricing would lead to improved water service and more efficient operation and maintenance in water governance the assumption is that such neoliberal incentives lead to efficient water use in practice however many studies have shown that privatizing public utilities has often failed to benefit water users rather tariffs hiked investments in infrastructure lagged behind quality of service provision did not improve and the environment was jeopardized in recent years protests have been organized in various parts of europe by citizens and civil society organizations to stop privatization of drinking water utilities or demand cancelation of these contracts challenging the neoliberal governance structure and calling for a vision on water as a common finally water justice movements address injustices both at the individual community and supralocal levels this is the case for right2water as well water justices involve both quantities and qualities of water as well as access to and distribution of water privileges and forms of control over water this entails also that water conflicts include questions about decision making authority and legitimacy these are intimately linked to the struggle over discourses favoring particular water governance notions and policies while obliterating othersin terms of thinking about and acting upon water as discourses sprout from substantiate and actively constitute policy arenas they become a necessary part of the struggle of social movements discourse change is not only a trigger for social mobilization and protest but also a precondition for policy change media attention which is one of this papers fields of scrutiny is an indicator for the domination of particular discourses in a specific period of time and it also reflects how governance processes and social movements are framed while it indicates resonance or influence in society the main research question that we seek to answer is how the european right2water movement has related to the spanish water movement and how the human right to water and sanitation has been instrumental in their struggles against privatization of water services literature and archival research and activist debates in the spanish institutional and movements landscape have been the main sources of information on human rights to water privatization and remunicipalization of water services in spain and how social movements have campaigned for public water provision five cases are analyzed as examples of local struggles with diverse settings and histories of privatization and movements the cases show different types of water governance and ways of activism and provide lessons for future debates over water services provision governance and remunicipalization besides the cases data collection was done for this study on drinking water service privatization remunicipalization of water services in spain and on debates around these issues and the human right to water in spanish newspapers we explored these issues and social movements more in depth by applying bibliometric methods and data mining with text mining software we searched and analyzed the number of times that these issues and movements were mentioned in spanish national newspapers and how this developed during the past decade between 2010 and 2022 we searched for unique articles on key words human right to water 15m eci right2water and marea azul in combination with water services besides this we searched for new water culture privatization and remunicipalization also in combination with water services thirdly we checked mentions of two social organizations that played an important role in water debates aeopas and fnca also in combination with water services provision we visualized trends in media attention in two graphs given that we consider newspapers as relevant media that reflect public debates and public issues of interests in spain we looked at the number of unique articles that dealt with these issues with this media analysis we expected to show if and how social movements have gained influence and attained to change discourse in the spanish newspapers with regards to water services management history of water services provision in spain water policies privatization and rise of the new water culture water management in the twentieth century in spain was characterized by a hydraulic paradigm stemming from the franco regime that aimed to develop spain through water infrastructure imposed upon the population and based on use of water resources to maximize state economic benefit in 2001 the spanish government introduced the national hydrologic plan and proposed construction of over 100 dams with a similar view on water as an economic good the nhp puts emphasis on technology to regulate rivers and use of water where it is the most profitable fitting tightly to the ideology of francos regime the plan was adopted after massive protests throughout spain and modification by the spanish parliament in 2005 as act 102001 on the national hydrological plan since the 1990s there has been a trend in spanish municipalities to privatize water services mainly through publicprivate partnerships this term is frequently used by multinational corporations to disguise a privatization through contractual arrangement often a longterm concession the spanish privatization model of water services over the last three decades is often described as mercantilizacion while being a natural monopoly this marketization of water services tends to favor the interests of powerful groups at the expense of the public interest and the commons as it is characterized by the absence of competition in the last decade of the twentieth century and beginning of the twentyfirst century the eu saw a wave of utility privatization spain was no exception to this phenomenon private companies in the water industry increased their share in provision of water services to the population from 37 in 1996to 48 in 2006to 55 in 2015 by focusing on water supply in urban areas because that can generate most profits in a market with many customers in a small area local governments often saw privatization as an easy way to increase their income at short term because of the concession bonus and by keeping water supply off their balance sheets this gave rise to an intense debate about the desirability of this privatization of urban water services with a clear oligopolistic dominant position for multinational companies political decisions were substituted by market instruments that favored corporations because of the structural imbalance between these players and municipalities simultaneously since the 1990s a coalition of academics social activists and water managers in spain and portugal has been promoting a shift from the hydraulic paradigm and seeing water as an economic good this new water culture placed the emphasis on ecosystem protection and ecological health as a means to guarantee the availability of sufficient goodquality water to sustainably meet needs in 2000 the water framework directive came into force in the eu this european law needed to be transposed into spanish law and water activists saw this as an opportunity to shift the priorities of the traditional economicminded water management system to a more holistic approach that recognizes ethical sociopolitical and environmental concerns the new water culture movement was founded in opposition to dam building and the interbasin transfer of water from the ebro river it emphasized participatory and transparent decisionmaking in water management and provided an alternative policy framework as it positioned water as a common and a human right the movement coalesced in the new water culture foundation or fnca one of the founders was pedro arrojo former professor at zaragoza university and now the un special rapporteur on the human right to water and sanitation who explained it as follows water services as services of general interest of society go beyond the logic of the market for this reason faced with the privatizing policies of neoliberalism that transform these public services into simple businesses we must face the challenge of building new models of public and participatory management based on principles of sustainability justice transparency and citizen participation the economic crisis of 2008 generated an increase in situations of social vulnerability and problems related with affordability and accessibility to water in urban contexts privatization processes of water services coincided with austerity measures that european institutions promoted in the countries most affected by the economic crisis european austerity policies aimed to reduce government budget deficits through cuts in public services which usually include water services and decrease government spending these savings on government costs came at the expense of providing vital services to citizens the european commission imposed privatization of water services as one of the conditions of bailouts to crisishit countries greece and portugal corporate europe observatory 2012 zacune 2013kishimoto and hoedeman 2015bieler and jordan 2017 and also in spain the pressure of european austerity measures was high in 2011 the european commission made a new attempt to further liberalize the services sectors in europe by means of a proposal for a concession directive this directive aimed to align concessions contracts with economic water operators and single market rules the directive promoted to open municipal water services for euwide bidding and aimed to create a european water services market which would open the door to privatization this was conceived by water activists as a privatization through the back door and in spain the directive was therefore called the privatization directive the right2water movements discontent with europes water policy and governance was exactly with this proposed directive and earlier attempts to apply internal market rules to water supply and the management of water resources because it would mean the commodification of water privatization of water services in spain in spain the process of privatization was instigated by the search for funding by municipalities in crisis it happened mostly through concessioning as the perverse mechanism of the concession fee allowed for a rapid injection of money into the municipal treasury but the backside of this coin was a decadeslong privatization and loss of control over the service this process was supported by european commission liberalization policies transformation of a publicservice ethos to a profitserving ethos combined with technocratic and neutral solutions to complex societal and political problems and commodification of natural resources are part of the neoliberal project of completion of the european single market privatization occurred by two major corporations aguas de barcelona and aqualia both multinational enterprises these two companies account for almost 90 of the total private water supply this privatization and the oligopolistic character led to an over emphasis on profit margins and resulted in environmental degradation by failing to comply with the environmental terms and conditions in contracts as market logics do not value or protect human rights nor sustainability of ecosystems the natural monopoly that is inherent to water supply the power imbalance between municipalities and multinational private providers and the drive for profit maximization form a hazard to the fulfillment of the human right to water and sanitation in case of privatization in the spanish model of privatizing urban water management all these risks became visible and reality costs were born by the citizen while private companies took benefit from water resource exploitation by setting on average higher prices than public companies the privatization process in spain was often accompanied by increasing rates sometimes up to over 60 local authorities lost control over the service and access to water provision was jeopardized for vulnerable people by greater pressure on users with payment problems and 300000 shutoffs in 2013 the relations between the causes and consequences of the crisis and privatization as well as the emergence of situations of water poverty have led to the rise of a social movement committed to defend the human right to water as well as the model of public and democratic management frwa social movements for public water in spain a movement for public water a number of citizen water networks have emerged from the new water culture movement with an aim to defend the social and ecosystematical values of water the fnca is seen as one of the most influential movements in water policy in spain in the beginning of this century these citizen networks were mostly active in opposition to dam construction and river management but also raised a voice for in their view marginalized groups in water policies they demanded influence in decisionmaking that was dominated by economic interests of the state and powerful groups the citizen networks created largescale awareness raising campaigns that incorporated many different types of calls to action but also local social mobilizations against dam projects one of these networks was the red agua publica formed in 2012 which focused exclusively on urban water privatization building on the plataforma contra la privatización del canal isabelii that saw light in 2010 in madrid this case will be discussed in the next section the rap rose from a local opposition to privatization of the water company in madrid to an extensive network of organizations in spain until today it promotes a vision of water as a common and a public service with the following objectives defending the integral water cycle as a public good supporting struggles against privatization of water services and for remunicipalization of already privatized services transparent public water management with citizen participation and effective achievement of the human right to water these objectives were completely in line with the objectives of the european right2water movement that emerged in the same year the recognition of the human right to water with resolution a65254 by the united nations general assembly in 2010 was a victory for global water activists as well as an inspiration for local activists the italian water movement and the referendum they organized inspired the european public services unions to organize a european citizens initiative on water framing it as a struggle for water as a human right and as a public good by asking civil society organizations and local water and social movements for support to this euwide campaign the right2water movement was born it reciprocally gave support and inspiration to other networks calling for citizen participation in water management and fighting privatization of water supply from 2012 onwards the european citizens initiative right2water united people and social organizations against water privatization and liberalization policies across europe the italian water movement and their successful referendum against water privatization also motivated spanish activists as they maintained a distance from traditional political parties and called for water to be considered a common spanish water movements also used the phrasing write water read democracy introduced by the italian water movement to emphasize this link widespread disappointment with the service that was provided by private companies resulted in reversals of the decisions to privatize water services such a reversion has happened in municipalities in developed countries as well as in developing countries the remunicipalization of water services in paris in 2010 was an example for other cities and water activists municipalities wanted to take back control over their resources so they could better provide for the needs of their citizens and remunicipalization turned to a global trend in the second decade of this century whereas spain counted only one case of remunicipalization in 2006 the number of remunicipalizations of water services had risen to 14 in 2014 and 40 in 2022 compared to the total number of 135 cases of water remunicipalization worldwide it shows that the spanish water movement has taken a leading global role in water remunicipalization the main reason for remunicipalization in spain was the same in all cases need for investments guaranteeing universal provision improving quality of services and taking back control over the service moreover water prices in spain are on average lower when services are managed by governments and tend to be higher under private management average tariff in spain was about 089 em 3 in 2012 but the highest tariff at that time was in murcia followed by barcelona and alicante in all three places water was provided by subsidiaries of suez another reason for remunicipalization was the demand for more transparency and democratic control in order to fight corruption which was seen as a democratic revolution at the local level that went beyond water and sanitation management confluence of austerity protests and water protests protests against the austerity agenda spread adopting an innovative format in the socalled indignados and occupy movements that occupied public spaces throughout member states of the eu in spain austerity related policies triggered many protests early 2011 where democracia real ya developed and grew within 3 months into a protest platform with over 200 organizations affiliated to it dry called for demonstrations to take place in cities across spain a week before the countrys regional and municipal elections of may 2011 demanding radical changes in spanish politics and an end to austerity policies mass demonstrations were held across the country on 15 may 2011 the largest of these protests was held in madrid where demonstrators chanted were not merchandise in the hands of politicians and bankers after attempts by the police to remove the protestors thousands of supporters occupied squares across spain to express support for the activists in madrid from these solidarity camps 15m was born the activists demanded a reform of the political system and an end to corruption the involvement of many different actors in the 15m movement made democratic participatory processes critical to maintain engagement since actors can have different backgrounds and motives for joining a movement it is essential to check and debate whether all participants are in the struggle together and to move forward protests continued over 2012 and a confluence of tides occurred after the 15m movement opened up to a new social ecology of critical spaces to protect vulnerable groups different social movements saw their interest threatened by the same neoliberal ideology that increased pressure on workers and citizens hitting hardest to the poor and caused a wide spread sentiment of people losing control over their lives trade unions in spain joined their forces with 15m social activists ecological and water activists protests against austerity confluenced with the marea azul protests against privatization of water and in defense of water as a common good in 2013 the rap called on all european public water operators to leave eureau after it had denied the success of the eci right2water showing its concern of the interests of private operators over the public operators an impressive list of around 100 groups and organizations from spain signed the appeal the right2water european citizens initiative was transferred to spain by the trade unions affiliated to epsufscccoo and ugtspand the new water culture foundation pedro arrojo was member of the citizens committee of the eci with an extensive network in spain according to him the eci was at that time the motor of the struggle for the human right to water in europe at first the campaign did not strike a chord but that changed when the unions and the water movement bonded with the antiausterity 15m movement and then reached a successful number of supporting signatures the cooperation between the movements was complicated as both the austerity measures as well as the eci were seen as european union policy how to combine action against eu policy and at the same time in favor of another eu policy this psychological barrier had to be overcome in the end over 65000 people signed the initiative whereas 40000 were necessary to surpass the quorum despite of practical barriers the encouragement of the association of public water supply and sanitation operators the statewide public water network ecologists in action the federation of neighborhood associations and the platform against the privatization of canal de isabel ii played a role in the success for right2water the spanish case is a national example of a political achievement reached by uniting diversity as the right2water movement did in europe the collaboration of trade unions with social movements was very important this had not occurred before also the combination of social and ecological values and objectives showed to be fundamental for a broad support for implementing the human right to water beyond anthropocentrism spanish water movements have been effective in linking the issue of water with other campaigns eg around housing or democratic platforms these organizations continued their collaboration in initiativa2015 by which they campaigned to implement the human right to water and achieve a 100 public service provision in spain this initiative tried to prohibit supply cuts to ensure a minimum of between 60 and 100 l per person per day in case of justified nonpayment and to eliminate the participation of private companies in water services it was about developing a new model of public democratic and participatory management this initiative was materialized a year later in the social pact for public water signed by 75 organizations at the start it led in several municipalities to measures to guarantee a vital minimum of water and prohibition of supply cuts the pact addressed water justice issues and demands that went beyond the topics included in the human right to water and sanitation and provided a level of specification for its effective implementation several propositions to implement the hrtws in legislation had been made but these efforts did not result in its implementation it shows that the process of incorporating the hrtws into the national water law is complex and troubled until 2020 and despite the strong social movement and sometimes formal political support this incorporation has not occurred until today no mention is made of the human right to water in spanish water law but the psap forms a basis for water policy in municipalities and public utilities as shown eg in the cadiz declaration in which several majors water utilities and social organizations in andalucía state their commitment to implement the human right to water and to ensure that water services remain in public hands the psap is also at the basis of the declaration for public water services management by majors from 10 spanish cities at the meeting for public water in madrid on 34 november 2016 media attention attention in the media shows how social movements have been able to take the stage in water services debates widely the human right to water as recognized by the united nations general assembly was mentioned in the media since 2010 but in 2011 attention to water services provision expanded thanks to the 15m movement more attention for the human right to water followed in the wake of the european right2water citizens initiative and the marea azul manifestations the spanish water movement managed to maintain an important voice in water services debates but media attention decreased examples of local water struggles in spain when the right2water campaign was launched in spain it could build on an already present network of social movements these networks appeared indispensable to get people to join the european campaign this was not easy as antieuropean sentiments were also strong because of austerity measures imposed upon spain by the european commission that led to increasing unemployment and worsened the economic crisis situation only when european policies were connected to local struggles the right2water campaign started to gain support in several cities and regions in spain this local struggle was present in 2012 in this section we explore five cases in which a local social movement was already struggling against privatization or for a more democratic public water supply four cases are about cities and one case is about a region madrid shows a fight against privatization the other three cities show successful cases of remunicipalization and a failed struggle for remunicipalization the case of andalusia highlights how a social movement for public water was built and changed discourse and policy on water management the case of madrid the platform against the privatization of the local water company canal de isabel ii was set up in 2010 to oppose the planned privatization of the company in madrid it was an urban movement in which social organizations unions environmental groups political parties and citizens belonging to 15m participated the incorporation of the 15m to the pcpcyii made it possible for the water movement to bond with other social groupsthe platforms for the defense of public health and educationthat also defended a right to the city imagining the city as a place to live contrary to for example real estate agencies and banks that see the city as a place to exploit it succeeded in 2012 to organize a popular consultation in which 165000 people an overwhelming majority in madrid voted against the privatization of the water company and in favor of a 100 public water supply this was the first time that a blue wave marea azul had gone over the city these blue waves came back in manifestations in 2012 and 2013 for the recognition of the hrtws in eu law when the spanish movements joined the european right2water movement as the struggle unfolded the movement switched from the earlier emphasis on opposition toward a more prepositive stance seeking not just to stop privatization but also to make the public utility 100 percent public with participatory management involving citizens making its goals more consistent with the principles of the human right to water although formally the government froze the privatization plans in june 2015 because of the heavy defeat experienced in the municipal elections in may that year the platform argues that the mechanisms that would allow the privatization to go forward are still in place from the pcpcyii the red agua publica grew that made the right2water campaign collaborate with the creation of the spanish iniciativa2015 and the social pact for public water in close cooperation with aeopas and the trade unions the case of valladolid in 2015 municipal elections brought in a new government and the opportunity to terminate the private water management contract with agbar in valladolid an important incentive was the lack of investment in the water network under private ownership although the company had consistently reaped high profits another motive was the relative price increase for citizens that had been 78 over 18 years under private concession whereas the city council foresaw that for the next 15 years a relative increase of 18 would be sufficient to cover all costs of supply if the company would be brought back under public management the proposal to remunicipalize the water company was ahead of the elections made by the rap and strongly supported by aeopas and fnca that had organized local mobilization ahead of the election and made the remunicipalization of water management an important electoral issue the new city council organized three rounds of public consultations to ensure participation of citizens recalling the right2water initiative that in turn increased citizens support for remunicipalization an absolute majority in the city council approved the remunicipalization of water services in december 2016 this was a milestone in remunicipalizations as it was the first big city in spain that brought water service back in public hands according to the valladolid city council direct management would provide the highest profitability with the lowest tariff increase and include all necessary investments after 2 years in operation aquavall the new public water company had already saved e133 million equivalent to 4 of the citys total budget in 2018 so far the new public company has had a total turnover of e264 million much of the profits are now used to maintain and improve the citys sanitation and distribution networks tariffs have decreased to become among the 10 lowest in spain in a period of 5 years the public company invested 46 million euros in improving its services against a 20 million euros investment in the 20 years before by the private company the company has taken a place in society by putting emphasis on promoting responsible water use promoting healthy habits a commitment to respecting the environment and cooperation with cultural and sporting events and various social causes one of the success factors of the remunicipalization of water services in valladolid has been the public financing model water and sanitation services are entirely financed through tariffs and income remains earmarked for water services this public financing model that is comparable to the system in the netherlands has made aquavall independent from banks and led to a sufficiently large cash flow to ensure economic social and environmental sustainability the case of terrassa in 2018 after years of debate and social struggle the municipality took back control over the water company when the concession contract with agbar terminated the water remunicipalization process has been the result of a long and intense process that has had citizens themselves as the main driving force laying a first stone with the signatories of the pact for the public management of water in terrassa with the complicity of 8000 citizen signatures principles that must govern the management of the citys public service are new water policy and culture in the city improvement of efficiency and the effectiveness of the service the improvement of water quality the fight against climate change and the forecasting of policies for adaptation and protection of aquatic ecosystems we have to display everything that has to do with the human right to water and a fair price in relation to access to water thinking of a tariff system that integrates the concept of social justice and human rights the campaign aigua es vida a coalition of community groups trade unions solidarity groups and environmentalists in catalonia has focused on spreading information building links with ecological movements and pushing public debate on the issue they linked with diverse struggles looking at the social pact for water such as in connection with campaigns around housing austerity or democracy a water observatory was set up as means for citizen participation and to increase transparency and accountability of the new water company toward the inhabitants of terrassa the new democratic public model of water management governed democratically and according to a public ethos such as in terrassa is symbolic and may offer important lessons for other struggles the case of barcelona in barcelona agbar established a powerful historicallygrown monopoly over the urban water service provision extending beyond the citys borders by acquisitions of competitors and smaller concessions in 2010 a local court questioned the regularity of the contract forcing agbar and the government body of the barcelona metropolitan area to form a ppp model and to establish the mixedcapital entity aigües de barcelona empresa metropolitana de gestió del cicle integral de laigua sa as of 2012 abem consists of 85 private capital where a majority of 70 is held by agbar another 15 belongs to the holding group criteria and 15 to the amb abem and its subsidiaries manage and control up to 93 of the urban water supply in 23 municipalities of the amb and thus nine out of 10 customers depend on the water supply by the company group activist groups declared this an abuse of power by the company in collusion with political actors to save the private management involvement and thus their profit revenues under the guise of more public control in 2016 the catalan high court declared that abems concession acquisition without a public tender was illegal this was a victory for the aigua es vida platform that argued that only remunicipalization of services into a public and democratic management model could assure necessary investments measures to improve water quality protection of water ecosystems and simultaneously create a just and transparent tariff system a public consultation about a referendum for remunicipalization was organized in 2018 with the help of barcelona en comú the progressive municipal platform forthcoming from 15m and other social movements that has been governing the city since 2015 activists collected enough signatures but the referendum was blocked by the opposition of other political parties subsequently the mapid was formed to further coordinate protests and alternatives to private management within the amb private actors have often influenced policymaking and public debate about water services through their economic and political power tough legal action against any remunicipalization effort also played an important role in agbars strategy but the company had to comply with the catalan law against shutoff of water supply and accept tariff setting by the amb through their appeal in 2019 the spanish supreme court annulled the catalan high court judgment of 2016 given this setback for social movements the only remaining opportunity to remunicipalize water services by legal means would be to dissolve the contract at a high cost through a bailout currently there is no sufficient political will to enforce such procedures and the administrative structure as well as the heterogeneous political composition of the amb further impede what would necessarily be a remetropolitization however movements claims in the context of energy poverty and service problems during the covid19 pandemic increased public awareness about water rights as well as about the structural problems caused by the private management model the mesa social del agua andaluz as a result of cooperation between the rapandaluz la marea azul del sur and the red andaluz de nueva cultura del agua the social organizations trade unions mayors and public water operators agreed upon the above mentioned declaración de cadiz 2017 it has become a point of reference for the spanish water justice movement the social organizations including also environmental organizations wwf seobirdlife greenpeace and the agricultural organizations upa and coag have constituted the andalusian roundtable on water with a strong and active commitment to defend and promote the hrtws in andalusia in a tenpointplan prepared by the msaa an andalusian social pact for water is proposed that promotes a model of active fair and diverse citizen participation as the central axis of integrated water cycle policies it also puts the human right to water and a 100 public management of water services central to achieve socially ecologically and economically sustainable water management to combat the impacts of the climate crisis and to face the challenges of an environmentally and socially just hydrological transition with these proposals the andalusian coalition goes a step further than implementing the human right to water as it addresses explicitly the needed changes in intensive agriculture and largescale irrigation in 2018 the andalusian government was in a process of revision of the water supply regulation for which a group of social organizations proposed the incorporation of the hrtws into the water regulation with special attention to vulnerable people and with supply of a vital minimum amount of water for free to all citizens this proposal was not dealt with before the elections that year and was rejected when a new andalusian government came into power after the elections currently this struggle lingers on who wins who loses water struggles on the ground and in the media right2water landed on fertile ground in spain as it could engage with the already present antiprivatization sentiments in the country and build on previous social movements focused on water in spain the andalusian parliament unanimously supported a motion promoted by the spanish association of public water and sanitation operators and by the new water culture foundation for the recognition of the hrtws and to stop liberalization and commercialization of water services this can be considered a victory for social movements even when the andalusian government did not incorporate the motion in legislation both the right2water campaign and the initiativa2015social pact for public water were successful because they drew together support from many social organizations and labor unions that struggled against the encroachment of privatization impacting everyday life of people unlike in germany where the european right2water movement achieved a lot of media attention thanks to contingency of a wellknown comedian promoting the citizens initiative on tv the water movement in spain had to conquer the attention of media they did so successfully in the wake of the 15m movement as shown in figure 1 broad societal pressure appeared to be the strongest force to make governments and water utilities acknowledge water as a common good and a human right right2water could capitalize on growing dissatisfaction with water policy concerns about access to quality water and worry over increasing water privatization the campaign strengthened the spanish networks that campaigned against urban water services privatization processes and gave an impulse to remunicipalization processes with regards to water services in several spanish municipalities more than 50 municipalities and provincial councils approved in their plenary sessions that water figure the number of times that issues privatization remunicipalization or new water culture were mentioned in spanish newspaper articles in relation to water supply and the last two cumulative with water movement organizations in the newspapers over the past years source own research is regarded as a human right and that in their political and territorial geographies it must and will remain outside liberalization and commercialization the increasing number of remunicipalizations in spain was an achievement of the spanish movements they also proved to be able to combine national pressure on government with local actions to convince and persuade municipalities and citizens that a new water culture integrating social and ecological aspects of water management is urgent as we have scrutinized through various regional and supraregional cases the spanish movement was built on among others the three pillars of environmental justice demanding that its voice was heard and its demands for a socially just water service provision recognized the demand for public and democratic water services resonated widely in spain the pressure coming from social movements and from european governing bodies in response to right2water were a catalyst for local policy change in spain the focus in the debate on water services in the past decade shifted from privatization to remunicipalization remunicipalization was an unknown issue until 2013 claims for a new water culture the human right to water and remunicipalization are all part of the same struggle for water justice reason why we can witness a cumulative number of mentions in the graph in 2014 the number of cumulative prowater justice issues and actors surpass the number of water privatization in the newspapers moreover the spanish movements managed at the same time to turn the tide in local water management as they politicalmaterially achieved a halt to privatization of water and a sharp increase in water remunicipalizations since 2014 the social pact for public water is the continuation of struggles for water that emerged in times of austerity built on local initiatives and united a diversity of organizations in spain in a similar way as right2water had done in europe examples of how the social pact goes beyond the hrtws and the eci right2water demands become manifest in the level of concretization for instance as several movement leaders explain when it comes to materializing the human right to water we will demand the implementation of supply management with criteria of social equity in tariff policies to do this it is essential to guarantee a minimum provision between 60 and 100 l per person per dayand the commitment not to cut off the supply in cases of socially justified nonpayment they also make clear how the movement more than just claiming the hrtws also speaks out unequivocally against privatization we consider that water and its associated ecosystems are common goods that cannot be appropriated for the benefit of private interests this was also clearly expressed during our meeting with one of the fnca founding members pedro arrojo who as was mentioned is now un special rapporteur on the human rights to water and sanitation there is a direct relationship between the 2 billion marginalized people who lack safe and secure water and the state of our rivers polluted depleted or monopolized by antidemocratic forms of government arrojo cs explained to support river governance approaches with a transdisciplinary and transcultural orientation toward commoning and publiccommons cogovernance initiatives the un special rapporteur achieving better river governance without recognizing the critical role of societal movements in reclaiming environmental justice is impossible over the past decade the spanish water justice movement has developed from a single issue alliance to a broad movement in favor of a more democratic and holistic water governance in spain the call for the democratic management of water services ie that citizens are not just users and owners of the resource but also actively involved in the management has been successful this is a powerful claim running counter to neoliberalism whilst empowering communities to take back control as well as ownership conclusions by the end of the twentieth century struggles for water justice in spain started with the struggle against the top down management of water stemming from the time that franco ruled and water was seen as a commodity water activists first used the eu water framework directive and later the human right to water as tools to demand for a new water culture in which water is considered as a common good the fnca organized citizen water networks local branches to fight for ecologically sustainable and socially just water management at the local level inspiration came from struggles around the world but most from the italian water movement and from the eci right2water after the european commission recognized that water is not a commodity but a public good and water was exempted from the concession directive the european struggle slowed down but continued in spain with renewed energy struggles for water justice in spain coincided with austerity policies in response to the eurozone crisis and led to a confluence of social movements an extraordinary broad and strong movement took the struggle further from antiprivatization to prodemocratization of water management and away from the mercantilist view to a holistic ecosocial view on the governance of water the spanish movement now seems to be the voice that brings this ecosocial view to the global water policy arena human rights principles were already brought into the debate on water management in spain by the fnca since 2002 it did not resonate until water supply became an intense battle ground of commodification vs commoning and the negative effects of the mercantilizacion of water became more visible when austerity measures hit hard to the poor and indignados rose up against it the fnca rap the psap and msaa are all examples of collective actions to promote a public management of water and working toward water justice their struggles are forthcoming from or strengthened by the cooperation of the european right2water movement with movements in spain with the latter continuing the struggle for water justice in spain after 2014 in various and sometimes extended compositions led by the rap the spanish water movements achieved recognition of the hrtws from local and regional governments awareness around water as a common good and a growing trend of remunicipalizations of water utilities from 1 case to 14 cases in 8 years between 2006 and 2014 and from 14 to 40 cases in the following 8 years between 2014 and 2022 remunicipalization is the concretization of water justice struggles in spain through which the spanish movement has shown that its powerful and resonating discourse can achieve a shift in local water policy and change the paradigm the rap fnca and aeopas played an important role in the water struggles in madrid valladolid terrassa and barcelona they succeeded in prevention of privatization in madrid and the remunicipalization in valladolid and terrassa but did not achieve remunicipalization of water services in barcelona as we have explained the cases of madrid valladolid and terrassa are three examples of how social movements have led to the integration of societal values in water services each one combining and balancing the 3fold claim for recognition redistribution and representation differently in barcelona corporate and financial pressure on the municipality was too big to give in to the wish of the population however the catalan law against shutoffs and tariff setting by the amb can be considered as achievements of the water movement the mapid continue to mobilize for remunicipalization and plan to create a citizen parliament and a water service observatory to put pressure on private actors and on politicians although remunicipalization resonates with many municipalities the financial and legal barriers to reverse water management from private to public are seen as too high by big cities where corporations control water services debates about more democratic water governance are continuing especially in face of pressures on the water supply through climate change and economic crises this bottomup voice is proliferating as recently was shown in among multiple othersa side event at the un water conference 2023 organized by the spanish and european water movements the claim of the human right to water in spain goes beyond an anthropocentric hrtws it constitutes today in spain the banner of a movement that revolves around the concept of water as a common good and aims to build a model of participatory and transparent public water management the andalusian roundtable on water goes a step further by including ecological aspects and the agricultural sector in the struggle for water justice the fact that the hrtws and the concept of water as a common resonate with so many people seems to coincide with the pursuit of sovereignty of people over their life simple as in a slogan water is life or write water speak democracy it shows that people act to regain control over water and their lives the right2water movement spotlighted issues arising from water service privatization and liberalization and gave a european platform to local water struggles advocacy at the eulevel has helped to build momentum for water mobilization efforts in spain and reciprocally local mobilization in spain has helped right2water gain success at eulevel despite of different cultural and political motives and backgrounds at the different levels notwithstanding social pressure on government and despite the huge efforts by social movements implementation of the hrtws in law has not been achieved neither in the eu nor in spain nor in andalusia the main victory of the spanish water movement may be that it has overcome the differences between organizations and has built an extraordinary broad and strong movement for water democracy that serves as an example for many around the world data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding author publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher supplementary material the supplementary material for this article can be found online at 1200440full supplementarymaterial

in several cities and regions in spain there has been a fight against privatization of water supply in the past decade some cities have decided to remunicipalise water supply and debates about implementing the human right to water and sanitation have been held in many parts of spain following the success of the right water european citizens initiative this paper examines how the european right water movement influenced struggles for access to and control over water in spain from a political ecology perspective it explores how right water fuelled the debate on privatization and remunicipalization of water services and what heritage it has left in spain we unfold relationships with and between water movements in spainlike the red agua publicaand relationships with other networkslike the indignados movement and subsequently how water protests converged with austerity protests in di erent places these struggles took di erent shapes by deploying five case studies madrid valladolid terrassa barcelona and andalucía we look at how the human right to water and sanitation framework served as a tool for social and water justice movements struggles for water justice in spain are ongoing and we seek to identify the temporarily outcomes of these struggles and whether power balances in spains water services provision have shifted in the past decade

introduction smart cities need smart citizens 14 15 25 the discourse on smart learningecosystems provides a conceptual framing to recognise the presence of a high density of highskilled people in a given area 13 as an indicator of a citys smartness on the wholecity level such performance is influenced by factors such as the quality of education or city governance yet taking a closer look at specific citizen communities reveals peer interactions among citizens as a source of new or improved skills and abilities rather than being driven by explicitly formulated learning goals these peer learning activities are often motivated by citizens basic core needs for autonomy relatedness and mastery 8 close attention to citizen communities also emphasises the plurality of citizens skills and motivations as a key factor of the communitys capacity building enabled through diffuse design 18 in this paper we explore the opportunities interaction design and architecture journal ixd a n43 201920 pp 8 29 of leveraging learning processes happening during civic hackathon events as catalysts for selfdirected learning in citizen communities hackathons are fastpaced events where teams of participants hack together prototypes of existing or new services apps or products 2 22 29 civic hackathons are an increasingly popular kind of hackathon aimed at improving city services and citizengovernment relationships and promoting the use of governmentpublished open data 17 unlike regular hackathons that cater mainly to software developers civic hackathons welcome a more diverse crowd of participants for example code for america 5 is an organisation running dozens of civic hackathons each year throughout cities in the us each generating dozens of app and service concepts and prototypes applications developed in civic hackathons include innovative services addressing various aspects of peoples lives examples include mapping healthrelated resources and services in an urban area providing community members with legal advice or finding vacant properties that are suitable for local businesses 23 while there is clear value in civic hackathons as sources of such applications in this paper we focus on another underrepresented advantage of civic hackathons namely their role as loci for peer learning from this perspective citizens participating in civic hackathons not only do so to be provided with solutions to their problems but also to acquire the capacity to solve civic problems through the use of open data in the presented work we seek to answer the question of how to hack the hackathon format such that it can better support citizen communities in obtaining the ability to work with open data and thereby how to empower groups of citizens to outsmart the smart cities the premise of the hackathon format is that the participants focus on the making of concrete services or products involves a learningbydoing 10 approach where the created solutions function as boundary objects 28 reducing communication overhead and enabling peerlearning through showing and experiencing ways of doing things joint making activities as identified by giannakos et al 12 a accelerate research across involved disciplines b promote rigorous multidimensional and multidisciplinary methods experimentation strategies and metrics c facilitate easy starts of ambitious projects and d enable learning through construction activities such forms of learning are commonly practiced not only in brief events such as hackathons but also over longer periods by maker communities in places such as hackerspaces makerspaces or fablabs 16 the premise of these places is not only to allow for the collaborative making of prototypes but also to accelerate and catalyse the learning processes of involved people in the contexts of these places communities of practice 32 emerge where participants share skills with each other and perform routines of collaboration however in civic hackathons participants are diverse in that they don not share professional backgrounds and they have only limited time to establish a community of practice within the event in this context we expect there to be a divide between professionals with clearly defined expertise or roles relating to the theme of the civic hackathon and laypeople citizens interested in the theme itself we hypothesise that engaging laypeople citizens in activities involving prototyping with open data can have a twofold effect on the one hand laypeople citizens may not have technical coding or design skills but are experts in their lived experience 26 within the local context and challenges in that way in the spirit of cocreation 26 professionals can learn from laypeople citizens about the intricacies of the context they develop solutions for on the other hand laypeople citizens can learn from professionals about the opportunities of working with open data and developing open data driven services apps and products empowering them in the context of smart cities 30 the goal of the presented work has been to understand the general principles governing peerlearning in citizen hackathons and to explore facilitation mechanisms for increasing the communitys capacity to work with open data to this end as part of a consortium of the horizon2020 capssi project open4citizens we have organised a series of civic hackathons in five large european cities we have defined the civic hackathon as a 23 day pressurecooker event actively involving citizens with no prior knowledge of coding or other data skills in joint making of a preliminary prototype of a technological product or service using one or more forms of open data by executing and analysing the learning processes of participants in these events we aimed to understand the potential of prototyping with open data as a social learning activity 1 accordingly in facilitating the process our focus has been split between understanding a the discovery of new opportunities of meaningful open data applications in a civic hackathon context and b identifying ways to support bottomup communitydriven learning and sharing of data literacy skills such as data scraping basic data analysis or understanding opportunities and constraints in embedding a dataset in a service or app methods exploring learning processes in civic hackathons is uncharted territory within academia scarce literature on learning in regular hackathons for example 11 takes the perspective of supporting the learning of welldefined programming skills in civic hackathons however the emphasis lies on combining and improving a wide array of skills by working together across disciplines in contexts that may vary greatly across cultures and between communities involved in the hackathons for that reason our studies were set up in an explorative way leveraging semistructured observations and interviews as the main method of enquiry standardised across five civic hackathon cases the five civic hackathons were organised under the auspices of the o4c project in barcelona copenhagen karlstad milan and rotterdam the organisation and facilitation of the events was performed by local o4c consortium members in collaboration with local stakeholders including among others citizen groups local governments nongovernmental organisations and universities the general guidelines for the o4c civic hackathons were predefined by the o4c consortium members and provided to individual pilot organisers in the hackathon organisation handbook the handbook specified the shared elements of the hackathon process it indicated the actors to be involved in the process the phases of the hackathon process the tools to use in the various phases as well as other practicalities in the organisation of the hackathon the 23 day civic hackathon event was preceded by a prehack phase where among other activities the theme for each hackathon was defined participants were recruited and relevant datasets were collected each hackathon was superseded by a posthack phase where various forms of support were given to hackathon participants to continue developing solutions initiated in the hackathon and in order to sustain the community established throughout the prehack phase and the hackathon event the organisational setup of the actual hackathon event has been inspired by ideos inspirationideationimplementation process 3 as summarised in figure 1 its steps included open data introduction sharing inspiration articulating needs to be addressed brainstorming data validation exploration of data using a dedicated platform and toolkit scenario design prototype planning prototype hacking and pitching final concepts and prototypes in a plenary session for each of the steps process facilitation tools were prepared one or more data exploration and data analysis platforms were accessible to support the whole process at the same time the process facilitation was prescribed but with some flexibility allowing individual hackathon organisers to adjust it to local specificities and to the interests and prior skills of participants throughout each of the o4c civic hackathon processes data on these processes was collected in a standardised way across all events and recorded in a variety of forms methods for collecting process data included surveys of participants carried out before and after each hackathon the work process of all teams was observed and noted as well as photographed andor filmed throughout the event by designated researchers the aim was to capture group dynamics the process of collaborative solution development and the mood of the participants including ahha moments where groups progress towards the development of a concrete solution surged forward participants were interviewed during the event to further explore their motivations and the skills and experiences brought to the event in addition where relevant participants interest in and knowledge about open data was explored further through additional interviews the process data was collected in order to understand hackathon participants learning experiences in light of their backgrounds and skills motivations for participating their individual experience of the hackathon process and their perceived gains from the event the hackathon process data gathering was guided by the facilitation support scheme shown in figure 1 whose standardised format was specifically tailored to the o4c hackathons and to the hackathon activities through which the participants were steered by event facilitators captured data was organised according to process stages in templates standardised across all the o4c hackathon cases hackathon results including designs and prototypes were documented visually catalogued and shared with the participants subsequently collected data was transcribed where necessary and analysed by teams of consortium members local to each hackathon including coding and clustering by distilling and capturing resulting insights in the shared format pilot teams were able to capture and compare participants learning processes in hackathons the individual experiences of participants and facilitators working to create opendatarelated solutions were captured and translated using significant quotes and visuals this standardisation of data capturing and analysis across all five hackathon cases enabled comparison of performed processes such comparison led to insights into opportunities and challenges in tailoring a structured hackathon process and toolkit to contexts with different thematic challenges varying skills of facilitators and stakeholders a range of participant motivations and variable quality of available inputs including open data further the collected data has also allowed for an assessment of how the given factors influenced the individual and collective learning processes of hackathon participants the described data has allowed us to further outline a number of trends related to social learning in civic hackathons the five o4c civic hackathons process the process of the hackathons involved a mixture of activities in all cases the facilitation was carried out flexibly the facilitation scheme in figure 1 for instance was considered as an orientation map rather than a prescriptive sequence of phases and the facilitators were free to use other tools that might be more familiar to them the flexible facilitation resulted from pragmatic decisions by the pilot teams about how best to support a good experience for participants as well as learning about the process and the development of solutions to challenges posed within the time available table 3 summarizes the resulting key differences between hackathons as a result of facilitation adjustments the hackathon processes in barcelona copenhagen and karlstad resembled fast design sprints with concepts being designed on paper during the implementation phase the milan hackathon process was the closest to a typical coding hackathon while the rotterdam hackathon involved mainly conceptual and openended designs albeit converging in concrete sketched design concepts at the end in most cases use of open data was limited to finding inspiration in descriptions of other opendatadriven solutions and in descriptions of the available and possibly useful open data sets in some cases inspiration was found in performing adhoc data visualisations and analysis or simply browsing through available datasets and discovering intriguing facts the posthack phase was in all cases considered as the phase in which the concept could be implemented using the most appropriate datasets among participating teams two distinct types of activities were observed in all hackathons many teams engaged in extended discussing of topics related to the hackathon theme and their design response to it where views and ideas were shared and the teams direction determined this type of activity typically took place with all participants assembled around a table whiteboard or flip chart as shown in figure 2 plenary presentations of teams work performed in some cases during and in all cases at the end of the event were a special form of discussing during plenary presentations teams had an opportunity to exchange views and ideas as well as share technical approaches or data findings and in this way influence each others work team members also performed focused activities these activities typically entailed some form of making either performed as drawing writing or coding but always directed towards producing a form of concrete representation or prototype of a designed solution or its part during such activities participants focused on specific tasks such as drawing a screen layout a diagram or a scenario browsing through data or writing a snippet of code during some moments of focusing every team member performed an individual activity at other times one person would work on a task and one or more of the other participants would look over that persons shoulder trying to understand and follow that persons activity making comments and asking questions and in this way familiarise themselves with the skills and knowhow involved the discussing and focusing activities were performed iteratively in hackathons the organisation of the hackathon influenced some of these iterations by limiting their time although the number of iterations between forced presentation moments or breaks varied by team and hackathon the time duration ratios between discussing and focusing varied significantly between hackathons although no exact account of the duration of these activities was recorded per team a general comparison is possible based on our observations for example in the rotterdam hackathon mainly discussing took place with only short intervals of focusing in milan focusing was the dominant activity in the middle of the hackathon with discussing mainly taking place at the outset of the event in the copenhagen hackathon the focusing elements were integrated around plenary presentations of tools by the facilitators and organisers or of work in progress by the teams of participants interaction design and architecture journal ixd a n43 201920 pp 8 29 outputs assessment of artifacts generated by hackathon participants revealed the intricacies of the performed processes on the one hand the teams generated various forms of written notes throughout their process typically using postits at times without structure and at times using some of the prescribed facilitation formats this documentation mainly intended for internal communication within teams showed the dynamic nature of the processes and the mix of ideas from various domains intertwining with each other on the other hand the teams also generated various forms of service design representations and prototypes which provided a more legible albeit indirect account of their processes design representations and prototypes varied significantly in their forms across hackathons which can be attributed to differences in team compositions and facilitation however we could generally discern two types of prototypes and design representations following their correspondence with earlier discussed discussing and focusing activities of participants the first type of representations and prototypes was typically made together by entire teams during the discussing activity and can be characterised by their low fidelity these representations and prototypes were made quickly using adhoc techniques figure 3 shows one example a paper prototype 27 developed during the rotterdam hackathon such prototypes are makebelieve sketches of an app interface made on postits attached to a mobilephone cardboard mockup paper prototypes are almost instantaneous to make and can be used to crudely explore app functions and communicate them within and outside of the team figure 4 shows another example of the same type where a user scenario was explored and enacted using lego blocks during the copenhagen hackathon similarly to a paper prototype such a representation of a service allowed the team to both explore and rapidly validate the intricacies of the designed service as used in various contexts the second type of representations were highfidelity drawings models and prototypes made during focusing activities typically not involving extended cooperation in the process of their making such representations and prototypes had different roles depending on the phase of the hackathon initially they could only address a narrow aspect of a possible solution for example by making a visualisation of a subset of available data using a spreadsheet program later in the process they were combined into highfidelity prototypes and detailed representations of designed services providing a believable outlook of how a designed service might function and feel figure 5 shows an example of a website mockup generated during the barcelona hackathon that fits in this category here various parts created by different participants were integrated in a way that could provide an experience of using the designed service such prototypes were used during the final round of hackathon presentations in order to show how attainable the concepts were and that their further development would be useful in all cases participants used the final prototypes and design representations as tools to tell the story of the specific city problems on which they had worked during the hackathon and to explain their visions of how these problems could be addressed however the way in which the different types of prototypes were integrated in teams activities clearly differed they either dynamically elicited discussions and explorations of a topic or consolidated teams conclusions individual work and individual expertise to represent and communicate a single design solution results the twofold goal initially formulated for the o4c civic hackathons was to support citizens in a discovering new opportunities of meaningful open data applications and b bottomup communitydriven learning and sharing of data literacy skills the two goals have proven to be tightly interlinked the open data applications whether instantiated as lowfidelity sketched ideas or highfidelity working app prototypes functioned as boundary objects in the hackathons they supported the consolidation of participants skills and ideas confronting these with the world as well as communicating and reflecting on them consequently the open data applications have also supported the learning and sharing of data literacy skills as such they helped reveal different competences involved in the hackathons and participants different expectations the learning processes at hand have also proven to be more complex and difficult to measure than initially expected as they differed considerably between participants and cases this complexity of measurement was also reflected in the different criteria proposed for measuring such goals the o4c team had clear and quantitative criteria regarding the number of viable concepts developed in the hackathons and the number of startups or entrepreneurial initiatives triggered by each hackathon on the other hand the learning objectives were only qualitatively defined interaction design and architecture journal ixd a n43 201920 pp 8 29 on the basis of the preand posthack interviews that provided information about initial skills and expectations and about new skills and knowledge acquired during the hackathon such qualitative evaluation is also influenced by the different cultural backgrounds and on the diversity of skills among participants in the same team the learning outcomes the heterogeneous mix of knowledge brought by the participants to the hackathons and the varying conditions of accessibility of open datasets has made it difficult to perform a quantitative evaluation of the learning outcomes of this process the participants learning expectations were in fact related to their motivations for participating in addition different types of participants had different motivations as summarised in figure 6 interviews with the participants were not carried out assuming that these motivations corresponded to learning objectives instead the interviews aimed to define the effectiveness of the hackathon as a tool to address the participants expectations regarding open data aspects considered in the interviews were not only related to the use or disclosure of the data but also to the systemic effects that the hackathon can trigger in the process of innovation the interviews revealed two ways in which participants experienced learning during the hackathon process first the majority of participants confirmed that in some ways they have acquired new knowledge regarding the expected learning domain for example a participant interested in understanding the potential of open data learned about the existence of several relevant open data sources and their application to his area of interest second most participants indicated that their most valued learning experiences lay in learning unexpected things for example one of the civic activists indicated that she came to the hackathon to find resources for her project in the city budget and instead she learned how to use open data to build a business case for the community project independent of city funding yet above all the majority of participants have indicated that the main benefits they saw in joining the hackathon was in the social connections they made developing mutual understanding of each others skills and goals and an expectation that the team working together will be able to continue their joint work after the hackathon in this way the increased capacity of the community to work with open data is larger than the sum of individual learnings of the participating community members and is evidenced by open data applications generated in the hackathons open data applications the hackathon activities across the various pilots generated a number of concepts with different levels of maturity ranging from sketched ideas to working prototypes table 4 synthesises the results of the hackathons the number of startups created after the hackathon is an additional metric indicating where the relevance and maturity of developed applications was high within the distinction of level of development between concepts prototypes and mockups reported in table 4 there were some further disparities for instance some hackathons only developed paper prototypes whereas others developed high fidelity prototypes also mockups had varying levels of detail some of them were used as proof of concept for presentations in the posthack phase whereas others were the starting point for the construction of apps that were further developed up to the commercial stage the further qualitative analysis of open data applications not developed as part of the o4c project has revealed the potential of these applications to increase the capacity of involved citizen groups to leverage open data to learn and meaningfully transform their city outside of the timeframe of hackathon events for example a prototype app for mapping valuable trees across the city promised to further spread the knowledge and awareness about the importance of natural ecosystems in cities and gives citizens a tool to actively protect that ecosystem by taking collective action to protect trees when needed and based on facts rather than emotions the diversity and richness of the opportunities coming from such applications prompts a more open discussion of the opportunities of civic hackathons not just as onetime learning and capacity building events but also as parts of learning ecosystems at a larger timescale discussion the results of the presented civic hackathon case studies have enabled us to derive considerations about the nature of the learning processes involved we have structured these considerations based on the four perspectives of a individual learning b community capacity building c learning through prototyping and d civic hackathon facilitation individual learning perspective the individual learning perspective was evaluated through interviews conducted before and after each hackathon which gave the o4c project team a chance to compare initial expectations skills of participants and the actual experience of participants in the hackathon the five hackathons took different approaches towards recruiting participants and responding to the hackathon themes as a result the distribution of participant types has varied considerably across the hackathons this has led to different hackathon profiles and differences in the characters and roles of created prototypes for example the milan hackathon had the highest turnout of coders and prototypes included snippets of working code and detailed app mockups on the other interaction design and architecture journal ixd a n43 201920 pp 8 29 hand the rotterdam hackathon mainly involved citizen activists and municipality employees no code was developed and prototypes were limited to paper app mockups in the first case participants were able to improve coding skills while in the latter the focus was mainly on developing conceptualisation skills the interviews with participants and posthackathon surveys have revealed a different perspective than analysis of participant activities and prototypes alone would indicate the first trend was for participants to question the nonnuanced classification of their own expertise for example several municipality employees emphasised that they are also regular citizens one indicated that coding is a hobby of his to give another example the differences between designers and coders were often difficult to clearly articulate as many designers had some coding skills and many coders had experience in app design most participants also demonstrated design and creative thinking capabilities even if they indicated they did not have any the other trend was for several participants to indicate that their perception of the social or institutional group they represent is that it is composed of individuals of very diverse skills motivations characters and underpinning values for example a municipality worker in the rotterdam hackathon said citizens see municipality as one thing while there are many very different people working there at the same time municipality workers see citizens as one mass of people without understanding the differences between individuals the third trend was that there was rarely a single clearly articulated motivation for each participant to participate in a hackathon participants typically stated only very general motivations such as a improving ones skills by applying them to a practical case b learning new skills from others or c only indicating general curiosity in the hackathons theme andor open data the above trends allow us to conclude that strong profiling of participants is to a large extent futile in the context of a civic hackathon participants generally shared a lack of explicitly articulated motivations to participate in the hackathon while they exhibited multiple combinations of prior skills and abilities during the hackathon itself and the roles that individuals eventually assumed in their teams were dynamic and organic throughout the processes the above insights have inspired us to use the tprofile of a designer popularised by tim brown 3 to summarise these insights for further reflection in the tprofile the vertical leg of the letter t symbolizes one persons core expertise and the horizontal bar represents their general overview of other knowledge figure 7 uses the tprofile metaphor to indicate three learning opportunities that we have observed among hackathon participants independently of the specifics of their core expertise red arrows indicate enhancing existing core expertise green arrows indicate developing new expertises during a hackathon the blue arrows indicate gaining a broad view of opportunities coming from the skills of others ie getting a taste of diverse skills and knowledge involved in the design and development of an app or service the advantage of this model is that it does not specify what the core competence of the hackathon participant is only that there is one while differentiating between learning that may occur within that competence regarding other expert competences or on a very broad level community capacity building the formulation and evaluation of the community capacity building perspective is based on prehack and posthack interviews the hackathon pilots were organised with a premise of supporting citizens to learn datarelated skills while developing meaningful solutions to problems found in their city however in the posthackathon feedback participants indicated that learning about other participants views improving their ability to work in a diverse team and gaining new perspectives on the citys problems were the learning outcomes that they valued the most furthermore we have observed that while jointly working on solutions participants views of the problem they were facing and ways in which they were articulating their cityrelated values were also transforming for example in the rotterdam pilot one participant changed the attitude towards the city from its their job as a municipality to support our park financially to we should come up with a business plan for our park that we could pitch to the city officials consequently understanding and taking advantage of involved social learning 1 happening between participants and resulting alignment of their values and perspectives called for a deeper investigation in an attempt to explain its root causes and mechanisms another aspect concerning social learning was the growing perspective on open data as a new resource for public innovation or a new commons 21 the elaboration of this perspective was purely conceptual in rotterdam where the hackathon produced concept prototypes whereas it brought about a concrete application in milan where a specialised prototype was further developed and integrated in the existing web portal that informs citizens about the construction of the new metro line in their discussion on constructivist and sociocultural perspectives on learning packer and goiocoechea 24 conclude that acquiring knowledge and expertise always entails participation in relationships and community and the transformation of the person and of the social world where the person is constructed in a social context formed through practical activity we can expand this general perspective on learning in a community by considering the notion of shared cognitive models as cooke et al 6 argue shared cognitive models develop through interactions between team members and enable teams to address problems in synchrony we will further refer to such synchrony as collaborative learning alignment as it can be applied to situations where not only teams but also other more fluid forms of collaboration can interaction design and architecture journal ixd a n43 201920 pp 8 29 take place the above view of the intrinsic nature of social learning matches our need to consider hackathon participants identities not only as being unique but also as actively evolving aligning with each other and stimulating each others growth throughout the execution of the making activities during hackathons this kind of learning contributes not only to individual abilities or skills but especially to the capacity of the community as a whole to perform certain actions connecting to the notion of community capacity building 7 especially popular in the discourse on governance collaborative learning alignment in the social learning context expands on the considerations that the previous section accounted for regarding individual learning figure 8 indicates how we can use the proposed participant knowledge profile to address how participant profiles overlap and how the values and perspectives of participants align while specialised learning occurs notably the diagram also suggests that the specialised learning of one participant can trigger other participants to follow in obtaining knowledge in the same or related areas of expertise prototyping perspective having gained a better understanding of individual learning and community capacity building happening in civic hackathons the third perspective that we take focuses on the hacking of a prototype as an activity that differentiates a civic hackathon from other peer learning activities what appeared significant is the role played by prototypes and other forms of intermediate design representations we have observed that talking about the application of individual skills to an app service or product gave participants a way to both align their general views on addressed problems and to position their individual skills in the context of what would need to be done to bring such an app service or product into being this supports the role that carlile 4 gives to prototypes and design representations as boundary objects representing learning about and transforming knowledge to resolve the consequences that exist at a given community boundary articulating this role of prototypes in the learning process during civic hackathons has given us ground to extend our enquiry into the way in which prototyping tools introduced to participants support or inhibit the prototypes boundary object role for example a code snippet written by one of the participants extracting and processing data from one of the data repositories was a specialised and functionally useful ingredient of a potential app however in and of itself it had a very limited role in communicating to other hackathon participants about the merits of the problem being addressed conversely for example a paper prototype jointly developed by participants could be easily understood by all of them on the conceptual level and supported discussion and team alignment as illustrated in figure 9 both such types of prototypes can be related to the different types of learning that we have previously identified conceptual prototypes overlap with team alignment while specialised prototypes support specialised skill learning the proposed distinction of prototypes raises numerous new questions regarding process organisation and the facilitation of civic hackathons different forms of process facilitation and various selections of prototyping and design tools provided to participants in the civic hackathon can effectively guide the learning process towards either alignment of participants or specialisation in given knowledge areas facilitation perspective the organisation of the o4c civic hackathon pilots was inspired by the inspireideateimplement approach of ideo 3 considering our findings regarding the different forms of learning and different roles that prototypes played in this process we can attempt to gain additional understanding of how participants learning process is affected by the organisational context of civic hackathons and how this context can be expanded beyond the physical and temporal scale of the hackathon event in this investigation von hippels concept of sticky information 31 sheds particular light on the role of context and locality in learningbymaking communities it also draws attention to the notion of a community of practice 10 32 that hackathon participants are stimulated to form within and beyond the hackathon event those perspectives provide us with a rich framing for the capacity building process occurring in the civic hackathons where individuals learning processes align in respect to one another around the prototype and within the nested loci of the hackathon event and the city in which the hackathon team operates the above theoretical framing brings two facilitation problems to the foreground which open further areas of enquiry for the next stages of our research first is the question of the role of data prototyping tools these tools need to accommodate both the specialised and conceptual role and in this may be used throughout the stages of the entire process not exclusively in the final implementation stage second is the question of sustaining the capacity building locus beyond what the hackathon temporarily provides the civic hackathon processes we have facilitated had an apparently linear structure they started with prehackathon preparations proceeded through inspire ideate implement stages during a hackathon and were followed with posthackathon activities aiming to follow up on designed and prototyped ideas taking the learning perspective on understanding this process gives us a framing that allows us to conceptually expand our understanding of the learning process beyond the spatiotemporal scale of a single event the above consideration can be translated to a threestep framework for facilitation of civic hackathons as a means to support smart learning ecosystems in smart cities illustrated in figure 10 the three steps correspond to the three discussed perspectives for understanding learning in civic hackathons individual learning community capacity building and generation of prototypes are consequently three different aspects of civic hackathons that have different key performance and key behaviour indicators yet are all essential ingredients of a civic hackathon event performed together they constitute a positive learning loop where individuals skills contribute to the capacity of the community lead to applications of these skills in a complementary fashion to prototypes and enable individuals to learn from these prototypes conclusions research presented in this paper has explored the opportunities of leveraging civic hackathon events as catalysts for learning in citizen communities the aim behind the five civic hackathon cases involved in our research has been to improve citizens capacity to use open data and to enable citizens to participate in the process of developing open data applications it was our key assumption that making with data interaction design and architecture journal ixd a n43 201920 pp 8 29 by jointly designing and prototyping apps services or products during a pressurecooker civic hackathon event creates conditions in which citizens develop data literacy and apply it for the common good performing and analysing five civic hackathon processes has given us an opportunity to confirm this assumption it has also expanded our understanding of how such learning processes happen and how they can be supported in evaluating collected data we have reached out to theories originating from a variety of disciplines providing us with a crossdisciplinary perspective on the civic hackathon learning phenomenon its challenges and opportunities in our findings we have identified and scrutinised four perspectives of the civic hackathon learning processes namely a individual learning b community capacity building c learning through prototyping and d process facilitation across these perspectives a view of citizens as individuals with a unique composition of prior skills and knowledge prevailed next to our initial goal of supporting these citizens in obtaining datarelated expertise we recognised the relevance of their different skills and abilities for the development of valuable open data applications during the civic hackathons we have observed the alignment of involved citizens values and motivations including learning about each others viewpoints and expertises and developing shared visions as an essential component of their learning process in fact without a shared understanding among hackathon team members of the merit of other participants viewpoints skills and knowledge successful collaborative work on applying open data to solving complex social challenges would have been very difficult in keeping with van waart et al 30 we found the value of participatory prototyping in strengthening such shared understanding among the local citizen activist networks joint prototyping allowed participants to make their own specific expertise and its usefulness for the job at hand explicit to themselves and to other team members this encouraged both individual and social learning during civic hackathon events it also formed bonds and shared goals among participants to continue their joint activities beyond the hackathon event the collected insights have brought us to a general framework defining individual learning community capacity and learning through prototyping as three mutually enforcing learning activities in civic hackathons this framework promises to serve as a guideline for defining appropriate key performance and behavioral indicators for assessing learning in future civic hackathons we also hope this framework will be of use to civic hackathon facilitators by emphasizing the relevance of capacity building individual learning and the knowledgegenerating role of prototypes

this paper investigates the opportunities of leveraging a hackathon format to empower citizens by increasing their abilities to use open data to improve their neighbourhoods and communities the presented discussion is grounded in five civic hackathon case studies organised in five european cities the research revealed specialised learning and collaborative alignment as two mutually complementary aspects of the involved learning processes which were achieved with the help of highfidelity and lowfidelity prototypes respectively consequently the paper identifies and discusses three main factors required to sustain social learning ecosystems beyond hackathon events and with the purpose of democratising smart city services these factors include a supporting individuals in obtaining specific expert knowledge and skills b nurturing dataliterate activist communities of practice made up of citizens with complementary expert skillsets and c enabling members of these communities to generate prototypes of opendata services of varying fidelity

introduction available research suggests potential associations between community characteristics and physical and economic availability of cigarettes to youth however much of this research is limited by the number of community characteristics that have been included and the lack of diversity of the communities that have been studied moreover although some studies have modeled characteristics related to tobacco sales to youths none has modeled a full range of contextual characteristics together with community characteristics since illegal tobacco purchase attempts by minors occur in an ecological environment that includes various contextual and community characteristics this approach can highlight ways to tailor policies to more effectively reduce youth access to cigarettes via commercial sources the present study investigates the associations between a wide range of contextual and communitylevel characteristics and retailer compliance with underage tobacco sales laws and with cigarette pack prices in 50 noncontiguous midsized california communities reducing youth access to tobacco products from commercial sources through implementation and enforcement of policies that target retailers and clerks who sell such products to young people and increasing taxes and therefore cigarette prices are recommended to control tobacco use by youth 1 2 3 4 a comprehensive review that evaluated efforts to prevent the sale of tobacco to youth concluded that every intervention that has successfully disrupted the sale of tobacco to minors has been associated with an observed reduction in tobacco use by youth 5 also higher cigarette prices decrease cigarette smoking 6 7 8 particularly among youth who are more price sensitive than adults 910 contextual factors associated with youth access to tobacco products from commercial sources include characteristics of youth buyers and retail clerks research has shown that girls and older minors are more successful in their purchase attempts 11 12 13 14 15 findings related to characteristics of store clerks including gender and age are mixed for example a study which used federal compliance data from 36 states found that female clerks were more likely to sell tobacco to minors 13 in contrast other studies have found that illegal sales are more likely when a clerk is male 1216 or did not find any relationship between clerk gender and tobacco sales to minors 1117 similarly while studies by pearson et al 15 and difranza et al 18 found that clerks judged to be less than 18 or 21 years of age were more likely to make an illegal sale no such relation was reported in other studies 1117 a few studies that examined youth and clerk ethnicity have shown that white clerks were more likely to sell cigarette to youth 1219 and that cigarette sales to minority youth were higher than to white youth 1220 factors related to the retail environment have also been examined for example a lower likelihood of illegal sales rate was associated with chain stores compared to independent stores in california 21 in another study sales rates were highest in gas stations 13 and a study in a metropolitan county in washington state found that convenience stores selling gas were more likely to sell tobacco products to minors than restaurants bars and tobacco discount stores 15 ageofsale signs asking about the purchasers age and requesting purchaser ids were also associated with lower rates of underage sales 13161722 less is known about the relationship between youth access to tobacco products from commercial sources and community characteristics in one study rural location was associated with increased underage sales 13 a study by lipton et al 23 found that areas of higher sales to minors in los angeles had lower mean family income a higher percentage of foreign born residents and greater population density in southern california klonoff et al 24 found that minors were able to purchase single cigarettes in 712 of visits to minority neighborhoods but could do so only in 344 of visits to predominately white neighborhoods no neighborhood differences in illegal sales of cigarette packs were found 12 similarly in a case study in miami florida underage tobacco sales were significantly more concentrated in hispanicmajority neighborhoods 25 these investigations are illustrative but omit other important community characteristics such as tobacco policies and adult smoking prevalence that might also be associated with higher or lower sales rates focusing on economic availability a minnesota study of pack prices in one metropolitan area observed that the maximum price was 17 to 18 times higher than the lowest price for the same brand 26 a positive association between percentage of nonwhite residents and the price of discount and premium cigarettes as well as the overall mean price was found no such relation was found with the price of menthol cigarettes prices of premium cigarettes and the overall mean price were lower in neighborhoods with a higher percentage of youth going beyond previous research the present study examines the associations between a wide range of contextual and communitylevel characteristics and retailer compliance with underage tobacco sales laws and with pack prices in 50 noncontiguous midsized california communities methods study sample and survey methods this study used data from access surveys conducted by 4 confederate buyers who were over age 18 but judged to appear younger by an independent panel purchase attempts were made at 997 tobacco outlets in 50 midsized california cities to select 50 noncontiguous california cities the initial sample frame comprised all 138 california cities with populations between 50000 and 500000 we randomly sampled one city and then eliminated all contiguous cities all cities contiguous to those cities and those that were within a onemile radius of the selected city this process was repeated until 50 cities were selected the resulting sample of 50 cities is a purposive geographic sample intended to maximize validity with regard to the geography and ecology of the state 27 there were no significant differences between the sampled and the unsampled cities in relation to population size ethnic diversity household size and median household incomes twenty randomly selected tobacco outlets in each city were surveyed to collect information on compliance with underage tobacco sales laws and cigarette prices because comprehensive address lists for tobacco outlets in california are not available outlets were randomly sampled from lists created specifically for the current study shape files of parcel or zoning areas with recent zoning attributes were obtained from each of the 50 cities for 5 cities without usable geographic information system files a zoning map was obtained zoning code definitions were reviewed to indicate which areas could include tobacco retailers map books were made for field study coordinators for all but the five largest cities the map books included all retail commercial areas within the city for the five most populous cities retailcommercial areas were randomly selected until a minimum of 124 outlets were identified observations in the 50 cities then documented retailer addresses randomly selected tobacco outlets in each city were surveyed by a team of two buyers at each outlet a single buyer attempted to purchase a pack of marlboro or newport cigarettes which are the most popular cigarette brands among highschoolaged students 28 each buyer asked for marlboro in one outlet and newport in the next one if asked about their age they stated that they were over 18 years old and if asked for age identification they indicated they had none if a sale was refused the buyers left without attempting to pressure the clerk after leaving the outlet the buyer recorded the purchase outcome and outlet data on a standardized form these protocols have been successfully used in studies of youth access to alcohol 29 30 31 and tobacco 3233 institutional review board approval was obtained prior to study implementation measures retaillevel measures independent variables the following data documented by the confederate buyers after leaving the outlets were used age requested clerk gender approximate age of the clerk the number of customers in line at the time of the purchase attempt the presence of warning signs about tobacco sales to minors in the store and the type of outlet buyers gender and actual age were also included as variables in the analyses outcome variables the confederate buyers documented whether the sale was made whether asked to show an id and the price of the pack of cigarettes they purchased or attempted to purchase outlets where buyers could not ascertain the price of a pack of cigarettes during the purchase attempt were later telephoned we excluded three surveys in which the confederate buyer attempted to purchase a pack of cigarettes other than marlboro or newport communitylevel measures city demographics measures of city demographics were obtained from 2010 geolytics data 34 city characteristics included population density percentage of population under 18 years old median family income percentage of population that was africanamerican percentage of population that was hispanic and percentage of population with a college education all citylevel demographics were standardized adult smoking prevalence adult smoking prevalence in each city was ascertained from a survey of 8918 adults over the age of 21 years old conducted in the same 50 cities as a part of another study respondents were surveyed through a random digit dial computerassisted telephone interview and were asked whether they currently smoked cigarettes every day some days or not at all adult smoking prevalence was computed as the percentage of everyday and someday smokers in each city tobacco outlet density the total number of licensed tobacco retail establishments in each city was obtained from state of california board of equalization datafiles for september 2011 these data include the total number of licensed tobacco outlets by city and zip code but not outlet names or addresses outlet density in each city was calculated as the number of outlets per 10000 persons local tobacco retailer licensing data about localities requiring tobacco retailer licensing were obtained from the california american lung association website 35 cities were coded as having or not having a local tobacco retailer licensing ordinance cigarette tax cigarette sales tax information was obtained from state of california board of equalization data available online 36 this tax information represents the local tax in each city at the time the access survey conducted data analysis multilevel logistic and linear regression analyses were conducted with hlm version 604 software to adjust for clustering of observations within cities 37 intraclass correlations were 15 30 and 08 for whether the sale was made whether retailer requested id and cigarette pack price respectively icc results indicate that the between city variation is less for cigarette price than it is for whether the sale was made and whether retailer requested id these intraclass correlation values suggest that observations within the cities were not independent and indicate the value of including cities as a random secondlevel unit in predicting retail compliance with underage tobacco sales and clerk request for id all retaillevel variables were included as well as all communitylevel variables in predicting cigarette price only the type of outlet was included at the retaillevel together with all communitylevel variables additional analyses were conducted to examine the relationships between cigarette price and contextual and community characteristics by brand in each model variables at both levels were entered simultaneously the models assumed that slopes were fixed and only the retaillevel intercept coefficient was allowed to vary across cities unitspecific models were used to evaluate results of the logistic regression analyses results retailer compliance with underage tobacco sales laws overall rate of retailer noncompliance with underage tobacco sales laws in the 997 selected outlets was 143 descriptive statistics from the access surveys are in table 1 a multilevel logistic regression analysis was conducted to examine the relationships among retail and community level characteristics and retailer compliance with underage tobacco sales laws at the retail level buyers actual age the clerk being male and asking young buyers about their age were each positively associated with selling a pack of cigarettes none of the other retail level characteristics were related to noncompliance at the community level higher percentage of minors in the population a greater percentage of residents with at least a college degree and a greater percentage of african americans were associated with increased likelihood of noncompliance an additional multilevel logistic regression analysis was conducted to examine predictors of clerks requesting identification at the retail level the presence of ageofsale signage was positively associated with clerks requesting id buyers actual age decreased likelihood of clerks requesting id at the community level lower percentage of minors lower percentage of residents with at least a college degree lower percentage of african americans and local tobacco retailer licensing were associated with retailers asking for id insert table 2 here cigarette price pack prices ranged from 431 to 872 and varied greatly across outlets for the same brand the maximum price was 19 to 2 times higher than the lowest price results of a multilevel linear regression analysis to examine the relationships among retail and community level characteristics and cigarette prices are presented in table 3 results indicate significant associations between the type of the outlet and prices of a pack of cigarettes more specifically supermarkets charged significantly more for a pack of cigarettes than small markets whereas smoketobacco shops and drug storespharmacies charged less on average turning to community level characteristics higher cigarette prices were associated with higher median household income and a greater percentage of hispanics in the community similar results were found with respect to outlet type in the brandspecific models supermarkets charged more for both marlboro and newport and smoketobacco shops and drug storespharmacies charged less differences however were observed in the community level variables while higher median household income lower prevalence of adult smokers in the community and not having local tobacco retailer licensing policy were associated with higher prices of marlboro lower percentage of minors and increased percentage of hispanics were associated with higher prices of newport none of the other community level variables that predicted either general cigarette prices or marlboro prices were related to prices of newport discussion we investigated the relationships of a wide range of retail and community factors with youth access to cigarettes through commercial sources results of our investigation suggest that after controlling for a range of community level characteristics only a few retail level characteristics are important whereas results of previous studies indicated associations between sales of cigarettes to minors and various characteristics of youth buyers store clerks the retail environment and factors related to the purchase attempt 1117 19 22 we only found buyers actual age being a male clerk and clerks asking young buyers about their age related to successful cigarette purchases by underage appearing buyers this supports our argument about the importance of studying a full range of both contextual and community characteristics in order to highlight ways to tailor policies to reduce youth access to cigarettes via commercial sources more effectively our finding that asking young buyers about their age was positively associated with successful purchases is contrary to findings from arday et al 22 who reported the opposite our finding suggests that retailers who do ask about the age may sell cigarettes to youth who state they are over 18 years old without requesting proof of age interventions with retailers should emphasize the importance of requiring clerks to request proof of age regardless of if the person states that he or she is over 18 years old procedures to verify that clerks consistently check ids may be critically important if such policies are to be effective 38 the importance of store policies is further highlighted by our results showing that visible ageofsale signs were associated with an increased likelihood that the clerk requested proof of age similar findings have been reported regarding the presence of signage sales of alcohol to minors 30 it is possible that the presence of such signs reminds clerks to be vigilant or that posting signs is simply one indicator that a retailer has implemented consistent and effective policies regarding checking id our findings also suggest that youth access to cigarettes from commercial sources is easier in some communities than in others youth in communities with higher educational levels greater percentage of minors or greater percentage of african americans may have easier access to cigarettes from retail stores it is possible that retailers in such communities might have more trust that minors will not try to illegally purchase cigarettes are less concerned with youth smoking in their communities or believe it is less likely they will be the target of a compliance check this result supports the importance of enforcing laws that prohibit selling tobacco to minors in all communities the likelihood that a retailer will ask for proof of age is greater in communities with local tobacco retailer licensing strong licensing policies usually include a fee set to fund enforcement of tobacco sales to minor laws a provision that a violation of existing local state or federal tobacco regulation results in a suspended or revoked license and financial disincentives through increased fines and penalties 35 our results suggest that requiring a license to sell tobacco may help reduce youth access to cigarettes through commercial sources similar to previous studies 2639 our findings suggest that drug storespharmacies and smoketobacco shops may provide greater economic access to cigarettes for youth than do large supermarkets because previous studies have shown consistently that cigarette prices decrease cigarette smoking 6 7 8 and that youth are more price sensitive than adults 910 control over cigarette prices in such stores may help to reduce youth smoking establishing minimum prices for tobacco products may be one effective policy that can be implemented locally interestingly the relationships between community characteristics and cigarette prices varied by cigarette brand higher median household income lower prevalence of adult smokers in the community and not having a local tobacco retailer licensing were all associated with higher prices of marlboros the finding about the inverse relation between prevalence of adult smokers in the community and price supports other studies which consistently have shown negative relation between cigarette prices and cigarette smoking 6 7 8 also it is very likely that retailers charge more for cigarettes in communities with wealthy households the positive association between local tobacco retailer licensing and marlboro price may be explained by the other communitylevel characteristics identified in this study it is possible that wealthiest communities with fewer smokers tend to adopt local tobacco retailer licensing ordinances which may also reflect broader community norms that are less supportive of smoking and therefore price promotion the findings that the price of newport was lower in communities with higher percentage of minors and higher in communities with higher percentage of hispanics may explain why newports are popular among high school students and less among hispanics 28 in another study in california henriksen et al 39 found that the price of newport was lower in high school neighborhoods with higher percentage of black students finally different results regarding the associations between some community characteristics and marlboro versus newport prices may be explained by other factors which were not included in the current study for example it is possible that more extensive newport price promotion in communities with local tobacco licensing diminishes any potential effect such policies may have limitations the results of this study should be considered in light of some limitations first only two confederate buyers conducted the surveys in each city which limits our ability to consider characteristics of the buyers other than gender and age other studies for example have identified buyer ethnicity as significantly associated with increased youth tobacco sales 1920 second we only collected price data for marlboro and newport cigarettes although they are the most popular cigarette brands among high school students 28 they may not represent the range of prices among all cigarette brands third the crosssectional design of the study limited our ability to make directional inferences about relationships between contextual and community characteristics and outcome variables for example in understanding the relationships between the presence of ageofsale signs and clerk requesting for id it is possible that posting these signs is simply an indicator that a retailer has implemented policies regarding checking id rather than serving to increase clerks awareness about legal age despite these possible shortcomings this investigation enhances our understanding of the associations between contextual and community characteristics and youth commercial and economic access to tobacco such understanding can help policymakers to identify and target atrisk communities and outlets to decrease youth access to tobacco what this paper adds going beyond previous research the present study examines the associations between a wide range of contextual and communitylevel characteristics and retailer compliance with underage tobacco sales laws and with pack prices in 50 noncontiguous midsized california communities since any illegal tobacco purchase attempt by minors occurs in an ecological environment that includes both contextual and community characteristics this approach may help to highlight ways to tailor policies to reduce youth access to cigarettes via commercial sources more effectively acknowledgments

objectivesthis study examines contextual and community level characteristics associated with youth access to tobacco through commercial sources in 50 noncontiguous midsized california communitiesthe study is based on data from access surveys conducted by 4 confederate buyers 2 males and 2 females in 997 tobacco outlets city demographics adult smoking prevalence and measures of tobacco outlet density local tobacco retailer licensing and cigarette tax were included resultsmultilevel regression analyses indicated that buyer actual age a male clerk and asking young buyers about their age were related to successful cigarette purchases buyer actual age and minimum age signs increased the likelihood that clerks will request an id at the community level higher percentage of minors higher education and a greater percentage of african americans were associated with increased likelihood of a successful purchase lower percentage of minors lower education lower percentage of african americans and having a local tobacco retailer licensing were associated with retailer asked for id additionally supermarkets charged significantly more for a pack of cigarettes than small markets whereas smoketobacco shops and drug storespharmacies charged less higher prices were associated with higher median household income and greater percentage of hispanics findings about community characteristics however differed by cigarette brand conclusionsthis study enhances our understanding of the associations between contextual and community characteristics and youth access to tobacco through commercial sources which can help policymakers to identify and target atrisk communities and outlets to decrease youth access to tobacco

introduction around 850 000 people live with dementia in the uk 1 by 2040 this number is likely to increase by 57 2 people with dementia have high rates of physical morbidities that are primarily managed in general practice 3 reducing physical morbidity improves quality of life for people with dementia 4 and may slow cognitive decline 56 the dementia good care planning framework recommended an annual gp review as a minimum standard of care as a quality outcomes framework measure in 2015 7 routine physical health monitoring should include tailored management and prevention of comorbidities with medication nutrition and hydration reviews 7 uk policies prioritise fair access to health care 8 but inequalities exist in the uk people from black ethnic groups living with dementia are less likely to be diagnosed and people from asian backgrounds less likely to receive symptomatic treatments postdiagnosis compared with people from white ethnic groups 910 rates of physical morbidities are higher among people from black and asian backgrounds compared with the white population 911 so it would be concerning if health inequalities extend to preventive care for physical disorders the study aimed to examine routine physical health monitoring for people with dementia in uk primary care and investigate whether this differs between white black and asian ethnic groups as the main objective as a secondary objective the study investigated physical health monitoring for the overall population by comorbidity status informed by guidelines 7 and expert consensus routine physical health monitoring was defined for the study method this cohort study used electronic primary care records from uk gp practices contributing to the health improvement network database 12 which is broadly representative of the uk population at the time of data collection thin included 744 general practices and 156 million patients in 2016 in the uk most physical health monitoring of people with dementia happens in primary care 13 clinical data are coded using read codes 14 thin captures demographic information on sex ethnic group birth year and patientlevel townsend score 1516 study population individuals included were aged 50105 years contributing to thin between 1 april 2015 and 31 march 2016 to coincide with the qof recording year individuals with dementia were defined by a read code indicating a dementia diagnosis or an antidementia drug prescription as in previous studies 910 individuals who were registered with a gp practice in the relevant period and had received a dementia diagnosis or been prescribed antidementia medication prior to that date were included all gp practices met standard criteria for acceptable mortality reporting and computer usage 1718 outcome and patient characteristics good routine physical health care was defined as over 1 year a record of the following being received a dementia review a bp measurement a gp consultation weight andor bmi recorded and an influenza vaccination ethnic groups were catergorised based on office for national statistics classification 9 white asian black and mixed or other ethnic groups 9 individuals from mixed or other ethnic groups were excluded from analyses owing to small numbers for comorbidity status people were identified with a diagnosis of hypertension myocardial infarction stroke diabetes or chronic kidney disease covariates were age sex townsend score comorbidities and prescribing index age was grouped in 10year categories the last category was 90105 years owing to few individuals being aged 100 years analyses multivariable poisson regression was used to investigate the relationship between ethnic group and the outcomes models were adjusted for age sex townsend deprivation comorbidities and prescribing index irrs were calculated for outcomes comparing black and asian ethnic groups with the white ethnic group comorbidities were also stratified comparing the cohort with and without comorbidity characteristics of individuals were compared with and without the ethnic group recorded and complete case analyses were conducted for those with a record of ethnic group and townsend score missing ethnic group data were then imputed using multiple imputation by chained equations 20 compared with complete case analysis multiple imputation can greatly strengthen results by collating all the information available from individuals with observed data 21 this way information was used from the full dataset in the analysis to provide more precise estimates of the outcomes the multiple imputation results presented in this article are considered to be the primary results they were consistent with the complete case analysis stata was used results included individuals of the 20 821 individuals aged 50105 years in the study 10 570 had their ethnic group recorded of 10 570 individuals with a recorded ethnic group 966 were recorded as from a white ethnic group 21 from an asian ethnic group and 13 from a black ethnic group after multiple imputation of ethnic group 966 were from a white ethnic group 21 from an asian ethnic group and 12 from a black ethnic group the mean age was 798 years among this cohort 59 had diabetes 55 had hypertension 44 had ckd 23 had a stroke diagnosis 9 had an mi diagnosis and 13 had no comorbidity recorded there were some slight differences in age and sex distribution between those with and without ethnic group recorded annual dementia review an annual dementia review was recorded for 14 105 individuals with dementia there was no significant difference in the proportion of people with dementia from black asian or white ethnic groups receiving a review neither was there significant difference in the proportion of people with dementia receiving a review according to comorbidity status annual blood pressure monitoring at least one bp check was recorded in 16 611 individuals with dementia with an average of 29 bp recordings per person per year there was no significant difference in the proportion of people with dementia from black asian or white ethnic groups receiving at least one bp check those without comorbidities were less likely to have at least one bp check compared with those with at least one comorbidity number of gp consultations at least one gp surgery telephone or home visit consultation was recorded in 20 231 individuals with dementia there was no significant difference in the proportion of people with dementia from black asian or white ethnic groups receiving at least one gp consultation there was also no significant difference in the proportion of people with dementia according to comorbidity status receiving at least one gp consultation annual weight andor bmi recording a weight andor bmi was recorded in 9927 individuals with dementia compared with white groups black people were 23 less likely and asian people 16 less likely to have their weight recorded people with dementia without any comorbidities were less likely to have at least one weight and or bmi check within a year compared with people with at least one comorbidity annual influenza vaccination receipt of the annual influenza vaccination was recorded in 16 781 individuals with dementia there was no significant difference in proportions of people with dementia from black asian or white ethnic groups receiving the vaccination there was also no significant difference in the proportion of people with dementia according to comorbidity status receiving the vaccination discussion summary in this large uk primary care study only twothirds of people with dementia received an annual review despite guidance recommending this as a minimum standard 7 less than half of people with dementia in the study had a weight andor bmi recorded this happened less frequently in people from black and asian ethinic groups compared with white ethnic groups and less frequently in people without comorbidities compared with those with ≥1 comorbidity a fifth of people with dementia did not receive an influenza vaccine or a bp check within a year and only 57 of people with dementia without other comorbidities had a bp check ethnic group was not associated with differences in bp monitoring gp consultations influenza vaccination or dementia annual review strengths and limitations thin comprises around 6 of the uk population and is broadly representative in terms of demographic and health variables 13 ethnic group was imputed to address missing data and results from complete case and multiple imputation analyses were similar imputing missing data meant the full sample of individuals with dementia could be used to provide more precise estimates of outcomes people living with dementia were identified through a coded dementia diagnosis or antidementia drug repeat prescription which may exclude a small number diagnosed with dementia within secondary care and not captured in gp records the study focused on ethnic group as black asian or white as data at more detailed levels were not well recorded however this may have obscured smaller intragroup differences ethnic groups are considered to share a common ancestry culture and feeling of solidarity with one another 22 there is wide variation within minority ethnic groups in country of origin language religion socioeconomic characteristics and experiences but enough shared culture with regards to family structures identity and health beliefs to make ethnic group relevant to health behaviours 22 while some comorbidities were accounted for analyses may have been confounded by unmeasured variables affecting service use this study also had relatively low numbers of people from black and asian backgrounds which may have obscured smaller differences between groups the study investigated the likelihood of receiving at least one bp or weight andor bmi measurement which is a crude binary outcome and it is not known whether those with abnormal values received adequate treatment or followup while read codes were used to capture influenza vaccination delivered in other settings some may have been missed if they were not documented in gp records comparison with existing literature to the authors knowledge this is the first study to explore routine gp physical health monitoring and ethnic group in people with dementia the finding that black and asian ethnic groups are less likely to have their weight andor bmi recordedx adds to other known barriers to good dementia care for these groups 910 contextual barriers to helpseeking among these groups include negative experiences of health services and perceptions that caring is a family responsibility 22 23 24 however for most outcomes no differences between ethnic groups were found this may indicate that among people with dementia barriers to accessing physical health care are shared among all ethnic groups or that smaller differences between groups were undetected owing to small numbers of minority groups the study found weight andor bmi had the lowest rates of completion of all the component of monitoring studied so perhaps inequalities emerge in less routine care activities because clinicians are more vulnerable to unconscious bias when exercising more discretion lower levels of overall comorbidity were identified among white groups compared with black and asian groups as is consistent with the literature 911 the findings contrast with those investigating mental health care where minority ethnic groups are less likely to receive antidementia medication where potentially indicated and receive antipsychotic medication for longer 10 the impact of stigma on mental health care access compared with physical health care may explain this difference between 20022013 dementia annual review uptake was under 50 25 the results of the present study show an improvement in 20152016 7 but still a third of people with dementia had no review recorded despite most having at least one annual gp contact this lack of review is important as pressures on secondary mental health services are rising and responsibility for routine monitoring may increasingly fall to primary care guidelines for the annual dementia review are extensive they emphasise a tailored review to consider physical health mental health nutrition optimising polypharmacy care needs functional ability and endoflife discussions among other areas 7 such broad guidance may challenge gps facing workload and time pressures 26 some studies suggest that gps may believe they have little to offer patients with dementia 27 the rationale for the dementia review needs to be clearly explained including the importance of routine physical health monitoring to dementia outcomes other factors explaining low uptake may include varying qof renumeration 28 and stigma related to dementia 29 gps may be undertaking the dementia review tasks but not recording them as such while dementia detection and diagnosis rates in primary care are rising 30 the findings suggest optimal care postdiagnosis lags behind the study found less than half of people with dementia had a weight andor bmi recorded consistent with another thin study reporting 47 had this recorded in 20102013 25 and other reports of poor weight recording in primary care 31 eating and drinking difficulties are common in dementia the risk of malnutrition increases as dementia progresses and people with dementia have 10 times more malnutrition or dehydrationrelated hospital admissions compared with agematched controls 32 antidementia drugs causing side effects such as nausea can also exacerbate difficulties other research has highlighted concerns that nutrition support for older people is insufficient 33 and weight loss may not be recognised as a problem 34 the study found over 80 of people with dementia had at least one bp check one gp contact and the influenza vaccination confirming previous studies 2535 an annual bp check is not specified in guidelines although this was used as a marker of good preventive health care while some studies suggest that good bp control can reduce risk of further cerebrovascular changes others describe a complex relationship between optimal bp and dementia 36 people with dementia are more likely to experience postural hypotension and adverse effects of low bp 37 which is an argument for regular monitoring regardless of comorbidities however standard bp monitoring may cause anxiety 38 so should be considered carefully implications for research and practice the results suggest routine physical health monitoring for people living with dementia particularly nutrition monitoring is inconsistent and requires improvement much emphasis in primary care has been on dementia detection where meaningful improvements have been achieved and sustained priorities should now shift to postdiagnosis support 39 dementia should be considered a longterm health condition requiring routine monitoring in its own right at present guidelines for the annual dementia review are extensive prioritising components of the review that are realistic and achievable in general practice should be central to any revisions improved weight recording and management of nutrition should be prioritised promoting ethnic and sex equalities in access the role of bp monitoring particularly for people living with dementia without other cardiovascular risk factors should be considered by researchers defining best practice in physical healthcare monitoring and management of comorbidities could shape future dementia guidelines ethical approval the nhs southeast multicentre research ethics committee approved the use of thin for scientific research in 2003 the iqvia world publications scientific review committee granted scientific approval in march 2017 provenance freely submitted externally peer reviewed

background good physical health monitoring can increase quality of life for people with dementia but the monitoring may vary and ethnic inequalities may exist aim to investigate uk primary care routine physical health monitoring for people with dementia by a ethnic groups and b comorbidity status design setting a retrospective cohort study was undertaken using electronic primary care records in the uk method physical health monitoring was compared in people with dementia from white black and asian ethnic groups and compared those with ≥1 comorbidity versus no comorbidity from 1 april 2015 to 31 march 2016 using the dementia good care planning framework and expert consensus good care was defined as receiving within 1 year a dementia review a blood pressure bp check at least one a gp consultation at least one a weight andor body mass index bmi recording at least one and an influenza vaccination results of 20 821 people with dementia 68 received a dementia review 80 at least one bp recording 97 at least one gp contact 48 a weight andor bmi recording and 81 an influenza vaccination in 1 year compared with white people black people were 23 less likely and asian people 16 less likely to have weight recorded adjusted incidence rate ratio irr 077 95 confidence interval ci 060 to 098084 071 to 100 people without comorbidities were less likely to have weight recorded adjusted irr 074 95 ci 069 to 079 and bp monitored adjusted irr 071 95 ci 068 to 075 ethnic group was not associated with differences in physical health monitoring other than weight monitoring comorbidity status was associated with weight and bp monitoring physical health monitoring in dementia in particular nutrition requires improvementgood physical health supports quality of life for people living with dementia routine physical health monitoring in general practice can support this and should be accessible to all this is the first study to explore routine gp physical health monitoring and ethnic group in people living with dementia findings can inform policies promoting access to good postdiagnostic support

background alcohol consumption among adolescents is a common concern that is growing in most countries and notably hazardous and harmful drinking patterns seem to be on the rise 12 there is extensive evidence that alcohol and physical aggression are associated it has been shown that adolescents who display violent behaviour are more likely to exhibit problematic alcohol consumption than other adolescents 34 excessive alcohol use or drunkenness 5 similarly it has been demonstrated that adolescents who misuse alcohol have higher rates of violent behaviours 6 7 8 according to fagan 9 alcohol consumption provides a provocative context for violence rather than a direct cause whereas another study proposes alcohol consumption as a moderating variable with a conditioning and reinforcing role in explaining aggressive behaviour 10 results from a longitudinal study 11 focusing on the relationships between alcohol misuse antisocial behaviour and alcoholrelated problems at particular ages strongly support the reciprocal hypothesis alcohol misuse and antisocial behaviour establish a feedback loop in a jointeffects model whereas the susceptibility hypothesis is prevalent in the shorter term model similarly results from a study on alcohol and violence 12 suggest that alcohol has a magnifying effect amplifying underlying aggressive tendencies even experimental studies support a strong relationship between acute alcohol consumption and aggressive behaviour confirming the idea that acute alcohol consumption facilitates or increases the expression of aggressive behaviour in the body of research on the relationship between alcohol consumption and aggression aggressive behaviours have been investigated in many respects our study deals with alcoholrelated aggression defined as the cooccurrence of drinking and physical fighting within a single episode 14 in this instance questions remain concerning which alcohol consumption indicators are most suitable to measure the impact on aggressive behaviours although the average amount of alcohol consumed is consistent with a range of physical and social consequences a growing number of behavioural studies provide evidence that not only quantity but also patterns of drinking are measures that relate to drinking outcomes 11516 and notably to alcoholviolence association 4 besides frequency of use a basic parameter indicating the regularity of drinking one of the most studied characteristics is binge drinking which exhibits high prevalence among youth 117 other studies focused on alcohols negative effects report that the extent of drunkenness rather than total volume of alcohol consumed relates to acute consequences such as various types of aggression and violence 4 18 19 20 all the indicators above of alcohol use if combined can capture the diversity of drinking customs however a difficulty arises when they are used concurrently in multivariate analyses due to multicollinearity that may result from the high functional correlation among them to overcome this difficulty we propose a different characterization of drinking patterns that constructs a composite metric that combines standard alcohol use parameters such as frequency of consumption frequency of binge drinking and frequency of perceived intoxication this new analytical approach could provide more detailed information on the relationship between alcohol consumption and aggression moreover since it has been demonstrated 2122 that preferences for alcoholic beverage may reflect different attitudes towards alcohol consumption such preferences were also taken into account the connection between alcohol consumption and aggressive behaviour operates at multiple levels and is the result of a dynamic interplay among personal and socioenvironmental systems 23 this comprehensive approach incorporating concepts derived from problembehaviour theory 24 offers a theoretical framework for better understanding underage alcohol use a broad array of factors potentially affecting alcoholrelated aggression in adolescents has been identified in previous research for this reason a number of individual environmental and behavioural variables that may be either protective or a risk factor for adolescent behaviour problems were also evaluated both violent behaviour and alcohol drinking undergo significant changes during adolescence and age and gender can characterize both behaviours the same applies to substance use and leisure time activity another set of factors whose influence has been repeatedly assessed involves the socioenvironmental system in this context family function vs dysfunction as well as school performance and peer influence are welldocumented confounders that can impact involvement in alcoholrelated aggression 131823 thus the purpose of the present study was threefold a to test the ability of observed drinking patterns for association with alcoholrelated aggression b to determine if drinking patterns as evaluated in this study add value to common indicators of alcohol use and c to verify the role of a number of factors as mediators between drinking patterns and alcoholrelated aggression methods a full description of sampling and data collection procedures has been reported in the 2011 european school survey project on alcohol and drugs report 25 briefly standardized data collection was performed using an anonymous selfadministered questionnaire completed on a voluntary basis in the classroom setting the authorization of the school head to fill in the italian espad questionnaire by the students was required alcohol use indicators indicators of alcohol consumption were assessed for the month prior to the survey three questions from the 2011 espad core questionnaire were used as screens a during the last 30 days on how many occasions have you had any alcohol beverage to drink b think back over the last 30 days how many times have you had five or more drinks on one occasion c during the last 30 days on how many occasions have you been intoxicated from drinking beverages for example staggered when walking not being able to speak properly throwing up or not remembering what happened questions a and c had 7 response categories 0 12 35 69 1019 2039 and 40 occasions while question b had 6 response categories none 1 2 35 69 10 times alcoholic beverage preferences and their frequency of use were also considered using the question think back over the last 30 days on how many occasions have you had any of the following to drink possible choices were beer alcopops wine and spirits with response categories 0 12 35 69 1019 2039 40 occasions alcoholrelated aggression alcoholrelated aggression was evaluated on the basis of the following question because of your own alcohol use how often during the last 12 months have you experienced physical fighting the response categories were 0 12 35 69 1019 2039 and 40 occasions due to the low number of observations reported in the upper ranges the response was dichotomized experienced physical fighting is intended as direct involvement in a fight we use the term aggression in place of physical fighting in the current text other variables some other variables potentially affecting adolescent behaviour were also considered these parameters were grouped as follows a family parental monitoring family structure b substance use use of substances at least once during the last year vs none having smoked cigarettes daily during the last month vs less than one cigarette per day c school having missed school without a valid reason for 3 days during the last month vs less than 3 days having obtained high marks in the last term vs low medium marks d frequent vs infrequent leisure time activity sports practice going out in the evening slot machines gambling e friends behaviour with alcohol categorized as nondrinkers regular drinkers but few get drunk regular drinkers and most get drunk statistical analysis principal component analysis 26 was applied to the three indicators of alcohol consumption expressed as frequencies to obtain three independent factors representing different drinking patterns and used simultaneously in the regression model pca extracts a set of principal components obtained as a linear combination of the original indicators no rotation procedures were required to facilitate the interpretation of the factors the contribution of each indicator is the loading derived from the analysis a positive loading means that higher levels of an indicator are associated with higher levels of that factor and a negative loading means that lower levels of an indicator are associated with higher levels of that factor each principal component represents a certain amount of total variance in the data by using all components the total amount of variance is conserved the components obtained were interpreted in terms of different alcohol drinking patterns each pattern can be treated as a numerical variable similar to an assessment scale with a minimum and a maximum value in each pattern an increase of one unit must be interpreted in terms of the composite indicators and their specific contributions for example a pattern would result from a linear combination of the three indicators with positive loadings characterized by a scale that increases with frequency of alcohol use or binge drinking or intoxication separately or in combination in this pattern the minimum drinking pattern value is equal to zero and means no alcohol use in the last month and the maximum value is equal to the highest frequency of intoxication and binge drinking pearsons correlation was used to explore the relationship among the three indicators and between drinking patterns and frequency of use of specific alcoholic beverages logistic regression analysis was performed to verify the association between aggressive behaviour and alcohol consumption evaluated both as individual indicators and as drinking patterns individual indicators and drinking patterns were treated as continuous variables three models were evaluated univariate logistic regression using indicators representing alcohol use multivariate logistic regression using indicators indicating alcohol use and multivariate logistic regression using drinking patterns results are reported using beta coefficients and standard errors odds ratios and 95 confidence interval univariate and multivariate logistic regression models were used to control for potential confounding effects alcohol indicators were tested for confounding effects by jointly introducing them into the model and examining beta coefficients a change in beta coefficient greater than 10 was considered to be a source of confounding in model 2 multicollinearity among independent indicators of alcohol use was also evaluated using the variance inflation factor a vif that exceeded 5 was taken as an indication of multicollinearity 27 all other personal and behavioural variables had been previously tested using univariate analysis and those that appeared statistically significant were included in the multivariate regression model along with drinking patterns all the analyses were performed separately against gender statistical significance was set at p 005 all the analyses were performed using stata software version 101 results descriptive statistics overall the majority of students who have consumed alcohol during the last year were also current drinkers in fact 82 of them consumed alcohol at least once in the last month among them alcohol use without binge drinking or perceived intoxication was a common habit binge drinking without any experience of perceived intoxication was also significant whereas perceived intoxication alone occurred infrequently finally 14 of students reported at least one experience of binge drinking and at least one of perceived intoxication significant correlations were found among the three indicators for alcohol use and binge drinking r 057 for alcohol use and perceived intoxication r 040 for binge drinking and perceived intoxication r 047 regarding alcoholrelated aggression about 12 of students have been involved predominantly males but only 37 of adolescents reported involvement more than twice drinking patterns drinking patterns were calculated on the basis of current alcohol consumption among adolescents who had consumed alcohol at least once in the last year there was a portion of adolescents who did not use alcohol in the month prior to the survey drinking patterns identified by pca were defined as 1 drinking to excess 2 drinking with intoxication and 3 drinking but not to excess table 1 summarizes the pca results de pattern accounted for 65 of the total variance and was characterized by a positive correlation with the frequency of all individual indicators and is interpreted as the pattern of those who 1 drink frequently 2 report perceived intoxication and 3 do binge drinking when using a composite numerical variable the minimum value was zero and the maximum value was 10 thus an increase of one unit in de pattern indicated an increase in frequency of excessive alcohol use de pattern showed that experience of excessive drinking alcohol among adolescents is both related to binge drinking and to experiencing intoxication di pattern exhibited 21 variance and also a negative correlation with frequency of alcohol consumption a positive high correlation with perceived intoxication and a small negative correlation with frequency of binge drinking and it is interpreted as the pattern of those who 1 drink infrequently 2 report perceived intoxication but 3 do not binge drink the corresponding minimum composite value was 4 and the maximum value was 2 an increase of one unit in di pattern indicated an increase in frequency of perceived intoxication during every drinking experience and a decrease in frequency of binge drinking di pattern showed that perceived intoxication among adolescents was not necessarily linked to binge drinking and there was a proportion of them who experienced intoxication even if they drank infrequently dne pattern exhibited a variance of 14 and a positive correlation with frequency of alcohol consumption a positive but low correlation with frequency of perceived intoxication and a negative high correlation with frequency of binge drinking and it is interpreted as the pattern of those who 1 drink frequently 2 do not report perceived intoxication and 3 infrequently binge drink the corresponding minimum ordinal value was 1 and the maximum value was 5 an increase of one unit in dne indicated an increase in frequency of alcohol consumption without binging dne pattern showed that there was a portion of adolescents who experienced moderate alcohol use drinking frequently but without experiencing binge drinking or perceived intoxication figure 1 shows a threedimensional representation of the aforementioned drinking patterns points represent all the theoretical values that the specific pattern could assume in correspondence of the combination of frequencies of the three selected indicators the points are presented in shades of grey from light grey at the lowest value to dark grey at the highest as shown ed pattern had higher values at increasing frequencies of all indicators di pattern had higher values at increasing frequency of both alcohol use and intoxication dne pattern had higher values in correspondence with higher frequency of alcohol use and lower frequency of binge drinking correlation between drinking patterns and alcoholic beverages pearson correlation between the de pattern and frequency of the specific alcoholic preferences resulted in significant correlations with all beverages whereas significant negative correlations were reported for the di pattern for dne pattern weak significant positive correlations were found with all beverages association between alcohol consumption and alcoholrelated aggression the association of individual alcohol use indicators and drinking patterns with alcoholrelated aggression was tested using logistic regression analysis table 2 shows results from several models first individual alcohol indicators were analysed in a univariate model the higher the frequency of the three indicators the higher the likelihood of being involved in alcoholrelated aggression and in both genders second these alcohol use indicators were analysed using a multivariate model although as expected a positive association with alcoholrelated aggression was found for all the indicators changes in beta coefficients of more than 30 denoted a substantial confounding effect mean value of vif was greater than 5 with the highest value for frequency of alcohol consumption finally in model 3 drinking patterns only were examined in both genders all were significantly associated with alcoholrelated aggression but while de and di patterns correlated positively dne pattern had a negative correlation table 3 reports results from logistic regression between alcoholrelated aggression and drinking patterns controlling for the other variables no changes in drinking patterns association were observed in males whereas in females di pattern was no longer significantly associated with alcoholrelated aggression age was negatively associated with alcoholrelated aggression only for males investigating the influence of the drinking habits of peers having many friends who become intoxicated was more likely observed in male adolescents who exhibited alcoholrelated aggression overall illegal drug use truancy and frequent evenings spent outside of the home were habits strongly associated with alcoholrelated aggression and without distinction of gender cigarette smoking showed a strong association but only for males other factors such as achieving high marks at school and high level of parental monitoring were negatively associated with alcoholrelated aggression whereas frequent participation in sports evaluated only in males was more likely associated with alcoholrelated aggression discussion regardless of the minimum legal drinking age the experience of drinking alcohol is widespread among young people in italy our findings have shown that alcohol consumption was higher in male students and that for both genders alcohol use without major consequences predominated even if binge drinking was observed as a widespread pattern it can be also observed that binge drinking and perceived intoxication occurred jointly supporting the idea of identifying and using patterns of drinkingresulting in composite relationshipsrather than evaluating alcohol habits using a single indicator or by type quantity of beverage consumed in addition although the espad questionnaire clearly defines a drink a glassbottle can of cider a bottle of alcopops a glass of wine a glass of spirits or a mixed alcoholic beverage it remains quite difficult to estimate the actual amount of ethanol consumed as well as the individual sensitivity to any specific alcohol volume for this reason using pca results we have examined the impact of three styles of alcohol consumption on alcoholrelated aggression 1 alcohol consumption leading to de pattern the greatest risk 2 consuming alcohol infrequently but leading to perceived intoxication popular behaviour among adolescents in the so called dry countries but now also increasing in italy 3 drinking but not to excess a moderate approach that is poorly studied regarding alcoholic beverage preferences the de pattern appeared to correlate with consumption frequency of spirits more than other alcoholic beverages while di negatively correlated with consumption frequency of beer to a greater extent lastly the dne pattern correlated poorly with all beverages it would be important to explore this in future studies using the espad data particularly comparing different drinking cultures to assess whether drinking patterns are connected to new drinking habits in investigating the relationship between aggressive behaviours and alcohol use some studies have considered single parameters to assess drinking 2328 whereas other studies have evaluated the interaction of several parameters to characterize different classes of drinkers 29 or have utilized a single drinking pattern score obtained by combining several indicators 30 the analysis of drinking patterns is a key factor in alcoholrelated aggression as it draws information which otherwise cannot be inferred in our study the main advantage of this approach was to highlight a drinking pattern that has so far been little studied in fact our study not only confirms what is already known ie excessive drinking is associated with an increased likelihood of alcoholrelated aggression but it has also identified a negative association with moderate drinking in other words moderate drinking significantly decreases the likelihood of being involved in alcoholrelated aggression a finding confirmed in both genders it should be further investigated as to whether this is due to a protective role of this drinking pattern or to a more general moderate behaviour actually little is known about young people consuming alcohol at lowrisk levels only recently research has addressed this issue in an attempt to establish drinking guidelines for youth 31 for this reason the dne pattern deserves greater attention in future studies because it is a drinking style adopted widely among young italian drinkers and a thorough understanding of this pattern may provide additional perspectives on other behaviours in addition di pattern also merits comment although less strongly associated with alcoholrelated aggression compared to de pattern it provides an insight into the risky behaviour of those who drink infrequently without experiencing binge drinking reflecting the fact that alcoholrelated aggression is not exclusively related to frequent or compulsive drinking many other factors enter into the relationship between aggressive behaviour and alcohol use among adolescents some gender differences were detected by the logistic regression model in fact while in males the relationship between alcoholrelated aggression and all the three drinking patterns was not modified by the potentially confounding variables in females the association between alcoholrelated aggression and di pattern was no longer present this finding suggests that in females socioenvironmental characteristics underlying alcoholrelated aggression and di pattern are similar and therefore responsible for the association alcoholrelated aggression varied by age only in males demonstrating that involvement in alcoholrelated aggression was more likely in younger males and that this behaviour gradually changes through the teenage years the effect of age appears therefore relevant especially in males as shown also in previous studies 1828 furthermore the drinking behaviour of peers has often been considered influential compared to other studies that have evaluated only the number of peers who drink in our study we have considered different friends habits nondrinkers regular drinkers but few get drunk regular drinkers and most get drunk from our results associating with friends who drink alcohol doesnt appear influential as long as they do not consume alcohol in excess as observed by others 18 the genderspecific analysis reveals significant differences and underlines the differential impact for males and females of drinking patterns and of the other factors that play a role in alcoholrelated aggression other correlates were equally relevant for both genders as already shown 32 the use of illegal drugs resulted as always positively associated with alcoholrelated aggression indicating a tendency to concurrent problem behaviours in addition truancy and simply spending many evenings outside the home environment represent attitudes that can contribute to problematic behaviours and as found in our study to alcoholrelated aggression involvement overall from the outcomes of the analysis it can be argued that alcoholrelated aggression in young people is more commonly associated not only with drinking to excess but also with a number of features that express discomfort converging towards an overall risktaking behaviour some limitations of the study should be mentioned first data were derived from a schoolbased sample of adolescents thus excluding school dropouts and were selfreported second the definition of alcoholrelated aggression was based on a question that asked participants if they had experienced physical fighting because of your own alcohol use in order to answer to this question the participants must attribute their fighting behaviour to their alcohol use since the question specifically asks participants only about fighting behaviours that were attributed to drinking our analyses may underestimate the number of all fighting and drinking that cooccur since a portion of these occurrences may not have been attributed to the drinking third conclusions on the causal relationships cannot be drawn as the data were crosssectional moreover we recognize the lack of other important indicators such as the volume of drinking or the drinking context that could provide more comprehensive information regarding alcoholrelated aggression conclusions our results suggest that alcohol consumption alcoholrelated aggression and their relationship are the result of a more complex system in which many other factors play important roles leading to overall risktaking behaviours therefore for longterm impact efforts to reduce aggressive behaviour in youths and policies aimed at curbing alcohol use need to adopt a whole system approach that should include both regulatory interventions and concomitant strategies for reducing the negative consequences of problems once they have emerged with specific regards to alcohol consumption interventions involving education and returning to mediterranean cultural traditions could possibly encourage a more responsible approach to alcohol consumption and a greater awareness of the consequences of excessive drinking competing interests the authors declare that they have no financial competing interests authors contributions sm obtained the funding for the study vs and sm developed the study design lm managed the literature searches and summaries of previous related work vs and vl undertook the statistical analysis vs sm sp and lm interpreted the data lm and vs wrote the initial draft of the manuscript all authors contributed to and have approved the final manuscript

background although there have been a wide range of epidemiological studies examining the impact of patterns of alcohol consumption among adolescents there remains considerable variability in both defining these patterns and the ability to comprehensively evaluate their relationship to behavioural patterns this study explores a new procedure for defining and evaluating drinking patterns and integrating wellestablished indicators the composite measure is then used to estimate the impact of these patterns on alcoholrelated aggressive behaviour among italian adolescents methods data were collected as part of the 2011 european school survey project on alcohol and other drugs espad a national sample of 14199 students aged 1519 years was collected using an anonymous selfadministered questionnaire completed in a classroom setting drinking patterns were established using principal component analysis alcoholrelated aggression was analysed as to its relationship to patterns of drinking behaviour of friends towards alcohol use substance useabuse school performance family relationships and leisure activities results several specific drinking patterns were identified drinking to excess de drinking with intoxication di and drinking but not to excess dne a higher percentage of males were involved in alcoholrelated aggression compared with females in males the de and di patterns significantly increased the likelihood of alcoholrelated aggression whereas the dne pattern was negatively associated similar results were found in females although the di pattern was not significantly associated with alcoholrelated aggression overall cigarette smoking illegal drug use truancy limited parental monitoring frequent evenings spent outside of the home and peer influence associated strongly with alcoholrelated aggression conclusions our findings suggest that drinking patterns as uniquely monitored with an integrated metric can 1 explain drinking habits better than commonly used indicators of alcohol use and 2 provide a better understanding of behavioural risks such as alcoholrelated aggression environmental background also appears to strongly associate with this type of aggressive behaviour

introduction school culture is one of the oldest most complex and important concepts in education in relation to school improvement it has also been one of the most neglected school culture considers the basic essence of an organizations culture to be the deeper level of basic assumptions and beliefs that are shared by members of an organization that operate unconsciously and that define in a basic takenforgranted fashion an organizations view of itself and its environment culture describes the way the institution operates and acts as a screen or lens through which the world is viewed in essence it defines reality for those within a social organization gives them support and identity and creates a framework for occupational learning each school has a different reality or mindset of school life often captured in the simple phrase the way we do things around here it also has its own mindset in relation to what occurs in its external environment culture is thus situationally unique as can be seen in the example of two ostensibly similar secondary schools located in the same area and drawing from the same population with the same number of students attending them these two schools view these students their work and external constraints they face in very different ways a schools culture is shaped by its history context and the people in it like the larger social culture a school culture results from both conscious and unconscious perspectives values interactions and practices and it is heavily shaped by a schools particular institutional history students parents teachers administrators and other staff members all contribute to their schools culture just like other influences such as the community in which the school is located the policies that govern how it operates or the principles upon which the school was founded schein provides a more specific definition of organizational culture by emphasizing its elements as pattern of shared values norms beliefs artifacts underlying assumptions and value systems among a group of people according to schein the values reflect the philosophy ideology moral and ethical codes goals ideas and standards of the organization including basic essentials that provide judgments regarding what is wrong and what is right organizations possess a cultural perspective that is centered on a system of values that define patterns and functions of the organization the key functions identified by parsons as essential to the organizations cultural perspective and driven by its value system comprised of goal achievement change management teamwork and agreement on values goal achievement is the manner in which the organization establishes goals and mobilizes resources to attain these goals change management relates to the way an organization can adapt to changes in goals and procedures while teamwork pertains the way members relate to each other and their commitment to the organization in this study school culture meant the extent to which teachers manage changes in schools extent to which goals are achieved extent of coordinated teamwork extent to which students needs are satisfied and the extent of agreement on values like respect for one another in different school settings this is in conformity with kaggwa who defines school culture as a set of cultural unique behavioural conduct that differentiates a school from other schools in the same locality teachers job performance mainly depends on the teacher characteristics such as knowledge base sense of responsibility and inquisitiveness the student characteristics such as opportunity to learn and academic work the teaching factors such as lesson structure and communication the learning aspects such as involvement and success and the classroom phenomena such as environment and climate and organization and management if the teachers take care of these factors their performance can be enhanced to the optimum level proxies implemented by states and districts of nigeria to determine teacher quality have been woefully inadequate teacher entrance and exit examination scores years of experience advanced degrees and teaching credentials are either not related to student achievement or ratings of teacher effectiveness leigh and mead clearly bring out the fact that the quality of teaching has come down gradually world over the skills of teachers have come down due to outdated preparation on the part of the teacher and stagnant compensation schemes by the management of the educational institution this condition in the recent years for the teacher has led to very few growth opportunities and inadequate compensation structures the condition is worse with disadvantaged students who require excellent teachers but have the least capability leigh and mead in their suggestion for lifting performance of teachers have emphasized the need for periodical performance appraisal just as it is in the corporate or business organization teachers need to be periodically evaluated and the compensation structure will have to be based on performance an effective policy needs to be developed in order to modernize and enrich teacher quality for hiring evaluating and compensating aacha describes performance of teachers as the teachers ability to integrate experience teaching methods instructional materials knowledge and skills in subject matter delivery to students both inside and outside the classroom on the other hand obilade states that teachers job performance can be described as the duties performed by a teacher at a particular period in the school system in achieving organizational goals in this study teachers job performance meant the ability of teachers to perform their prescribed duties teachers job performance was operationalized as scheming of work lesson planning involvement in extracurricular activities involvement in discipline management involvement in guidance and counseling participation in staff meetings lesson deliveryactual class teaching maintenance of records of work and teachers physical presence in school bukhuni and iravo carried out a study to establish the effect of school culture on employee performance in public secondary schools in bungoma north subcounty kenya the study included 36 head teachers and 140 teachers from 36 public secondary schools the study findings revealed that employee performance was more likely to be enhanced in schools with established cultures the study further revealed a significant direct relationship between school values like employee collaborations and employee performance discrete indicators like beliefs convictions values norms philosophy mission vision goals assumptions and moral values also contribute to higher performance of a school a positive and strong school culture motivates teachers increases academic achievement by students increases job satisfaction commitment and cooperation among teachers increases teachers dedication to work the six basic components of culture in schools with high achievement among teachers are shared vision traditions collaboration shared decision making innovativeness and communication in a related study gruernet reveals that collaborative school culture is effective in building cooperation confidence purpose and team spirit leading to creativity and productivity in a school higher performance of teachers and students in schools is basically attributed to effective and strong cultures whereas negative cultures lead to poor performance the existing culture in a school may either serve as a hindrance or boost towards achieving school results according to lomax there is little chance for school improvement unless the issue of school culture is directly addressed the development of a strong school culture leads to higher performance of the institution through increased participation of teachers and other stakeholders in the school affairs literature review according to edelstein factors that reflect the schools culture like goal achievement shared ideology or mission cohesion and collaboration among teachers tend to increase job performance and effectiveness of teachers related studies by clark and mills reveal nine features of usually effective schools in which school culture is mentioned first according to clark and mills an effective school is characterized by an orderly environment with interpersonal relationships discipline collaboration consensus participative approach to decision making and all these cultures enhance commitment of staff members so that they perform their duties with due diligence school culture formation makes all members of the school to get involved making them able to identify and agree on the values beliefs ambitions intentions and purposes of the school and then individually or in small groups develop key words to encapsulate these values that constitute the school culture according to hopking et al effective schools exist within a climate of supportive culture in a related study glasser asserts that cultural conditions like change management and goal achievement are necessary for the growth and expression of employee potential according to deal and kennedy school cultures can improve educational productivity culture provides an internal cohesion that makes it easy for teachers to teach students to learn and for parents administrators and the rest of the school community to contribute to instructional processes school culture determines how the school needs to function to become effective school culture impacts teachers engagement by influencing the kind of attitude students demonstrate towards schooling and participation in school activities kruse and louis further add that the culture of a school plays a significant role in fostering its outcomes including teacher effectiveness some studies have revealed that the relationship between many cultural attributes and high job performance has not been consistent over time according to burke changes in school culture are either positive or negative and these changes in culture affect every aspect of the school further studies concur with burke since norms guide attitudes and behavior of members of a school and they act as strategies to bring about change and improve productivity of the school deal asserts that school reform policies are only successful when tied to school culture sarason further noted that if change is to improve the climate and outcomes of schooling for both students and teachers then some features of the school culture need to be changed or else the wellintentioned efforts get futile ghanney antwi and humu conducted a study in ga south municipality ghana to investigate the effect of school culture on teachers job performance in private and public basic schools ghanney antwi and humu collected quantitative data from 46 teachers using census sampling the study findings revealed that school culture was a good predictor of teacher job performance the study further revealed that adaptability culture significantly contributed to teacher job performance whereas involvement culture that involves team orientation did not significantly contribute to teacher job performance some scholars have revealed that establishment of a culture of professional learning communities is a good strategy for improving schools and helping students to learn at high levels the professional learning communities help teachers collaborate and build social relations to discuss their profession to enable them to perform their fundamental duty of getting committed to the learning of every student dufour et al further explains that professional learning communities have a collaborative culture made of collaborative teams working interdependently to achieve common goals of impacting their classroom practices hence better outcomes for learners staff and the school as a whole some studies on effective schools reveal that clarifying and reaffirming the goal of a school makes the school effective the clarity of the goals among members makes them to be more effective by establishing priorities and guiding decisions the school goal helps members to create a compelling attractive and realistic future of what they wish the school to become hence the staff is able to drive the school to where it hopes to be when the goal is shared school values as a constituent of school culture are collective commitments that answer the question how must we behave to create a school that will achieve our purpose dufour argues that when members understand the purpose of their school know where it is moving to and pledge to act in certain ways to move it in the right path they do not need prescriptive rules and regulations to guide their daily work according to fullan creation of a school community with shared commitment increases its effectiveness macneil prater and busch support the notion that schools with good cultures have highly motivated teachers who have greater success in terms of student performance and outcomes in a related study omusonga kazadi and indoshi revealed that there was a strong correlation between school culture and students performance in french language as a result of teacher participation in french cocurricular activities such as observance of french days music and drama festivals many teachers in unfavorable school cultures lack commitment to their social systems and this inhibits teacher collaboration motivation problem solving community building and achievement according to kamaroellah and mubarak school culture has a significant influence on work satisfaction and motivation which then influence job performance the best employee is really satisfied with his job and this employee will show his best performance nakanwagi conducted a study in wakiso district to examine the influence of school culture on students academic performance in private secondary schools the study findings revealed that school culture in form of strategic direction sets standards and helps to galvanize the efforts of all staff members towards a common goal owens the school culture plays a significant role in defining for teachers their commitment to task it evokes the energy of teachers to perform their tasks loyalty and commitment to the organization and its ideals sergiovanni revealed that in successful schools culture serves as a compass setting to steer people in a common direction provides a set of norms that define what people should accomplish using suitable techniques provides source of meaning and significance for teachers school heads learners and others as they work schools with strong cultures have a vision of excellence while those with weak cultures lack understanding determination and drive to accomplish assignments cheng carried out a study in hong kong to observe the crosssectional relationship between school culture and organizational characteristics the study findings revealed that schools with strong cultures are effective characterized by higher teacher job commitment higher teacher morale all which culminate into higher teacher job performance schools with weak and ineffective cultures on the other hand had low teacher job commitment low teacher morale and low job performance methodology research design the study used a crosssectional survey design this study design was used because it typically involves collection of data at one point over a short period of time to provide a snapshot of the outcome and characteristics associated with the population data collection tools self administered questionnaires were used to collect data from study participants with perceived school culture a thirtyitem organizational culture assessment questionnaire with a validity of 096 and reliability of 089 adapted from sashkin and rosenbach was employed this was based on a fivepoint likert scale with teachers job performance a sixteenitem teachers job performance scale with a validity of 0849 and reliability of 087 adapted from kigenyi kakuru was used this was also based on a fivepoint likert scale reliability and validity content validity was established through interjudgement four judges rated the items on a twopoint scale of relevant and not relevant the content validity index was calculated by summing up the items considered relevant divided by the total number of items in the questionnaire organizational culture assessment questionnaire had a validity of 096 and teachers job performance scale had a validity of 0849 were used which were all above 070 making the scale valid the reliabilities of the instruments were determined using the cronbachs alpha provided by spss internal consistency of the instruments was determined by piloting the questionnaire to 10 of the study population for those who will not be part of the actual study the questionnaire was administered twice to the same population and the two scores were correlated using cronbach alpha coefficient a cronbach alpha coefficient of 089 was obtained for organizational culture assessment questionnaire and 087 was obtained for teachers job performance scale data collection procedure an approval was sought from mbarara university of science and technology research ethics committee permission was sought from municipal inspector of schools and the head teachers of the respective government aided secondary schools consent was then sought from the respondents and thereafter administered questionnaires data from the structured questionnaire was coded by assigning values to responses and entered into spss version 200 percentages were employed to describe the sociodemographic data of teachers descriptive analysis was used to generate means for objective one and two pearson correlation coefficient was used to determine the association between perceived school culture and teachers job performance results and discussion research question 1 what is the perceived school culture in government aided secondary schools in sheema municipality mean scores in reported school culture ranged between 270 and 480 with a mean of 398 the largest percentage of teachers reported strong school culture and 226 reported moderate levels no significant mean differences in school culture were found among teachers of different age groups education level teaching experience and gender research question 2 what is the level of teachers job performance in government aided secondary schools in sheema municipality mean scores in reported teachers job performance ranged between 250 and 500 with a mean of 417 majority of teachers reported high level of job performance and 88 reported moderate levels of job performance in terms of demographic variations teachers job performance was independent of age gender and time spent in service however statistically significant differences were found between teachers of different academic qualifications teachers with post graduate diplomas and masters degrees reported higher performance levels than all other groups h0 hypothesis there is no statistically significant relationship between perceived school culture and teachers job performance in government aided secondary schools in sheema municipality pearson correlation coefficient between perceived school culture and teachers job performance was significant there was a weak positive correlation between perceived school culture and teachers job performance school culture explained only 84 of the variance in teachers job performance the null hypothesis which states that there is no statistically significant relationship between perceived school culture and teachers job performance in government aided secondary schools in sheema municipality was therefore rejected pearson correlation coefficient between perceived school culture and teachers job performance perceived discussions the study findings showed that strong cultures exist among government aided secondary schools in sheema municipality especially coordinated teamwork and satisfaction of students needs the findings further reveal that there are high levels of job performance among teachers in government aided secondary schools in sheema municipality the study findings revealed that a significant relationship exists between school culture and teachers job performance the findings agree with a study conducted by bukhuni and iravo who conducted a study in bungoma north subcounty kenya to establish the effect of school culture on employee performance in public secondary schools their findings revealed high levels of job performance in schools with strong and established cultures it further revealed that there was a direct relationship between school culture attributes like teacher collaboration and job performance cheng conducted a study in hong kong to examine the crosssectional relationship between school culture and organizational characteristics including job performance the findings revealed that schools with strong cultures were characterized by high levels of job commitment teacher morale and job performance it was further revealed that schools with weak cultures had low levels of job commitment morale and job performance chengs findings especially on the relationship between school culture and job performance are in consonance with the findings of the present study that revealed a positive significant relationship between perceived school culture and teachers job performance ghanney et al conducted a study in ga south municipality ghana to investigate the effect of school culture on teachers job performance in private and public secondary schools ghanney et al collected quantitative data from 46 teachers using census the findings revealed that some dimensions of school culture like change management contributed to teacher job performance this agrees with findings of the present study it comprised of dimensions of school culture like change management and also revealed a significant relationship between school culture and teachers job performance however in the same study ghanney et al revealed that teamwork did not significantly contribute to teachers job performance thus disagreeing with the findings of this study the findings further agree with edelstein who asserted that factors that reflect the schools culture like goal achievement shared mission cohesion and collaboration among teachers tend to increase job performance the findings also agree with kamaroellah and mubarak whose study revealed that school culture has a significant influence on work satisfaction and motivation which then influence job performance the major study limitation was that the study only focused on a quantitative research approach and this narrowed the researchers understanding of the relationship between school culture and teachers job performance the study dwelt on only teachers and therefore generalizing the results to other staff should be done with caution the study was carried out in only government aided secondary schools and the results may not easily be generalized for private secondary schools the research findings will assist school head teachers to uphold strong and good cultures abandon weak and poor cultures and strengthen weak cultures where necessary and possible to boost job performance among teachers for increased teacher efficiency and effectiveness the study findings will help teachers to understand the vitality of a school culture and work towards maintaining and strengthening meaningful school cultures for policy makers the understanding of school culture may be of paramount importance in the education management process and the findings may help them to come up with better strategic policies that can promote positive school culture that may improve teachers job performance the aim of the study was to explore the relationship between perceived school culture and teachers job performance in government aided secondary schools in sheema municipality the study findings revealed that school culture has a positive significant relationship with teachers job performance implying that strong cultures promote better performance of jobs by teachers and weak cultures negatively affect teachers job performance levels conclusion and recommendations conclusion the study findings showed that strong cultures exist among government aided secondary schools in sheema municipality especially coordinated teamwork and satisfaction of students needs the findings further reveal that there are high levels of job performance among teachers in government aided secondary schools in sheema municipality and this differs from nsubuga and the sheema municipality statistical abstract school culture significantly relates to teachers job performance implying that strong cultures promote better performance of jobs by teachers and weak cultures negatively affect teachers job performance levels recommendations 1 school administrators board of governors and other stake holders should put in place strategies to maintain high job performance among teachers through practices like proper definition of goals and school mission and vision delegation use of good human resource management practices and motivation among others 2 the ministry of education and sports should come up with clear training programs for teachers so that they are taught about the vitality of upholding strong cultures in their schools in a bid to support higher job performance

the purpose of the study was to explore the influence of perceived school culture on teachers job performance in government aided secondary schools in sheema municipality uganda the study was quantitative and adopted a crosssectional survey research design a selfadministered questionnaire was used to collect data from 252 respondents using census strategy descriptive statistics were used to analyze objectives 1 and 2 pearson correlation coefficient was used to test the relationship between perceived school culture and teachers job performance the study findings revealed that 774 of the teachers reported strong school culture and 226 reported moderate levels of school culture it was revealed that 912 of teachers reported high levels of job performance while 8 reported moderate levels of job performance the study established that positive significant relationship exists between perceived school culture and teachers job performance r 29 p ˂ 01 the findings agree with studies conducted by bukhuni and iravo 2015 edelstein 2012 and kamaroellah and mubarak 2019 the study findings however disagree with ghanney et al 2017 the study recommended that the ministry of education should come up with clear training programs for teachers to teach them about the vitality of upholding strong school cultures in their schools to boost job performance

introduction unmarried adolescent pregnancy is a major health and social problem in many developed as well as developing countries with unique medical and psychosocial consequences for the patient and society despite a high female literacy rate in kerala observational studies suggest that many unmarried adolescents seek abortion majority of them report in the second trimester and few go for unsafe abortions leading to complications like septic abortion future infertility and even maternal death as pregnancy among unmarried is a highly sensitive issue a large proportion of these abortions go unreported resulting in paucity of data on this results of few studies available cannot be implied to indian scenario due to cultural difference as premarital pregnancy is considered a taboo here in kerala no analytic study is available exclusively on unmarried adolescent pregnancy and their risk factors it is in this background this study was undertaken to identify the factors leading to pregnancy among unmarried adolescents and young adults of kerala the study was designed as a casecontrol study sample size with the smallest acceptable odds ratio as 2 alpha error 5 beta error 10 with single control per case 181 cases and 181 controls were recruited for the study consecutive sampling technique was adopted in the selection of cases and controls cases unmarried adolescents and young adults attending family welfare clinic of the three major government postgraduate teaching hospitals of kerala ie medical college thiruvananthapuram kottayam and kozhikode seeking abortion services were the cases controls unmarried nonpregnant adolescents within the same age range receiving services at the same study hospitals were the controls those who failed to give consent and who did not cooperate were excluded from the study data collection data were collected from october 2004 to july 2006 using a prepiloted structured interviewer administered closed ended questionnaire and information was elicited on sociodemographic characteristics familyrelated factors and individual factors owing to the sensitive nature of the research for deriving community relevant variables to be included in the study focus group discussions were also conducted among doctors nurses teachers and mothers of unmarried girls b24 years ethical issues the study was started after obtaining ethical clearance from the institutional review board informed consent was sought from respondents for minors parents consent was taken data analysis the data were analyzed by means of spss software and epi info 33 versions bivariate and multivariate analyses were performed and the risk factors for unmarried adolescent pregnancy determined subgroup analysis stratified by age were also done test of association was by chisquare odds ratio and 95 confidence interval computed as the estimate of relative risk results of bivariate analysis distribution of abortion seekers according to age is shown in the pie chart unmarried girls ranging from age 13 to 24 reported for pregnancy termination out of the total 181 abortion seekers 20 cases were below the age of 16 70 cases were between 17 and 19 years and rest of them ie 91 cases were 19 years sociodemographic characteristics as shown in table 1 majority of cases and controls were hindus hailing from nuclear families and also from rural areas no significant difference was observed between the study and control group with respect to religion family type and residence however the bivariate analysis showed significant association between unmarried pregnancy and low socioeconomic status those with low socioeconomic status were found to be having 4 times higher risk for unmarried pregnancy familyrelated factors the three main variables studied under familyrelated factors were family problem parental control and intrafamily relationship family problem it is evident from table 1 that 646 of the cases hailed from problem families when compared to 144 of the controls in the present study family problem was due to any of the following reasons broken family children from polygamous families parents with marital disharmonyproblematic stepfather relations extreme povertymentally challenged parentsvery old and debilitated parentssingle parent without family support etc the study pointed out that the chances for unmarried pregnancy was nearly 11 times more among adolescents from problem families parental control majority of cases had lack of appropriate parental supervision and control it is found that those with no control or strict control by parents had 14 times higher risk for unwanted pregnancy and this was found to be statistically significant intrafamily relationship association between intrafamily relationship and adolescent pregnancy indicated that 74 of the cases had poor intrafamily relationship compared to 155 of controls and showed nearly 15 times higher risk for unwed pregnancy individual factors the important variables studied were education occupation and knowledge about sexual and reproductive health educational level more than threefourth of the cases had studied only up to 10th standard or less and those girls with less number of school years were 4 times more likely to have an unwanted pregnancy productive engagement adolescents and young adults not engaging in any productive activity were more in the cases than in the control groups they showed 2 times higher risk for unwanted pregnancy sexual and reproductive health knowledge this variable included knowledge about menstruation conception sexually transmitted infections contraception and safe sex it was found that lack of knowledge on sexual and reproductive health had a significant association with unmarried pregnancy the poor knowledge about sexual and reproductive health was higher than that of controls this difference was found to be statistically significant multivariate analysis logistic regression was used to find out the independent association between unmarried teenage pregnancy and the study variables the model was constructed based on p 025 in the bivariate analysis and clinically important variables results of logistic regression analysis in the final model children hailing from family problems lack of appropriate parental supervision and control poor intrafamily relationship lack of engaging in any productive activity and lack of knowledge about sexual and reproductive health were found to be significant independent risk factors for unmarried adolescent pregnancy subgroup analysis showed strength of association of all the above risk factors to unmarried pregnancy more among the b19year age group compared to 19 discussion comparison of observations with other studies even though very few studies are available in the literature to know about the risk factors for pregnancy among unmarried adolescents and young adults these studies and their findings are not really comparable as they were poorly designed and no acceptable sampling techniques were employed association of lack of participation in any productive activity and teenage pregnancy had been observed by different authors in the present study 445 of the cases were not engaged in any productive or academic activities and they engage in risky behavior at a very young age the observations made in this study is consistent with the reports observed by kasen et al 1 and kirby 2 who have conducted studies on the influence of school dropout and school disengagement on the risk of adolescent pregnancy family problem as an immediate determinant of adolescent sexual activity has been pointed out by various studies 3 4 5 6 the present study also supports this and revealed that more pregnant adolescents hailed from family problems when compared with nonpregnant controls it is also found that these children having family problems lacked love and encouragement by the family and they felt insecure at home they received less support for their problems in or outside the family and had lesser life satisfaction and happiness in general parents play a significant role in the sexual development and behaviors of their children parentchild closeness or connectedness parental control and parentchild communication have all been implicated in adolescent sexual behavior parental monitoring and supervision are important ways for keeping adolescents from risky situations and activities while the teen develops responsible decisionmaking skills association of lack of appropriate parental supervision and control and adolescent sexual activity has been shown in different studies 7 8 9 the present study is in agreement with this and confirmed that either lack of parental control or strict control by parents is a highly significant risk factor for adolescent pregnancy another important observation made out from the study is that a few percentages of the cases were not staying with their biological parents they were residing in the hostels staying with relatives or working as housemaids all of which resulted in lack of appropriate parental supervision and control the current study showed that poor intrafamily relationship is associated with unwed adolescent pregnancy several mechanisms may underlie the associations between family relationships and adolescent sexual activity a supportive relationship between the parent and adolescent is important for enhancing communication and supervision 10 a study by guijarro et al 11 on family risk factors associated with adolescent pregnancy has shown that motherchild communication about sex contributed to decreased likelihood of sexual risk family connectedness may be a protective factor related to sexual risktaking even among highrisk youth 12 the present study also backs up the above observations and showed that almost threefourth of the pregnant adolescents reported poor intrafamily relationship compared to controls and this finding was found to be statistically significant these pregnant adolescents with poor intrafamily relationships were not in the habit of openly communicating or discussing their problems with parents or other members of the family and their parents in turn never discussed family life issues with them nonpregnant adolescents showed better parentdaughter communication higher levels of cohesion connectedness and higher future expectations the study also showed a close link between lack of knowledge on sexual and reproductive health and adolescent pregnancy overall knowledge about human sexuality reproduction and contraception was poor among the abortion seekers compared to controls majority of the girls did not have clear information on the consequence of sexual relationship the observations made in this study supports the findings of dr anuragini sharma and joseph ga who have conducted cross sectional studies on sexual knowledge and practices of school and college students in india 1314 the present study also revealed that ignorance myths and misconceptions concerning sexual matters were prevailing more among the pregnant adolescents around onethird of the abortion seekers were unaware that it is possible for a girl to get pregnant the first time she has sex and about half of them believed that sexual activity after marriage only would result in pregnancy another observation was that 54 of the cases did not suspect pregnancy for them as they had irregular menstrual cycles hence there was delay in seeking abortion services as evidenced by the fact that out of the total 181 pregnant adolescents only 365 reported in the first trimester more than half reported in the second trimester and the rest progressed to third trimester delay in seeking abortion services was largely the result of unawareness of their pregnancy fear of revealing the matter to family members and due to social stigma contraceptive knowledge was found to be low the reasons for nonuse of contraceptives were the unplanned nature of the sexual act and no prior discussion between the partners regarding contraception even though low level of education of subjects and poor socioeconomic status of parents were found as significantly associated with unmarried adolescent pregnancy in bivariate analysis they were not found to be statistically significant in multivariate analysis the major policy implication of this study is the finding that girls with teenage pregnancy had 5 times less knowledge about sexual and reproductive health highlighting the importance of introducing adolescent healthfamily life education in schools limitations of the study 1 as the study was conducted in government hospitals there may be a possibility of exclusion of women from high socioeconomic status 2 peer group influence was not studied as a risk factor as both cases and controls viewed their friends as being good and there was no independent way to find out if their influence was actually compounding the problem 3 even though childhood sexual abuse was included as a study variable only very few subjects gave a positive history hence was not considered for analysis conclusion this study suggests that familyrelated matters namely family problem poor intrafamily relationship and lack of appropriate parental supervision and control have independent association with unmarried adolescent pregnancy the study also points out that lack of engaging in any productive activity and lack of knowledge about sexual and reproductive health have significant roles leading to unmarried pregnancy the number of adolescent pregnancies can be reduced by introducing adolescent health education programs through educational institutions and for out of school adolescents through anganwadis under icds scheme and nongovernmental organizations family counseling centers should also be organized at taluk and district hospitals under national rural health mission to guide parents in improving intrafamily relationship appropriate parental supervision in managing adolescents and to give correct information on sexual and reproductive health issues

to determine the risk factors for pregnancy among unmarried adolescents and young adults method s casecontrol study was done over a period of 2 years data collected from 181 unmarried abortion seekers and 181 unmarried nonpregnant controls b24 years attending three medical colleges of kerala results logistic regression analysis showed a strong association between unmarried adolescent pregnancy and lack of parental supervision and control or 874 p 0000 poor intrafamily relationship or 701 p 0000 family problem or 441 p 0000 lack of knowledge on sexual and reproductive health or 495 p 00003 and nonengagement of adolescent in any productive activity or 441 p 00373 lack of parental control family problem poor intrafamily relationship lack of knowledge on sexual and reproductive health and lack of engaging in any productive activity were found to be significant predictors for unmarried adolescent pregnancy

introduction the uk is in a period of superdiversity that is characterised by an increased number of new small and scattered multipleorigin transnationally connected socioeconomically differentiated and legally stratified immigrants 1 this presents challenges for the delivery and configuration of maternity services in achieving equality of provision which forms a key aim of the national health service in the uk 2 one in four births in the uk is to foreignborn women 3 indeed some immigrant women appear disproportionately in confidential inquiries into maternal and perinatal mortality 4 perhaps indicating possible deficits in the delivery of care access and utilisation our review contributes to amelioration of this situation by synthesising knowledge related to maternity care access and interventions so as to configure appropriate interventions as identified per the nhs midwifery 2020 vision to guide professional development of healthcare professionals 5 reshaping care to ensure culturally safe and congruent maternity care that will not only benefit immigrant women but also improve the health of future generations in the uk 3 4 6 without the delivery of culturally appropriate and culturally safe maternal care negative event trajectories may occur that range from simple miscommunications to lifethreatening incidents 7 8 9 risking increased maternal and conceptual definitions there is no consensus definition in the uk regarding the definition of the term immigrant 20 with the terms immigrant and migrant which are frequently used interchangeably across different data sources and datasets whilst conveying the same meaning country of birth is used by the annual population survey of workers and labour force survey as a precursor for defining a migrant this survey therefore declares a person born outside the uk is classified as a migrant noteworthy is the fact that workers born outside the uk may become british citizens with increasing residence in the uk a second source of data on migrants is applications made to obtain a national insurance number this differs from the former in that the term migrant is conferred on the basis of nationality all applicants who hold nationality other than the uk are therefore considered migrants however the situation is dynamic in that the nationality of a person may also to change over time and in some cases individuals may acquire dual citizenship involving several nation states a third and significant source of data on migrants is the office for national statistics ons utilises a different strategy classification which focuses on the notion of shortterm international migrant and longterm international migrant in this definition the term longterm refers to holding the intention of residing longer than a year whereas shortterm is intention of residing less than a year the implication of this is that the ons considers length of stay of a person in the uk as critical in determining migrant status which reflects the united nations recommended classification of migrant into short and long term additionally ons utilises the un definition of longterm international migrant accordingly a migrant is someone who changes his or her country of usual residence for a period of at least a year so that the country of destination effectively becomes the country of usual residence 20 in longterm international migration data students and asylumseekers are also included which differs for example from the situation in the usa immigrants and the uk nhs in respect of service provision the nhs adheres to the mandates set by central government that determines immigrants entitlement to free nhs care these mandates are concerned with the immigrant status and the type of service provision 21 within these mandates an asylumseeker woman may not be entitled to full maternity care because of immigration status 22 moreover data collection by the nhs on this topic is not well established or comprehensive currently the nhs usually collects data on ethnicity and nationality and not on migrationrelated variables such as length of stay country of origin and so on the national institute for health and care excellence which provides clinical guidelines for healthcare practice in the uk see nice 23 identified recent migrant women as having complex social needs in its guidelines on pregnancy and complex social factors a model for service provision for pregnant women with complex social factors identified recent migrant women having complex social needs within the nice definition a recent migrant woman is a woman has who moved to the uk within the previous 12 months this generic definition of the term migrant conflates migrant women of all classifications this suggests that there is implicit acceptance of the term migrant women in healthcare in respect of being born outside the uk and being subject to immigration regulations together with possible challenges in english language proficiency the operational definition of an immigrant women used in this review the preceding paragraphs suggests that the term immigrant is defined in various ways in different countries and by different authors however two features are frequently referred to in these definitions namely country of birth and length of stay these factors are noted by the nice guidelines 23 on the provision of maternity care as important in entitlement access and ability to use healthcare in the uk for example if you are born outside the uk it is unlikely that you are knowledgeable about the uk healthcare provision we adopted the following definition of an immigrant woman for the purposes of our review and most importantly to inform our inclusion and exclusion criteria we defined a woman as an immigrant if she was ► born outside the uk ► living in the uk for more than 12 months or had the intention to live in the uk for 12 months when first entered we therefore included studies on immigrant women where the population studied fulfils these two characteristics and included population groups of foreign students asylumseekers recent legal refugees and immigrants and illegal immigrants in cases where the study populationssample was not accurately or fully described we employed the criteria of linguistic ability as demonstrated by the need for an interpreter as a proxy for immigrant status notwithstanding all of these perspectives we acknowledge that the term immigrant women is generic and refers to a highly heterogeneous group of individuals with a complex and vast array of ethnocultural groups aim and rationale we consider in this paper how accessibility and acceptability manifest as important dimensions of access to maternity care services in terms of womens perception about availability of services and their experiences of accessing these services we also consider whether evaluated interventions exist that challenge inequalities in maternity healthcare provision our review employed two theoretical frameworks these are gulliford and colleagues theory of access and second the concept of cultural safety a theory of access to services developed by gulliford et al 12 map out four dimensions 1 service availability 2 utilisation of services and barriers to access 3 relevance effectiveness and access 4 equity and access we used this theoretical model in our systematic review which was based on a synthesis project funded by the national institute for health research unlike most access models in the usa this framework reflects the philosophy of the nhs in that its key principles are to provide horizontal access in terms of ensuring equality of access in the population and to achieve vertical access in terms of meeting the needs of particular groups in the population such as minority ethnic groups the application of these principles is influenced by availability accessibility and acceptability the gulliford model 12 has been widely used in empirical research with the main paper cited over 730 times this model with its emphasis on accessibility acceptability relevance and effectiveness is entirely appropriate for assessing the provision of maternity services to minority ethnic groups and was employed in this review to assist in initial theme development and to examine how this access model intersected with our evidence second concepts of cultural safety provided a theoretical lens for the production of recommendations cultural safety is a theory that aims to assist the understanding of deficits in care by considering the historical and social processes that impact power relationships within and beyond healthcare 24 cultural safety is achieved when programmes instruments procedures methods and actions are implemented in ways that do not harm any members of the culture or ethnocultural group who are the recipients of care those within the culture are best placed to know what is or is not safe for their culture which suggests the need for increased dialogue about immigrant and partner approaches 25 26 27 28 29 methods we employed popays approach to narrative synthesis 30 which consists of four elements for a comprehensive explanation please see our published protocol 31 the unique feature of this approach is that it provides highly specified steps team members have successfully employed ns previously and have vast expertise in its usage 7 ► element 1 developing a theory of why and for whom ► element 2 developing a preliminary synthesis of the findings of the included studies following implementation of the search strategy ► element 3 exploring relationships in the data ► element 4 assessing the robustness of the synthesis thens approach relies primarily on text to summarise the findings and produce asynthesis of the narrative findings of included papers ns may be used with all paradigms of research quantitative qualitative studies and mixed methods research studies as the emphasis is on an interpretive synthesis of the narrative findings of research rather than on a metadata analysis 30 search strategy refinement and implementation the search strategy employed key terms used in consistently formulated textbased queries and search statements these terms were based on subject headings thesaurus terms or related indexing and categorisation terms appropriate for each literature database an example of a detailed final search strategy is given in online supplementary file 1 first we searched 10 electronic databases using the aforementioned strategies following this we searched for appropriate grey literature in si web of knowledge conference proceedings citation index dissertations and theses and the cochrane methodology register we also searched using google and google scholar and consulted with the study expert advisory group in conclusion we hand searched the reference list of all included studies and relevant systematic reviews citations were downloaded into an endnote library and following this all duplicates removed the bibliographic databases that we searched are listed in box 1 we adopted the pico approach to implement the search strategy as follows pimmigrant women imaternity care cnonimmigrant womenimplicit comparator emerging in the results oexperience of care our search strategy development was therefore based on search concept 1pregnancy childbirth explicit terms covering womenfemales requiring all types of maternity care search concept 2immigrant populations search concept 3terms used to identify access to use of deficiencies in and so on service provision this comprehensive search strategy generated high rates of retrieval of records however many were not pertinent screening for relevance in many cases the study populationssample was not fully described in this situation we contacted the authors for further clarification and in some cases used linguistic ability for example the need for an interpreter as a proxy for immigrant status our focus was on firstgeneration immigrant women regardless of their phenotype which led to inclusion of women of white ethnicities although we encountered few studies that focusing on these groups study screening was undertaken independently by two team members who employed our screening tool to assess the relevance of titles and abstracts in respect of our screening tool the entire team reviewed papers classified as ambiguous papers in order to achieve a consensus agreement and where necessary full text papers of potentially included studies were retrieved and appraised the exclusion and inclusion criteria can be found in online supplementary file 3 when we retrieved fulltext papers which were later rejected we have documented these excluded papers and presented a rationale for exclusion these can be found in online supplementary file 4 results studies included in the review findings and evidence our systematic review identified 40 empirical research studies in the scientific and grey literature the included studies embraced a broad range of ethnocultural groups and methodological genres the search outcomes are comprehensively detailed in figure 2 the preferred reporting items for systematic reviews and metaanalyses flow chart 32 the distribution of the studies across the themes are shown in figure 3 and publication dates in figure 4 data extraction and assessment of relevance we conducted the following foundational activities in order to extract data 1 textual description a systematic textual narrative was written for each study we used headings adapted from popay et al setting participants aim sampling and recruitment method analysis results 30 tabulation and summarisation of all studies to be included these tables described the attributes of the studies and the results information was extracted from the textual description using the same headings as above and additional headings as necessary papers in the pdf format were imported into atlas ti qualitative data analysis software using the attributes option to allow the tabulation of relevant data quality assessment in element 4 we conducted the quality appraisal 33 all included studies were critically to determine the nature of the barriers confronting women when they used antenatal and postnatal services pollokshields glasgow qualitative semistructured questionnaire not specified not specified qualitative thematic analysis twenty women were interviewed in depth by a centres health development worker of these 17 were born outside the uk 47 to determine the current clinical practice of maternity care in england including the service provision and organisations that underpin care from the perspective of women needing the care to identify the key areas of concern for women receiving maternity care in england and to determine whether and in what ways womens experiences and perceptions of care have changed over the last 10 years england not specified quantitative survey not specified survey not specified quantitative crosssectional design random samples of women selected for the pilot and main studies were identified by staff at the ons using live birth registrations for births within two specific weeks 28 january and 410 march 2006 the same method of sampling was used as had been employed in 1995 to enable direct comparisons random samples of 400 women for the pilot survey and 4800 women for the main survey who were aged 16 years and over and who had delivered their baby in a 1week period in england were selected the sampling was stratified on the basis of births in different geographical areas no subgroups were oversampled the usable response rate was 60 for the pilot survey and 63 for the main survey the samples included 229 women of bme born outside the uk 48 to explore the healthcare experience of vulnerable pregnant migrant women london mixed methods participants were contacted by phone and interviewed using a pro forma questionnaire designed to determine their access to antenatal care barriers to that access and their experiences during pregnancy labour and the immediate postnatal period further data was extracted from their records at the doctors of the world clinic to see how they had accessed the clinic not specified phone survey qualitative thematic analysis quantitative not clear pregnant women who presented to the dropin clinic of the dotw in london were approached between january 2013 and june 2014 to study the maternity care experiences of somali refugee women in an area of west london this article focused particularly on findings relating to the language barrier which to a large degree underpinned or at least aggravated other problems the women experienced west london qualitative case study six semistructured interviews and two focus groups not specified not specified qualitative thematic analysis snowball sampling 12 somali women were selected from a larger survey involving 1400 women theory of interactions and transformational educational theory hospital settings or womens homes qualitative thematic analysis women were approached if the status of asylumseeker or refugee was written in the hospital notes taken at their booking appointment fourteen women were approached but nine women declined to participate five women consented but one woman was dispersed before 20 weeks gestation and therefore was not included in the study of the remaining four participating women three were asylumseekers and one was a refugee to address the research question that postulates that immigrant women experience sensitive care through the use of an ethnically congruent interpreter and that such women prefer to meet health providers of the same ethnic and gender profile when in a multiethnic obstetrics care setting greater london qualitative indepth individual and focus group interviews openended questions were presented by an obstetrician and an anthropologist framework of naturalistic enquiry not specified qualitative naturalistic inquiry participants were recruited throughout greater london between 2005 and 2006 snowball sampling was used to recruit 36 immigrant somali women and another three were selected by a by purposive technique for a total of 39 a purposive technique was used to select further 11 ghanaian women who had delivered at least one child within the british healthcare system and who were living within the study area at the time of data collection 61 to study the relationships between somali women and their western obstetric care providers the women interviewed came from 14 different countries and had been dispersed or relocated to or within six regions of the uk at the time of dispersal 14 had been awaiting a decision on their asylum claim and six had been refused asylum protos is a maternity care recording system hcp healthcare professional table 1 continued appraised by two reviewers using tools from the center for evidencebased management 34 we used good reporting of a mixed method study 35 for the mixedmethods studies differences were resolved in our reflective team meetings we also used high medium and low as appraisal categories this is approach is congruent with recent publications from the cochrane qualitative research groups confidence in the evidence from reviews of qualitative research publications and was previously used by in published studies by higginbottom and colleagues 7 9 studies were classified in three into domains high medium and low to enable a macro evaluation ► high was assigned to studies that used a rigorous and robust scientific approach that largely met all cebma benchmarks perhaps equal to or exceeding 7 out of 10 for qualitative studies 9 out of 12 for crosssectional surveys or 5 out of 6 for mixedmethods research ► medium was assigned to studies that had some flaws but that did not seriously undermine the quality and scientific value of the research conducted perhaps scoring 5 or 6 out of 10 for qualitative studies 6 to 8 out of 12 for crosssectional surveys or 4 out of 6 for mixedmethods research ► low was assigned to studies that had serious or fatal flaws and poor scientific value and scored below the numbers of benchmarks listed above for mediumlevel appraisals in each type of research the past decade has witnessed a growth in approaches to assessing quality and popay et al 30 recommends evaluating not only the scientific quality of studies but also the richness of studies defined as the extent to which study findings provide indepth explanatory insights that are transferable to other settings 30 thick papers create or draw on theory to provide indepth explanatory insights that can potentially be transferable to other contexts by contrast thin papers provide a limited or superficial description and offer little opportunity for generalising each paper was assessed against the criteria as set out in higginbottom et al 28 33 and categorised as either thick or thin analysis and synthesis following construction of the preliminary themes we produced codenarrative theme tables to demonstrate how the basic meaning units related to the theme this involved utilising the codes produced in atlas ti and aligning these to the manually extracted key findings we reviewed all these processes in our reflective team meetings to ensure the rigour and robustness of our analytical steps this iterative process is similar to the process of qualitative research and involved grouping the narrative findings into meaning units and social processes as they manifested in the maternity care experiences of immigrant women individual team members engaged in independent theming of tabular and coded data we subsequently merged these individual perspectives to form the final harmonised themes representing a metainference which is a term used in mixed methods research to describe merging of findings from the positivistic and the interpretative paradigms tashakorri and teddlie 36 describe metainference as an overall conclusion explanation of understanding developed from the integration of inferences obtained from the qualitative and quantitative strands following construction of the preliminary themes we produced codenarrative theme tables to demonstrate how the basic meaning units related to the theme utilising the codes produced in atlas ti and aligning these to the manually extracted key findings during the analytical processes we interrogated the data identifying using the concept suggested by roper and shapira 37 we have constructed the themes in a policy directive fashion in terms of containing implicit indications in order to provide tangible guidance for policy and practice that might be developed into relevant strategies that benefit immigrant women and the nhs rigour reflexivity and the quality of the synthesis reflexivity in the review process requires a selfconscious and explicit acknowledgement of the impact of the researcher on the research processes interpretations and research products reflexivity therefore demands acknowledgement of inherent power dimensions hierarchies and prevailing ideologies that might shape and determine interpretations and the consequent knowledge production and research products gender sexuality professional socialisation ethnocultural orientation and political lenses as these impact on social identities further coalescing to provide a specific perspective on any given phenomena the review team members are imbued with a strong personal and professional commitment to the eradication of inequalities and allegiance to contemporary equality and diversity agendas from a reflexive perspective this is important given that immigration is global phenomena and the inherent vulnerability of some immigrant women open access figure 3 the total numbers of studies involved in each theme figure 4 the range of publication dates for the included studies reflexive analysis alerts us as researchers to emergent themes and informs the formal and systematic process of analysis with reflexivity defined as sensitivity to the ways in which the researchers presence in the research setting has contributed to the data collected and their own a priori assumptions have shaped the data analysis 38 our collaborative decisions required constant review and reading and in some cases reviewing the theme allocation and evidence to reach consensus therefore we believe we achieved a nuanced and comprehensive approach higginbottom et al have successfully employed this review genre previously and have vast expertise in its usage 39 within the published ns reviews we have not given great attention to the issue of publication bias however we strove to eradicate any potential bias by undertaking a comprehensive and exhaustive literature review that included grey literature and followup emails with authors seeking greater clarity and explanation of opaque issues a number of the included research studies were identified via proquest and etheses and do not appear as publications in peer reviewed scientific journals we also held a national stakeholder event during which we presented our preliminary findings to a wide range of health professions academics voluntary and community workers possibly this approach may be considered contentious in the respect of systematic review as attendees had no previous knowledge of the original included papers although they held deep topic knowledge notwithstanding this we found broad support for our findings and facilitated groups work activities in order to open access table 2 thick and thin criteria higginbottom et al 33 richness operational definition thick papers ► offer greater explanatory insights into the outcome of interest ► provide a clear account of the process by which the findings were producedincluding the sample its selection and its size with any limitations or bias notedalong with clear methods of analysis ► present a developed and plausible interpretation of the analysis based on the data presented thin papers ► offer only limited insights ► lack a clear account of the process by which the findings were produced ► present an underdeveloped and weak interpretation of the analysis based on the data presented challenge our initial interpretations these challenges resulted in the construction of theme 5 discrimination racism stereotyping cultural sensitivity inaction and cultural clash in maternity care for immigrant women these focused activities collectively contribute to the confidence in the review findings providing verification and validation of the themes we identified 40 research studies that met our inclusion criteria and we extracted and synthesised key findings into five themes for the publications informing each theme methodological genres quantitative studies we identified eight quantitative studies that all used a questionnaire for data collection 40 41 42 43 44 45 46 47 these populationbased studies and cohort surveys were all crosssectional none were longitudinal mixedmethods studies we identified 10 mixedmethods studies that employed both qualitative and quantitative dimensions 2 4856 for example duff et al 49 reported a twostage psychometric study in which focus groups and interviews were used in the first stage to develop a questionnaire for an ethnocultural group in the second stage quantitative methods were used to test and evaluate the acceptability reliability and validity of the questionnaire other mixedmethods designs included interviewing a small sample of the participants after collecting data from a largescale survey conducting semistructured interviews with a small sample of participants based on quantitative data routinely collected from a large group of participants and using facetoface postal and online questionnaires to collect data one of the studies used q methodology which uses questionnaires with structured and unstructured questions qualitative studies of the 40 studies included in this review we identified 22 as qualitative research studies employing a range of qualitative methodologies and approaches 17 5777 however many of these studies did not specify a qualitative methodological genre but instead employed a more generic qualitative approach and described only the data collection tools used for example some presented multiple longitudinal case studies of participants about their maternity care experiences that included photographs taken by the participants field notes and observations in addition to researcher interviews another example was a case study of an ethnocultural group immigrant women of somali origin that used semistructured interviews and focus groups some studies used focus groups and interviews conducted in the language of the population group for example bengali sylheti urdu and arabic others used indepth interviews openended questions group storysharing sessions and individual biographical lifenarrative interviews in contrast a few studies specified a qualitative interpretive approach that used hermeneutic phenomenology and focused ethnography studies focusing on specific ethnocultural groups the chosen studies included participants from a wide range of ethnocultural groups that originated in diverse countries in different continents including asia africa and europe in some cases the sample was drawn from a single ethnocultural group such as pakistani 72 however most of the studies were undertaken with mixed samples of immigrant women originating from different countries studies focusing on immigrant women without a clearly specified ethnocultural group we identified 16 studies that used the term immigrant women generically and not clearly specify an ethnocultural group in deciding to include these studies we believed that legitimate proxies for immigrant status could be the specified use of an interpreter or the participants having countries of origin or birth outside the uk some studies reported immigrant women arriving from 14 different countries but did not specify the country of theme 1 access and utilisation of maternity care services by immigrant women late booking emerged as an important dimension in this theme with immigrant women study participants often booking and accessing antenatal care later than the recommended timeframe of during the first 10 weeks of pregnancy this delayed utilisation was found to be multifactorial in nature with influencing factors including the effects of limited english language proficiency immigration status lack of awareness of the services lack of understanding of the purpose of the services income barriers the presence of female genital mutilation factors associated with differences between the maternity care systems of their countries of origin and the uk arrival in the uk late in the pregnancy frequent relocations after arrival the poor reputations of antenatal services in specific communities and perceptions of regarding antenatal care as a facet of medicalisation of childbirth the range of factors affecting the access and utilisation of postnatal services were similar to those reported for antenatal services theme 2 maternity care relationships between immigrant women and hcps our included studies identified the perception of service users in this group and their interactions and therapeutic encounters with hcps as significant in understanding access utilisation outcomes and the quality of their maternity care experience included studies identified both positive and negative perceptions of study participants regarding the ways hcps delivered maternity care services were both positive and negative a number of studies illustrated positive relationships between hcps and immigrant women with the hcps described as caring respecting confidentiality and communicating openly in meeting their medical as well as emotional psychological and social needs conversely some studies provided evidence of negative relationships between participants and hcps with hcps described from the perspective of immigrant women as being rude discriminatory or insensitive to the cultural and social needs of the women the end result of these negative encounters was that these women tended to avoid accessing utilising maternity care services consistently open access theme 3 communication challenges experienced by immigrant women in maternity care it is axiomatic that limited english language fluency presents verbal communication challenges between hcp and their patients families and carers moreover this is compounded when hcps use complex medical or professional language that is difficult to comprehend nonverbal communication is culturally defined and challenges can occur through misunderstandings of facial expressions gestures or pictorial representations poor communications result as illustrated in our included studies in limited awareness of available services in addition to miscommunication with hcps study participants often expressed challenges in accessing services failed to understand procedures and their outcomes and were constrained in their ability to articulate their health or maternity needs to healthcare providers and disempowered in respect of their involvement in decisionmaking they therefore sometimes gave consent for clinical procedures without fully comprehending the risks and benefits and did not always understand advice on baby care studies also identified communication as not reciprocal with hcps often misunderstanding participants these issues of communication were described as leading to feelings of isolation fear and a perception of being ignored theme 4 organisation and legal entitlements and their impacts on the maternity care experiences of immigrant women the study participants in our included studies had mixed experiences with the maternity care services in the uk positive and commendable experiences included feeling safe in giving birth at hospital rather than at home being able to register a complaint if poor healthcare was received being close to a hospital facility not being denied access to a maternity service and having good experiences with postnatal care conversely negative experiences included lack of continuity and being unaware of the configuration of maternity services work that limited appropriate use participants in our included studies found services bureaucratic and perceived within the uk maternity care model as having a propensity towards medicalobstetric intervention and lower segment caesarean section births the legal status of an immigrant women in the uk has a profound influence on their on their access to maternity care women without entitlement to free maternity care services in the uk were deterred from accessing timely antenatal care by the costs and by the confidentiality of their legal status moreover some women arrived in the uk during the final phase of their pregnancies that resulted in interruptions in the care process loss of their social networks reduced control over their lives increased mental stress and increased vulnerability to domestic violence positive experiences included receiving information from their midwives on the benefits of breastfeeding together with demonstrations on how to position the baby negative experiences included poor support from hospital staff on how to breastfeed their babies consequently these reported experiences are mixed theme 5 cultural sensitivity inaction and cultural clash in maternity care for immigrant women inequalities in access navigation utilisation and the subsequent maternity care outcomes are influenced by discrimination and cultural insensitivity in maternity care services according to the perspectives of women in several included studies although discrimination is often subtle and difficult to identify direct and overt discrimination was reported in some studies specifically study participants of muslim faiths challenged assumptions held by hcps including those held regarding muslim food practices and that their partners or husbands should help the women during labour moreover hcps were reported in some studies to lack cultural sensitivity and cultural understanding for example these women did not optimally benefit from antenatal classes facilitated by a nonmuslim educator who had no knowledge of the relationships of muslim culture to maternity furthermoremuslim participants often expressed dissatisfaction with antenatal classeshaving a gender mix which contravened religious edicts studies illustrated that some women of muslim faith also regarded their cultural and religious needs were not met and they felt that the staff lacked insight knowledge and understanding of fgm evidence from our included studies suggests some immigrant women perceived that the staff did not treat them with respect or attended fully to their healthcare needs and they felt devalued unsupported and fearful while receiving maternity care our findings also identified instances of cultural clash and conflicting advice during pregnancy and maternity care mostly resulting from differences between the cultural practices and medical systems of the home countries of the immigrant women and those in the uk in a few cases however midwives were happy to meet the cultural and religious needs of the study participants in our included studies in both antenatal and postnatal settings which is a positive finding we conceptualise the findings graphically in figure 5 patient and public involvement the systematic review questions were developed in consultation with our project advisory group including service users priorities experience and preferences this systematic review did not include empirical research therefore there were no human participants discussion and conclusions the uk is in a period of superdiversity defined as being distinguished by a dynamic interplay of variables among an increased number of new small and scattered multipleorigin transnationally connected open access socioeconomically differentiated and legally stratified immigrants 1 responding to this level of diversity is challenging for uk maternity care health services and may require the development of new and innovative strategies the experiences of immigrant women in accessing navigating and utilising maternity care services in the uk are both positive and negative in order to enhance services it is essential that strategies are developed to overcome the negative experiences reported the experience of maternity care services is multifactorial in nature with a number of issues appearing to coalesce to determine the poorer experience reported by some immigrant women important factors identified by the review included a lack of language support cultural insensitivity discrimination poor relationships between immigrant women and hcps and a lack of legal entitlements and guidelines on the provision of welfare support and maternity care to immigrants implications of findings and recommendations for maternity care policy practice and service delivery inequitable access appeared to be a consequence of the immigration and legal status of asylumseeking women which has a profound impact on healthcare experiences and consequently health and was also influenced by language fluency we concluded that addressing language barriers and ensuring culturally sensitive care are essential elements of providing optimal maternal care for immigrant women the issue of confidentiality may be compromised by having known interpreters in small communities one solution may be the setting up of a nationallevel website offering standard information on maternity care and the option of translation in a wide range of languages additionally the identification of best language practices should be identified in order to improve the current language service model the knowledge understandings and attitudes of maternity care healthcare providers is a critical determinant of care ethnoculturally based stereotypes racism judgemental views and direct and indirect discrimination require eradication requires challenging discrimination and racism at all levels individual institutional clinical and societal interventions to improve maternity care for immigrant women are scant and formal evaluations of these interventions were largely absent increasing the social capital available to immigrant health literacy and advocacy resources may empower women to access and use maternity care services appropriately maternity care staff require a greater level of mandated education to have better cultural awareness of needs of diverse client groups including newcomers to the uk our findings highlight the importance of demonstrating compassion empathy and warmth in their relationships with these women to reinforce positive attitudes among immigrant women it is contingent on maternity care providers to value diversity among service users and to offer individualised and culturally congruent care one way to achieve this goal would be through birth plans that can be jointly agreed and discussed in advance by the maternity care staff and recently arrived newcomers and immigrant women maternity care staff should seek to empower immigrant women by providing comprehensible information and better education concerning the configuration of the maternity system in the uk conveying accurate information about care delivery central to these suggestions may be to enable volunteer and thirdsector organisations to work as links between the statutory maternity services and immigrant women we found evidence of such links in our national networking event representatives of immigration control agencies may feel obligated to adheres to immigrant rules and consider the maternity care needs of immigrant womens and babys health as a secondary issue the policy context regarding data protection and sharing information with the home office about the immigrant status of women was at issue as well especially since variabilities have been seen in the policies for sharing this information the results suggest that the legal and policy context is important in addressing the maternity care needs of immigrant women it would seem imperative as reflected in current policy directives to adopt a universal of aim of achieving optimal maternity care for all and not just for immigrant women however maternity care services should strive to give more information to immigrant women about their rights to care the availability and configuration of maternity services and how to navigate maternity care systems the child in utero of an immigrant is a future uk citizen and optimising maternity care is a dimension of securing the future health of the nation in a period of super diversity is incumbent on health professional to have an awareness of immigrant womens legal rights and perhaps education on this topic should be mandated for maternity hcps continuity in maternity caregivers and compulsory provision of interpreters would also help to improve the experiences of these women decisionmakers and healthcare leaders should address the findings at a strategic level a focus on diversity equality and the needs of immigrant women could reasonably be embedded in the role and responsibility of board level maternity champion and of maternity clinical networks maternity service providers could consider the appointment of one obstetrician and one midwife jointly responsible for championing maternity care provision to immigrant women in their organisation as these dimensions feature within the bespoke maternity safety improvement plan 78 key areas of action include ► focus on learning and best practice issues of equality and diversity should be featured in the saving babies lives care bundle for use by maternity commissioners and providers ► focus on multiprofessional team working continuous personal and professional training open access ► focus on data greater focus on ethnicity and immigration within the maternity services dataset and other key data sets ► focus on innovation create space for accelerated improvement and innovation at local level gaps in the evidence some locally developed and locally based interventions to address inequalities in access and quality in maternity care for immigrant women were described during the final feedback meeting however there are very few interventions to address these issues in the published literature and their effectiveness has not been evaluated robustly none of the interventions had also included economic evaluation of the intervention studies of the usual 6 weeks postnatal checks by a general practitioner were not identified nor studies that focused on the intrapartum period as mentioned earlier we found few studies that focused on immigrant women with white ethnicity in our review time period for example women of eastern european origin strengths and limitations ► we were challenged and constrained by the lack of consistency in describing immigrant population sin the published literature there exists a great deal of variation and no unified approach within the uk literature ► immigration is an international phenomenon and this review increases understanding of how immigrant women navigate maternity services in the uk ► the review systematically maps our positive and negative aspects of maternity care provision as experienced by immigrant ► the review provides strategic policylevel direction for enhancement of maternity care services ► the review does not address the experiences of maternity care for secondgeneration women nor does it consider refugee and asylum seeking women as a separate group implications for future research more research is required into how the term immigrant is used and the changes in its use over time that may affect immigrant womens care at present the term is used very broadly and simplistically which masks its inherent heterogeneity furthermore more research is required to understand how the intersections of particular characteristicssuch as gender education status time in the uk immigration status wealth and country of originmay influence or alter the experiences of these women in their maternity research is also required that focuses on developing and evaluating specific interventions to improve maternity care for immigrant women twitter gina marie awoko higginbottom awoko1 and catrin evans catrinnotts open access

► immigration is an international phenomenon and this review increases understanding of how immigrant women navigate maternity services in the uk ► the review systematically maps the positive and negative aspects of maternity care provision as experienced by immigrant women ► the review provides strategic direction for enhancement of maternity care services ► the review does not address the experiences of maternity care for secondgeneration women eg women of black and minority origin born in the uk

introduction tobacco smoking is associated with higher risks of noncommunicable diseases 12 and is responsible annually for 6 million deaths globally 3 over the last forty years smoking prevalence shifted becoming concentrated in lowand middleincome countries 4 as the tobacco industry employed a variety of tactics to exacerbate tobacco smoking in lmics such as targeted marketing and combatting effective tobacco control measures 5 smoking is a leading ncd risk factor in the pacific 6 7 8 with particularly high levels among men ranging from 3050 in this region in other lmics tobacco use is higher among men than women most often through smoking manufactured cigarettes and higher in those with lower socioeconomic status and educational attainment and among manual laborers 9 10 11 12 13 samoa is one lmic where smoking is identified as an essential area for focused health promotion activities 14 smoking prevalence in samoa among older and younger adults declined significantly from the late 1970s to 2013 15 from 19782013 the percentage of men who smoked cigarettes daily decreased from 76 to 36 and among women from 27 to 15 from 19912013 current tobacco smoking decreased from 64 to 40 in men and 21 to 17 in women 15 the samoa 2014 demographic and health survey reported that 472 of men and 170 of women 2554 years of age used tobacco 16 in 2015 as part of a nationally representative screening survey of 2234 adults aged ≥18 years conducted before whosponsored villagelevel intervention programs 45 of men and 15 of women reported smoking tobacco in the last 12 months 17 to date most tobacco research among samoan adults focused very little on societal and individual correlates of smoking 1819 with a few exceptions in a 2005 study among samoans in american samoa hawaii and california smoking was associated with being male younger married and less educated 20 in the temporal trends study in samoa among men nonsmokers had higher education than smokers 0508 years but among women there were few differences by education except in 2013 when smokers had 06 years more education than nonsmokers 15 temporal trends of lower cigarette smoking were accelerated with more education in men but impeded with more education among women 15 among men aged 1549 years the 2014 samoa dhs described lower tobacco use in the highest wealth quintile those with more than secondary education and residents of northwest upolu in women in the same age group there were few sociodemographic differences except for lower use among rural residents especially those from savaii 16 a 2009 study of 1056 adults aged ≥40 years residing in 11 villages in rural savaii found a smoking prevalence of 526 for men and 162 for women with an apparent decrease with older crosssectional age only in women 21 a recent qualitative study identified specific cultural patterns to smoking in samoa including insights into the early initiation of smoking at young ages and the deeply rooted social contexts of smoking 22 given these prior findings current smoking among adults warrants aggressive measures to combat its financial and health burdens identifying specific sociodemographic correlates of smoking is necessary to target tobacco control efforts to subgroups and even to tailor interventions based on specific individual characteristics 12 designing and adapting tobacco interventions for specific groups of samoan adults may reduce ncds and be cost effective for underresourced health systems 23 younger adults aged 40 years in particular would benefit from targeted interventions as smoking cessation by the age of 40 years reduces allcause mortality by 90 compared to those who continue to smoke 24 reducing adult smoking may also help reduce adolescent smoking considering that 447 of young samoan adolescents use tobacco and 322 smoked cigarettes both the highest levels among 68 lmics 25 given these gaps in the existing literature the purpose of this study is to present prevalence of smoking and number of cigarettesday and their sociodemographic correlates from a large nationwide survey of adults aged 2565 years in 2010 in samoa we focus on sex and age stratified multivariable analyses to provide detailed information on correlates of tobacco smoking necessary for designing more targeted interventions methods research design and participants this is a crosssectional study of health survey data from a genomewide association study conducted from february to july 2010 in samoa details on the design and methods for the gwas have already been reported 26 there were 3745 participants who a selfreported having four samoan grandparents b were aged 2565 years c were nonpregnant d had no severe physical or cognitive impairments and e completed the interview in the samoan language participants resided in 33 villages from all four census regions ranging from the most rural to the one urban or town region savaii rest of upolu northwest upolu and apia urban area the sample was representative of the wider samoan population in terms of marital status educational attainment and access to basic household amenities but had a greater proportion of women residents from the more rural rest of upolu and savaii regions and older participants compared to 2011 census data 2627 the study was approved by the health research committee of the samoa ministry of health and the brown university institutional review board written informed consent was given before participation in the study assessing outcome of interest current smoking was assessed using the question do you currently smoke cigarettes cigars or pipes we considered stratification of outcome into current smokers those who quit smoking and those who had never smoked but we chose a binary outcome of current smokers versus those not currently smoking due to a negligible proportion of those who quit smoking as such we classified former smokers as not currently smoking along with those who had never smoked the reported total number of manufactured cigarettes handrolled cigarettes and cigars smoked per day among smokers was measured continuously and also classified as ≤5 610 1119 or ≥20 cigarettes or cigars per day information on number of tobacco products per day was provided by 93 of men and 923 of women who were current smokers correlates several sociodemographic characteristics were explored as potential correlates of tobacco use in addition to age and sex education was classified into three categories less than secondary education completed secondary education completed and university completed or greater the three categories used to classify occupation were 1 unemployed retired or student 2 subsistence farmers and fisherman and semiskilled and skilled wage laborers and clerks and 3 administrative managers professionals and political leaders among men in the first occupation group for example 93 were unemployed and in the second group approximately 72 were subsistence farmers and fishermen among women in the first group about 96 were unemployed census region was included as described above given substantial rural to urban differences across samoa a household assets inventory of 10 items as a sensitive measure of family economic resources in modernizing societies was used previously used to study the adult samoan population 2829 higher scores represent higher income andor wealth levels following exploratory data analyses we dichotomized this index into the lowest tertile versus the two top tertiles in order to assess the link between low income and wealth position and smoking current alcohol use was identified if participants indicated they had consumed alcohol at least once in the past twelve months statistical analyses sexstratified analyses were used throughout bivariate analyses provided descriptions of current cigarette smoking in association with the categorical covariates anova and spearmans correlations were estimated to determine associations of number of cigarettesday and sociodemographic characteristics logistic regressions identified significant associations of covariates with current smoking and produced final models with variables that were significantly associated covariates included in the final model were those significantly associated with smoking in initial analyses and initial multivariate models lastly because age in a transitioning society may influence exposure to tobacco levels of education and health literacy we performed ageand sexstratified logistic regressions to identify significant associations with current smoking we classified age as ≤40 years or 40 years old in the agestratified analyses analyses were performed using the statistical software packages stata 15 and sas 94 results more than half of men and more than onefifth of women reported current tobacco smoking approximately onethird of adults smoked tob prev cessation 2019550 the vast majority of current smokers used manufactured cigarettes only 6 used handrolled cigarettes 3 used cigars and 1 used pipes bivariate results showed that among men cigarette smoking was significantly associated with being single unemployed or a subsistencefarmer laborer having a low level of household assets and current alcohol use among women smoking was associated with younger age being single residing in the less rural census regions of upolu island and consuming alcohol adjusted odds ratios among men showed that subsistence workers laborers or clerks had significant 44 higher odds of smoking compared to men working as professionals or administrators men who consumed alcohol had more than three times the odds of being a current smoker compared to men with middle or high household assets those with low assets had significant 36 higher odds of current smoking adjusted odds ratios among women indicated that those not completing secondary education had twice the odds of smoking compared to those who had a tertiary education compared to women aged 2534 years women aged 5564 years had nearly half the odds of being current smokers compared to women in the apia urban area residents in the northwest upolu region had lower odds of smoking while residents of savaii had less than half the odds of being a current smoker women who were current alcohol users had more than ten times the odds of being a current smoker compared to nondrinkers though this adjusted association had a wide confidence interval driven by the low percentage of women reporting alcohol consumption in the past 12 months adjusted odds ratios from agestratified logistic regression models for men are provided in table 5 among men aged ≤40 years being married was associated with lower odds of smoking while those who had consumed alcohol in the past 12 months had more than three times the odds of smoking residents of northwest upolu had higher odds of smoking than those in the apia urban area among men aged 40 years only alcohol consumption was associated with higher odds of smoking among women aged ≤40 years those not completing secondary education had nearly 27 times the odds of smoking compared to those with a tertiary education younger women who reported alcohol consumption had more than ten times the odds of smoking though the confidence interval was very wide due to the low prevalence of women who were current smokers and alcohol consumers this low prevalence also influenced our results for women aged 40 years as current alcohol users were far more likely to smoke than those who did not consume alcohol but with a drastically wider confidence interval among men who smoked the mean number of cigarettescigars per day was 109 with a median of 10 and a range 0560 per day among women who smoked the mean daily consumption was 87 with a median of 6 and a range 0540 per day men smoked significantly more cigarettes daily than women there was a significant gender difference in the percentages of total cigarettes day in the categories ≤5 610 1119 or ≥20day for men they were 277 399 124 and 200 compared to women with 418 350 103 and 130 respectively onefifth of men who smoked consumed ≥20 cigarettesday in multivariable models among men who smoked age and household assets were positively associated with number of daily cigarettes consumed as well as occupation and census region subsistence workers and laborers consumed more cigarettes daily mean 118 than professionals or administrators mean 107 and the unemployed or retired mean 94 cigarettesday increased across the four census regions from rural savaii to urban apia in multivariable models among men aged ≤40 years those in the upper two tertiles of household assets smoked 28 cigarettesday more than the lowest tertile and the unemployed smoked fewer per day than managers professionals or subsistence workers and laborers among older men only household assets were significantly and positively associated with daily cigarette consumption education was marginally associated with daily consumption in older men those completing university smoked per day more than those completing secondary or primary school among women multivariable models of daily cigarette smoking showed only marginal associations with increasing age and census region with lower consumption among women from rural savaii multivariable models stratified by age among women found no significant associations discussion the prevalence of smoking in 2010 in samoa among men was 513 and for women it was 218 for the age group 2565 years these were higher than those reported for 2013 from the steps survey 19 and used in the publication on temporal trends in tobacco use in samoa 15 the 2010 prevalences of current tobacco smoking for men and women are also somewhat higher than levels reported in the samoa 2014 demographic and health survey report 16 472 among men aged 2554 years and 170 among women aged 2549 years while among adults screened in 2015 these were 45 for men and 15 for women 17 the slightly lower levels we found in 2010 compared to those from several studies from 201315 may be part of the temporal decrease in current smoking levels in samoa 15 as well as due to methodological differences new national level surveys are needed to look at the trajectory of these positive trends into the third decade of the 21st century considering that regardless of several recent studies in the last decade 4550 of men and 1520 of women smoke tobacco we found among tobacco smokers that 20 of men and 13 of women consume ≥20 cigarettes or cigars daily estimating daily tobacco use among all participants including nonsmokers 95 of men and 26 of women smoked ≥20 cigarettes or cigars daily in 2010 which compares well with 2013 estimates in the temporal trends report 15 the 2014 dhs reported that approximately 67 of all men and 40 of women smoked ≥10 cigarettes daily 16 the similarities of the results from 2010 shown here and for later years from various sources 15 16 17 18 provide confidence in the findings prevalence of adult tobacco smoking and daily smoking in samoa appears to have decreased notably in men within the second decade of the 21st century suggesting both the need for more research on factors associated with this decline to sustain these likely temporal changes into the third decade of this century and on developing targeted tobacco interventions at the structural and individual levels having shown that tobacco smoking levels in 2010 are similar but somewhat higher than those of later studies we focused on the age and sex specific socioeconomic and behavioral correlates of smoking in samoa in order to provide evidence for intervention development our multivariable results stratified by age and sex identified risk factors in different subgroups not seen in aggregate calculations of smoking prevalence for participants of all ages in these regions such as the 2014 dhs report 16 although the 2014 samoa dhs reports plausible patterns such as lower tobacco use in men among the wealthiest those with the highest education and residents of northwest upolu and lower use in rural women it is impossible to disentangle associations with educational attainment wealth and age on tobacco use our findings especially among men of all ages follow similar trends across lmics that link lower economic position socioeconomic status and agricultural and physical labor to increased prevalence of cigarette smoking 9 10 11 12 13 among women smoking was higher in those aged 55 years residents of the capital apia census region and those with lower education levels further research on the context of initiation continuation and cessation of tobacco use in younger urban samoan women is urgently needed to follow up on recent qualitative insights from that subgroup 22 education was associated with current smoking only among younger women and in the inverse direction these findings in women differ from the temporal trend analysis which found education was not associated with current smoking until 2013 when there was a positive association 15 our 2010 results in younger women did show independent associations of smoking with both urban residence and alcohol use further research on the expanding economic roles and potential ncd risks of women is needed to clarify the nature of these associations for intervention development global patterns of targeted tobacco advertising to lower social status communities and young urban people have been shown elsewhere 5 and despite samoas tobacco 2013 law regulating tobacco advertising more research is needed on its community and individual impacts findings from ageand sexstratified models demonstrate some key differences in correlates across age and gender that may be important for the design of tobacco interventions while no factor was associated with smoking among older adults besides current alcohol consumption the variety of correlates identified among younger men and women provides some interesting considerations men aged ≤40 years who were subsistence farmers fisherman laborers or clerks had higher odds of smoking consistent with results in other lmics 10 11 12 13 while married men in this age group had lower odds of smoking this indicates the need to target younger single men in manual labor and clerical positions in future smokingbased programs in samoa including assessment prevention and interventions focused on cessation this age and sex group generally uses less primary care than other adults so implementation research is needed on community level tobacco use interventions 1623 indicators of social position and socioeconomic status ie household assets and occupation were associated with daily consumption of tobacco products in men this could be attributable to higher incomes associated with work and household income and wealth some of which is used for cigarette purchases the samoa household income and expenditures report from 201314 found that nationally 03 of all household expenses were for tobacco ranging from 02 in apia to 04 in rural savaii 30 these expenditure estimates for the purchase of cigarettes in samoa are of considerable interest given evidence across many lmics that household expenditures for tobacco were associated with lower education and health care expenditures 31 these opportunity costs of tobacco in combination with the likely substantive financial burden of health care costs for individuals and for households with cigarette smokers are concerning the findings that almost onefourth of women of reproductive age smoked cigarettes and those with low education levels had more than twice the adjusted odds of smoking is alarming given the welldocumented associations with later adult health outcomes as well as maternal smoking and child health in the context of the existing high levels of adult adiposity and cardiometabolic risks among women 26 there is an urgent need to develop societal and public health programs to prevent cigarette smoking by avoiding initiation and helping cessation among women pregnancy was one reason for smoking cessation cited by women in apia 21 for example research is needed to determine the efficacy of screening for tobacco use and behavioral interventions within standard prenatal care the recent report on individuallevel mhealth intervention for smoking cessation being developed and tested in samoa is noteworthy 32 there may be opportunities for information education and communication campaigns sponsored by employers religious organizations and local villages to encourage smoking cessation and prevent initiation among young people more broadly research on smoking cessation and primary prevention of tobacco use is urgently needed in samoa as there is very little systematic evidence after adjusting for all other variables regional differences in smoking correlates among younger men and women are notable men aged ≤40 years in the savaii and northwest upolu regions had higher smoking percentages compared to those in the apia urban area women aged ≤40 years in the savaii region had lower smoking levels compared to those in the apia urban area and women in the northwest of upolu area had an odds ratio that was marginally insignificant these regional findings for women are consistent with previous research but the findings for men are in conflict with previous reports that smoking prevalence was also lower in savaii compared to other regions 161821 among men who currently used tobacco we found that those in rural savaii smoked fewer and those in urban apia smoked more cigarettescigars per day in multivariable models but results from agestratified models of daily tobacco consumption in men found no census region or ruraltourban effect rather in young men indicators of social position and income such as household assets and occupation were associated with tobacco consumption this suggests that the census region socioecological influences on smoking prevalence and daily consumption need more detailed examination for the purpose of developing public health interventions across all models consuming alcohol in the prior 12 months was associated with current smoking regardless of age in both men and women as lmics like samoa continue to develop patterns of cooccurrence of smoking and drinking may begin to match those in developed countries where the association of smoking and drinking is wellestablished 3334 the cooccurrence of these risk behaviors represents opportunities for structural interventions targeted at both behaviors simultaneously structural level tobacco interventions currently in operation in samoa including smoking bans in offices advertising bans in the media and raising the excise taxes on retail prices need to be continued and expanded 35 given the high proportion of our sample and the samoan adult population who were unemployed eg among women or subsistence workers among men workplace smoking prohibitions need to be complemented by broader community interventions such interventions should be informed by the sociocultural context of smoking as has been recently described 22 the government of samoa has been enacting laws since the early 21st century to address tobacco use including the tobacco control acts of 2008 2013 and 2019 3637 after having joined and ratified the framework convention on tobacco control a few years earlier finally it is worth noting that samoa has increased the excise tax on retail prices of all tobacco products as of 2015 total taxes account for 516 of the cost of tobacco purchases and an estimated wst 286 million or us 109 million in tobacco taxation may be available for increasing public health and clinical efforts to reduce the health consequences of cigarette smoking 38 limitations this study has a few limitations first we used crosssectional data limiting interpretations about causality second social desirability bias may have caused underreporting of smoking and drinking behaviors though our findings related to prevalence are roughly in line with prior research 14 15 16 17 third unmeasured confounders like stress and social interaction patterns of smoking were unmeasured making it impossible to interpret more proximate determinants which are important for tailoring intervention designs in tandem with qualitative work 1732 fourth our research data were collected in 2010 which creates the potential that correlates of smoking may have shifted over the last decade although our estimates of current smoking prevalence are somewhat higher than those of studies 34 years later the correlates identified are plausible and similar to other work and will be useful in developing interventions we are following up a subsample of 500 adults from 2010 and will report on changes in prevalence conclusions our findings point to the need for continued structural and subgroup interventions targeted at reducing smoking prevalence and intensity among samoans especially those aged ≤40 years which may reduce their likelihood of developing serious cardiometabolic and lung disease later in life interventions designed for different age sex and socioeconomic status groups within the samoan context are important 2232 implementation research will be needed to determine 10 tob prev cessation 2019550 intervention content customization and evaluation across subgroups in addition work on biological susceptibility to tobacco may be needed recently the number of cigarettesday was associated in native hawaiians with a singlenucleotide polymorphism variant that is very rare globally but of 17 occurrence in native hawaiians 39 as samoa continues to grapple with unacceptable high smoking levels particularly among men and women of reproductive age efforts to reduce the prevalence of smoking and understand what interventions work is necessary to protect the health of samoans moving into the future conflicts of interest the authors have completed and submitted the icmje form for disclosure of potential conflicts of interest and none was reported authors contributions stm conceived and led the study aca performed the majority of the statistical analysis and with stm wrote the initial draft of the manuscript with guidance from stm nlh led the fieldwork data collection in 2010 and contributed to writing the manuscript msr facilitated the 2010 fieldwork in samoa and with tn contributed to the discussion of the interpretation and public health implications of the findings all authors read and approved the final manuscript provenance and peer review not commissioned externally peer reviewed

introduction tobacco use in samoa has been described over time by age sex and education but little work exists on other sociodemographic factors associated with tobacco use we describe current smoking and daily tobacco use in adults from samoa with a focus on sex and age stratified analyses of the influence of occupation education census region household asset ownership and alcohol use in order to help develop potential targeted interventions methods in 2010 a nationwide survey of 3745 adults aged 2565 years from 33 villages was completed in samoa current smoking status daily tobacco use as well as current alcohol use and a variety of sociodemographic factors were assessed by interview bivariate and multivariable models and sex and age group stratified analyses were performed to determine different patterns of correlates results more than half of all men 513 and 218 of women were current tobacco smokers men and women smoked on average 109 and 87 cigarettes day respectively twenty per cent of men consumed ≥20 cigarettesday in men being married a subsistencefarmerlaborer an alcohol user and having low household assets were independently associated with being a tobacco smoker all p 001 among women not completing secondary education being 2534 years residing in urban apia and being an alcohol user were independently associated with being a tobacco smoker all p 001 conclusions tobacco use in samoa remains high and correlates of smoking suggest that interventions for cessation need to be developed within the contexts of sex age education and household socioeconomic status

introduction children are the fundamental guarantee of human sustainable development 1 as an important resource for the future construction of a country their physical health is a strategic issue directly related to the future and destiny of the country childrens physical fitness has always been a health issue of global concern a survey of children and adolescents aged 219 including toddlers showed that obesity rates rose by 69 for males and 64 for females in developed countries obesity rates in developing countries rose by 48 for males and 50 for a female between 1980 and 2013 according to the 2014 national physical fitness monitoring survey the level of morphological indicators such as height has improved in china while the level of physical fitness has decreased ranging from 01 to 23 the report on childhood obesity in china points out that the obesity rate of children in largeand mediumsized cities alone is 43 without effective intervention measures the obesity rate of children will rise to 6 by 2030 which seriously threatens childrens physical health therefore it is of great significance to pay attention to childrens physical quality for the sustainable development of childrens physical health since 2000 by the national physical fitness monitoring indicators issued by the state china has conducted regular and unified tests on the monitored objects nationwide in the form of sampling surveys children aged 36 are the important monitoring objects the age of 36 is a critical period for childrens growth and development a followup investigation found that obesity in early childhood can increase the probability of obesity in adulthood and obesity can cause chronic diseases such as hypertension diabetes and cardiovascular disease therefore it is of great significance to investigate and monitor childrens family environment sports behavior and shape quality function and other content indicators at this stage among physical measurement indexes body mass index which is calculated as bmi weight height 2 is an objective index commonly used in the world to measure the degree of body fat and thinness bmi as one of the important indicators for child nutrition monitoring and obesity screening has reached broad consensus on theory and practice many organizations and countries around the world have established the standard curve of bmi percentile and the threshold of overweight and obesity screening for preschool children such as the international obesity organization who relevant research found that bmi was not only significantly correlated with the occurrence of hyperglycemia hypertension hyperlipidemia and other diseases but also can directly reflect the body fat level of the human body this index was also significantly correlated with the health of children and adolescents after adulthood due to their cognitive characteristics childrens cognitive ability is lower than that of adults generally children cannot rely on direct experience when acquiring information and they need to rely more on people around them to provide information studies have found that parents upbringing static screen time was too long and inadequate activity would lead to childrens physical deterioration and parents upbringing was the integrated embodiment of its education behavior and idea which also was a kind of performance in the process of childrearing behaviors and tendency beyond that family structure and the cultural level can significantly affect their parents upbringing although there are many studies on the influence of the family environment on the next generations sports healthy behavior previous studies mainly focused on the influence of the family capital on its healthy behavior moreover very few studies focused on the influence of family sports attitude on their sports behavior screen time and bmi in addition previous studies on childrens bmi mainly focused on descriptive analysis without effectively exploring its path relationship therefore the path relationship between the influence of family sports attitude on childrens bmi especially in different family structures remains to be further studied therefore based on the analysis of previous studies and by the characteristics of childrens growth and development this study constructed a theoretical framework model of family sports attitude affecting childrens bmi this study explored the influence mechanism of family sports attitude on childrens bmiit is found that family sports attitudes can affect childrens physical health by influencing childrens screen time and sports participation the results of this study will provide a useful reference for the rational design and planning of childrens physical and mental health courses and it will provide a useful reference for improving childrens physical activity level and preventing childrens obesity therefore based on the analysis of previous studies and by the characteristics of childrens growth and development this study constructed a theoretical framework model of family sports attitude affecting childrens bmi thus providing a useful reference for the future design and planning of childrens physical and mental health courses promoting their physical activity levels and the prevention of childrens obesity in the future literature review family sports attitudes with childrens physical activity and screen time social psychological studies have proved that values affect attitudes and attitudes affect behaviors sports attitude is an outer variable which can only affect children through sports behavior the characteristics of childrens physiological cognition lead to the need for nurturing children to provide them with sports experience and information and sports are highly infectious researchers have found that children from families with supportive attitudes toward physical activities were significantly better than those who did not therefrom family sports attitude would have a certain influence on childrens physical activity participation behavior and psychology it was found that children were more affected by the feedback of parents sports evaluation and they were more susceptible to the influence of peers in adolescence from that parents play a key role in the influence of childrens physical activity behavior in early childhood compared with children without parental support children with parental support were more likely to participate in sports activities and believed that they have the better athletic ability a study that followed daily activities of 155 children aged 47 for 3 years found a high correlation between low levels of gaming activity and high bmi while the high level of physical activity was positively correlated with the bmiz score in preschoolers the bmi of children with moderate to highintensity physical activity was significantly lower than that of children with lowintensity physical activity however there are also inconsistent results with the above studies researchers conducted a randomized controlled intervention experiment on children in 36 nurseries in douglas scotland three times a week and found that the bmi of the children in the lowintensity physical activity experimental group was not lower than that of the control group however there was a significant difference in bmi between the moderatetohighintensity group and the control group so the amount of moderatetohighintensity physical activity would significantly affect the bmi of children fitzgibbon et al found that moderate to highintensity hiphop was effective in reducing subsequent increases in bmi in preschoolers in chicago illinois but had no significant effect in latin america in addition sedentary behavior has also attracted a lot of attention from researchers especially since the screen time of sedentary behavior has almost become the focus the survey found that the average screen time of primary school students in hong kong was 4 h per day on weekdays and 6 h on weekends there was a positive correlation between screen time and bmi among children threeyearold children with more than 8 h of screen time per week had an increased risk of obesity at the age of 7 a finding found in another study which also reduced bmi triceps sebum thickness and abdominal circumference when screen time was reduced parents education level and childrens bmi as the core of the family and the first teacher of children the influence of parents on their childrens behavior and attitude is the focus of scholars research parents education levels are an important background characteristic that affects childrens development a large number of studies have reported that parents socioeconomic status is closely related to their childrens cognitive ability social emotion and physical health the indicators of social and economic status include parents education levels income occupation etc among which parents education levels are a stable and important indicator cheng et al found that a mothers occupation and length of education had a significant impact on the bmi of her children the higher her occupational class and status the longer her education the lower the bmi of her children the more time children spent in physical activity with their parents the lower their bmi was in the study of family social economy and bmi of children and adolescents shi et al found that the education level of parents can significantly affect the bmi of children and adolescents and the higher the education level of parents the lower the probability of the childrens bmi being obese in consequence the mechanism of the parental educational level in the influence of family sports attitude on childrens bmi needs to be further studied family structure and childrens bmi early childhood is a critical period for the development of physical health when children choose physical activities at a young age they can only complete them under the guidance of caregivers so caregivers play a pivotal role in this process and the family environment in which children grow up and its composition are of great importance the researchers found that the physical activity style of the caregivers the degree of support and supervision for their childrens physical activity and the parenting methods would all affect childrens sports participation therefore the composition of family members and the time and the way of accompanying children in their growth process have a significant impact on childrens sports participation and eating habits and these factors are related to childrens bmi there are mainly nuclear families living with their parents and nonnuclear families such as singleparent families intergenerational families and threegeneration families children with different family structures have different primary caregivers and childrens sports participation and other factors are different due to different parenting styles and health concepts in recent years the influence of family structure on childrens health behaviors has gradually attracted the attention of scholars however the focus is mainly on the mental health problems caused by intergenerational rearing and singleparent families while the influence of family structure on childrens physical health and sports behaviors is rarely studied then the specific mechanism of childrens health differences caused by family sports attitude is still unclear and the influence of different family structures on childrens physical fitness needs to be further studied in conclusion first previous studies have confirmed that family sports attitude has a certain influence on childrens physical activity and screen time second exercise participation and screen time were important factors affecting childrens bmi however whether exercise participation and screen time have a mediating effect on the influence of sports attitude on childrens bmi has not been verified third since the family structure can influence childrens sports behavior it has not been confirmed whether the influence path of sports attitude on childrens bmi will change in different family structures that is nuclear family and nonnuclear family because of this this study hypothesized that h1 family sports attitude was negatively correlated with infant bmi hypothesis h2 childrens activity participation and screen time played a mediating role in the relationship between family sports attitude and childrens bmi materials and methods instrument the instrument of this research was a questionnaire which was designed and based on a large number of research literature the following three parts were sorted out and formed personal background the content includes childrens gender age height weight and other actual basic information and the corresponding bmi is calculated according to their height and weight childrens sports participation in this part the exercise participation calculation formula used by fox was adopted exercise participation exercise frequency × the higher the value the higher the exercise participation degree this part includes the number of days for children to have screen activities in a week the number of times of exercise in a week activity intensity and activity time etc specifically the classification of exercise time is as follows 1 means 30 min or less 2 means 3160 min and 3 means 6190 min 4 means 91120 min of exercise 5 means 121 min or more exercise intensity is also divided into five levels 1 means not tired at all 2 means not tired 3 means a little tired 4 means very tired 5 means very tired the frequency of exercise is the number of exercises per week 1 means less than one time per week 2 means one to two times per week 3 means three to four times per week 4 means five to six times per week and 5 means more than six times per week home environment this part includes the basic information of childrens main caregivers occupation education level physical exercise frequency and attitude toward sports the physical exercise attitude scale contains nine items such as do you think your childs physical fitness is enhanced by playing sports games the scale was quantified by a likert fivepoint scale according to the options disapprove not very agree general somewhat agree and strongly agree the scale was rated as 15 points respectively the higher the total score the more support the parents have for childrens sports the pretest of the scale showed that the retest reliability was high and the overall cronbach α coefficient was 087 the overall verification results of the measurement model were as follows χ2df 184 rmsea 003 agfi 098 cfi 099 tli 099 ifi 099 gfi 099 which shows that the questionnaire has good measurement validity and reliability statistical analysis ssps statistics 210 was used for the statistical analysis after the shapirowilk normality test the independent sample ttest and onefactor anova were used to analyze the differences in demographic variables pearsons crossproduction correlation was used in parents education levels family sports attitude sports participation screen time and childrens bmi amos 210 was used to construct the structural equation model and conduct path analysis the mediation test process proposed by gerbing and anderson was used to explore the mediation effect first the independent variable had an impact on the dependent variable and the regression coefficient was significant second the independent variable affected the intermediary variable and the regression coefficient was significant third the joint influence of the independent variable and intermediary variable on the dependent variable was significant the significance level of all indexes was set to α 005 results demographical variance analysis of sports attitude and sports behavior the results of the independent sample ttest show that in terms of gender there was no difference in boys and girls family attitudes toward physical activity there was no difference in the physical activity behavior between boys and girls there was no gender difference in screen time there was no gender difference in infant bmi the results of analysis of variance showed that in terms of a mothers education level there were differences in the family sports attitude score childrens sports participation screen time and childrens bmi among different mothers education levels specifically the scores of the mother with primary school education were lower than those with high school education while those with high school education were lower than those with a college education or above there were also significant differences in childrens sports participation between fathers with different education levels children with fathers education levels had the highest sports participation in college or above followed by children with fathers education levels in middle to high school there was no significant difference in childrens sports participation between fathers education levels in middle and high school and primary school children the screen time of children was significantly different only between primary school and college or above groups the screen time of mothers with primary school education was significantly higher than that of college or above groups in terms of childrens bmi there were differences between mothers with different education levels the bmi of children whose mothers had primary school education was significantly higher than that of those from middle school to high school and the bmi of children whose mothers had middle school to high school education was higher than that of children whose mothers had a college education or above in terms of fathers education levels there was a significant difference in sports attitude among families with different fathers education levels the score of a fathers education from middle school to high school was significantly higher than that of primary school and there was no significant difference in the score of family sports attitude when a fathers education was higher than middle school there were also differences in childrens sports participation among fathers with different education levels fathers education levels in college and above were significantly higher than those in primary school while there was no difference between fathers education levels in primary school and middle school to high school in terms of screen time there was no difference between fathers with college or above education background and those with middle school to a high school education level while there was no difference between fathers with middle school to high school and primary school education levels in terms of bmi of children the fathers education level from middle school to high school was significantly lower than that of primary school and the fathers education level from university or above was also significantly lower than that of primary school there was no difference in bmi of children between a fathers education level from middle school to high and those education levels from a college or above family structure there were differences in family sports attitude sports participation and screen time among children with different family structures but there was no significant difference in bmi multiple comparisons showed that the scores of family sports attitude in families with parents living together intergenerational parenting and three generations living in the same house were significantly higher than those in singleparent families the results showed that the childrens sports participation of three generations in the same family intergenerational parenting and singleparent family was significantly higher than that of a small family screen static time per week in families with three generations and parents living together was higher than that in singleparent families correlation analysis of family sports attitude parents education levels sports participation screen time and childrens bmi correlation analysis showed that there were significant correlations among the variables there was a significant negative correlation between family sports attitude sports participation parents education levels and childrens bmi and there was a significant positive correlation between screen time and childrens bmi hypothesis h1 of this study was confirmed there was a significant positive correlation between sports participation and family sports attitude there was a significant negative correlation between family sports attitude and childrens screen time there was a significant negative correlation between family sports attitude and childrens bmi linear regression of family sports attitude sports participation screen static time and childrens bmi the results of linear regression showed that family sports attitude was negatively correlated with childrens bmi sports participation was negatively correlated with young childrens bmi one week of static screen time was positively correlated with childrens bmi and they all reached a significant level path relationship analysis of family sports attitude sports participation screen static time and childrens bmi the relationship of family sports attitude sports participation screen time and childrens bmi the mediating effect between screen time and exercise participation were examined by wen and ye mediating effect test procedures figure 1 shows a structural equation model testing the mediating effect of exercise participation and screen time the structural equation model contains four potential variables and the results show that the fitting indexes of the structural equation model are as follows x2df 184 df 1 rmsea 003 agfi 098 cfi 099 tli 099 ifi 099 which indicated that a model can be established well figure 1 shows the standardized coefficient in the mediation model diagram and table 5 shows the results of indirect effects as shown in table 5 the confidence interval of each mediation path does not contain 0 so the mediation effect is significant hypothesis h2 in this study is valid as shown in figure 1 the direct effect of family sports attitude and childrens bmi in the model was not significant but the negative prediction effect of family sports attitude and screen time was significant family sports attitude and childrens sports participation had a significant positive predictive effect the bmi of children was predicted negatively by sports participation while the screen time could predict bmi positively from the significant levels and the standardized path coefficient b values in the structural model in figure 1 it is not difficult to find that screen time and sports participation in the model play a mediating role between family sports attitude and childrens bmi and the mediating role includes three paths the single mediating effect of screen time and sports participation and the chain mediating effect of screen time → exercise participation to verify the mediating effect of sports participation and screen time between family sports attitude and childrens bmi nonparametric percentile bootstrap was used to test the significance of mediating effect the original data were sampled 2000 times and a 95 ci was estimated if the confidence interval did not include 0 the mediating effect was significant the results in table 5 show that screen time and sports participation played a complete mediating role between family sports attitude and childrens bmi while screen time → sports participation played a chainmediating role none of the three intervals contain 0 indicating a significant mediating effect therefore hypotheses h1 and h2 of this study have been confirmed difference test of a mediation model in different family structures relevant studies found that different family structures in childrens lives can lead to significant differences in childrens sports participation screen time and bmi this study verified whether sports participation and screen time have a stable mediating role in different family structures firstly the mediating effects of childrens sports participation and screen time in nuclear and nonnuclear families were examined respectively the results showed that the model fitting indexes of nuclear families were χ2df 251 agfi 096 cfi 099 tli 096 ifi 099 rmsea 0067 the model fitting indexes of nonnuclear families were χ2df 167 agfi 096 cfi 099 tli 098 ifi 099 and rmsea 0052 the results showed that the fitting indexes of each group were good which could be compared with different groups of models then the set equivalent model was used to compare the different groups of models and the results showed that the model had good fitting indexes and the fitting index difference cfi and tli values were less than 005 the results show that the mediation model is stable in different family structures discussion analysis of influencing factors of infant bmi family sports attitude sports participation and screen time this study found no gender differences in childrens bmi family sports attitude weekly sports participation and static screen time which is consistent with the results of the xinran shis study at the same time this study found that children with different family structures have significant differences in sports attitudes screen time and sports participation further analysis found that children with singleparent family structure scored the lowest in family sports attitude and there were significant differences in living with their parents grandparenting and three generations in the same family previous studies showed that children living in the singleparent family structure were more likely to have physical and mental health problems than those who live in a twoparent family structure quarmby et al confirmed that the lower socioeconomic status of singleparent families compared with twoparent families partly explains the poorer physical health of their children compared with european and american countries the major feature of chinese family structure is grandparenting there are different conclusions about the advantages and disadvantages of grandparenting opponents believe that grandparents are prone to develop bad health habits due to poor health habits and lack of nutrition knowledge supporters believe that grandparents love for their grandchildren abundant time and energy investment in a company education and nurturing experience are all beneficial to the healthy development of grandchildren in this study we found that the sports participation of threegeneration families was higher than that of families living with parents only which may be related to the time advantage of grandparents to pay attention to and accompany their childrens activities other researchers have suggested that the threegeneration family structure is more conducive to the formation of healthy concepts in young children as the role of family bonding is played by grandparents living in the same family in addition this study found that the higher the mothers education level the lower the childrens bmi qian et al conducted a study on chinese students aged 810 and found that the group whose parents have a low educational level has a low score in dietary habits and nutritional knowledge while dietary habits are significantly correlated with bmi han hui et al found a significant correlation between childrens food preference risk and their mothers education levels and the higher the mothers education level the lower the risk of childrens food preference risk the study also found that parents education levels were negatively correlated with childrens screen static time researchers also found that the daily screen time of children whose parents have a college education level or above was significantly lower than that of children whose parents have a primary school education level or below the study also found that children whose parents had college education levels spend more time on moderateintensity activity than children whose parents had middle school education levels or below the results of this study are also consistent with those of other studies so the results of this study are not only limited to chinese children but also consistent with those of spanish and caucasian children the results showed that the educational level of the parents was related to the health habits of children wang et al found in their research that the concept of exercise will gradually internalize into selfidentity with the improvement of the education level and the influence of the education level on physical exercise behavior will be increasingly enhanced therefore parents education levels have a profound influence on family physical exercise family sports attitude and childrens bmi there is a significant negative correlation between family sports attitude and childrens bmi which is consistent with the previous research results of gao yan et al a large number of studies have shown that the decisions of childrens sports participation at the beginning middle and end are related to the environment human behavior is formed by the interaction between individuals and the environment the environmental models that affect human development include micro medium and macroenvironmental models family is an important part of the microenvironment which plays a key role in the process of childrens growth family is not only the gatekeeper of childrens sports activities but also the key factor of childrens screen time duration effective intervention measures aimed at family factors can affect childrens physical condition therefore a better understanding of the influence of family sports attitude on childrens physical health is helpful to reduce the incidence of childhood obesity and malnutrition caused by family factors previous studies have shown that the influence of family parents and elders on childrens sports behavior can be divided into two aspects the support of elders for childrens sports and the shaping of the role model of elders all the above results indicate the importance of family sports attitude in childrens physical health among the influencing factors of the family on childrens physical health and family should be regarded as the implementation focus of childrens physical health intervention chainmediated effects of childrens screen time and exercise participation in this study screen time and sports participation were used as mediating variables to construct a mediating model of family sports attitudes affecting childrens bmi the mediating effect of sports participation and screen time is significant which indicates that they played an important role in family sports attitudes in interpreting childrens bmi fan huiying et al found that family support has a significant impact on childrens physical activities and family as the starting point of childrens sports participation there was the strongest correlation between their support for childrens physical activity attitude and childrens sports so family sports attitudes play an important role in young childrens sports participation and static screen time limitation parents as the first teachers of childrens physical education class will have a positive impact on childrens sports by setting an example in sports participation and supporting the concept of physical education whereas the negative performance of family physical education attitude and behavior will have a negative impact on children reilly et al found that scottish childrens physical fitness declined due to insufficient sports participation in recent years one important and direct reason is that parents have a negative attitude toward sports participation researchers found that the longer childrens moderateintensity activity time was the shorter their screen time was which was related to childrens family sports cognition this view was consistent with the results of this study parents support for childrens sports can improve their childrens sports participation while childrens sports exercise is negatively correlated with childrens bmi sports attitude can influence childrens bmi through sports participation another important factor affecting bmi is sedentary behavior which includes screen time homework time and so on related studies have found that sedentary behavior mainly based on screen time has a negative impact on health problems such as overweight and myopia in adolescents and children moreover the study found that family and peer support had a significant impact on sedentary screen time and parents support for childrens physical activity was negatively correlated with screen time it can be seen that the family environment constitutes an external driving force for childrens screen time which is mainly manifested in exercise support and participation when family members form a state of high screen timelow exercise time childrens screen time can be invisibly increased thus leading to the increase of their bmi this indicates that the mediating effect of screen time and exercise participation in this research model is feasible and it can be seen from figure 1 that the mediating effect is completely mediating to some extent this result explained the influence mechanism of family sports attitude on childrens bmi and provided evidence for the intervention of family factors in childrens physical health development differences in mediating effects of screen time and exercise participation among different family structures screen time and exercise participation were fully mediating effects in different family structures and the chainmediated effects held in both nuclear and nonnuclear families in the family structure the nuclear family is the family composed of husband and wife and unmarried children while the nonnuclear family includes three generations living under the same family single parent and grandparenting families this study found that the total mediating effect of screen time and exercise participation in nonnuclear families was higher than those in nuclear families which may be related to the higher proportion of three generations living in the same family in nonnuclear families the family structure of three generations under one roof is the most abundant and complete children grow up in this environment with both parents and grandparents the study found that grandparents had more time and energy to spend with and participate in childrens activities than busy parents however the lack of parents company and upbringing may result in childrens bad health behavior habits due to the lack of scientific sports knowledge nutrition knowledge and poor health concept of their grandparents therefore both parents and grandparents play important roles in the development of healthy behaviors in young children in this study there were significant differences in childrens family sports attitude sports participation and screen time among different family structures but there was no significant difference in the mediating role model of sports participation and screen time the results indicated that the three factors of family sports attitude sports participation and screen time were different due to the influence of family structure variables but the chainmediating effect of sports participation and screen time in the influence mechanism of family sports attitude on childrens bmi had internal similarities among different childrens family structures conclusion and prospect conclusion there are significant differences in childrens family sports attitude sports participation screen time and bmi with different parents education levels specifically the higher the parents education levels the higher the family sports attitude score the better the sports participation and the lower the screen time family sports attitude is positively correlated with sports participation and a mothers education level and negatively correlated with childrens screen static time and bmi sports participation and screen time play a completely mediating role in the influence path of family sports attitude on childrens bmi the mediating mechanisms of sports participation and screen time were not affected by family structure but the total mediating effect of sports participation and screen time was higher in nonnuclear families than in nuclear families the results of this study will provide a useful reference for teachers and parents to control childrens physical health and the influencing factors of childrens physical health research in the future limits and prospects this study identified the mediating role of sports participation and screen time the structural equation model of the relationship between the attitude of plus family and childrens bmi was constructed and verified and the study still has the following limitations and suggestions for future research among the family influencing factors of childrens bmi this study focused on examining the mediating effects of childrens sports participation and static screen time this study was a crosssectional study future research can further support the conclusion of this study by using the exercise tracking method and providing direct evidence for variable causality data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding authors ethics statement the studies involving human participants were reviewed and approved by the ethics committee of sports school of southwest university in china written informed consent to participate in this study was provided by the participants legal guardiannext of kin 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

background childrens physical health is an important resource for a countrys future construction however researchers found that the physical fitness of young children around the world has declined during the two decades from 1992 to 2012 the decline in the physique of young children has caused widespread concern around the world childrens main living places are families and kindergartens so this research explores the impact of family factors on childrens body mass index bmi from the perspective of family attitudes childrens sports participation and screen time methods a crosssectional study was used to conduct a questionnaire survey of children in china a total of 600 children were investigated and 589 valid questionnaires were obtained spss210 statistical analysis software was used for descriptive analysis mean comparison and correlation analysis of the data amos 210 was used to construct a structural equation model and carry out path analysis 1 there are significant differences in childrens family sports attitude sports participation screen time and bmi with different family structures and parents education levels 2 family sports attitude is significantly positively correlated with parents education levels and childrens sports participation and negatively correlated with childrens screen time and bmi 3 childrens sports participation and screen time play a chainmediating role between family sports attitude and childrens bmi and the role is a complete mediating role therefore family sports attitudes can affect childrens physical health by affecting childrens sports participation and screen time to promote childrens physical health we should pay attention to the intervention of family sports attitude 4 the mediating effects of exercise participation and screen time are similar in different family structures so the structure of this study can be applied to different family structures

introduction the region of southeast asia exemplifies both the benefits and drawbacks of globalisation due to its wealth in resources and its advantageous location this region has for a very long time been subject to the influence of outside forces the association of southeast asian nations which has introduced a new degree of regional cooperation to the area has the purpose of integrating sea countries in the region the region of sea is split into two subregions the mainland and the islands there are 11 different countries that make up this region membership in asean which was founded on august 8 1967 in bangkok thailand and this has served to bring together the states that are located in this region indonesia malaysia the philippines singapore and thailand were the founding member states of asean brunei darussalam became a member of asean on january 7 1984 this was followed by vietnam on july 28 1995 lao peoples democratic republic and myanmar on july 23 1997 andcambodia on april 30 1999 bringing the current total number of asean member states to 10 sea comprises 105 of the overall land area of asia and 3 of the total land area of the earth the population of this region is over 675 million people which accounts for around 85 of the total population of the world the mainland subregion of sea is referred to by names such as the indochinese peninsula and indochina it is located to the east of the indian subcontinent and to the south of the chinese mainland to the west it is bounded by the indian ocean while to the east it is bounded by the pacific ocean cambodia laos myanmar thailand and vietnam are all members of this group of countries buddhism predominates across the board in the cultural landscape of this subregion it is also one of the regions in the world with the lowest rate of urbanisation and features a multicultural and multiethnic population human rights are routinely violated in this region as a direct result of the political instability that exists here for instance in the span of just more than a century thailand has seen 13 successful and 9 unsuccessful military coups the most recent military coup occurrence in this subregion took place in february of 2021 in myanmar malaysia singapore brunei east timor indonesia and the philippines are the countries that make up the insular sea subregion known as the islands of sea this area is a subrealm that is made up of a number of peninsulas and islands however despite its status as a developing region it is frequently the site of environmental and regional strife all of the states histories in this subregion include periods of colonial rule in fact thailand was the only country in sea that was never colonised religions were introduced into this region through western colonisation and traders colonial powers such as the portuguese introduced roman catholicism to malacca malaysia and areas of eastern indonesia during the 15th century buddhism is currently widely practised in four states such as myanmar thailand laos and cambodia muslims traders were the first to bring islam to sea by 1650 islam had surpassed other religions and became the dominant religion in malaysia and indonesia as a direct consequence of this sea is one of the regions in the world with the lowest religious diversity for example with approximately 87 of its 244 million people identifying as muslims indonesia is now the worlds largest state with a muslim population so when thailand became the first country in asia to decriminalize the consumption of cannabis in 2022 several states were not comfortable with the new law thailands new law allows marijuana foods beverages and medical use in thailand such behaviours are part of thailands subculture but remain counterculture in other sea states the impact on sea subregions was investigated in this study this study seeks to answer the question could thailands recent cannabis culture have an impact on other sea countries because this is a new study qualitative and digital ethnography were employed the secondary government data were analysed via thematic analysis it is anticipated that due to tourism people in this sea region will be able to learn respect and indeed practise thailands new subcultures themselves thailands tourism industry recovered well in 2022 but international arrivals will not return to prepandemic levels until 2024 the gradual border reopening has resulted in an increase in international visitors in 2022 with 44 million tourists by the end of august 2022 up from slightly more than 380000 in 2021 the increase in visitor arrivals is expected to continue in the coming years supporting tourism jobs and revenues in thailand tourism shall be a primary sector of economic growth and it is expected to increase thailands gdp in 2023 the new cannabis law is expected to attract more international tourists and promote weed tourism in thailand thailand is currently the home of thousands of cannabis dispensaries and is unofficially known as the amsterdam of the east literature review social conservatism the historical and religious influences in the region contribute to the social conservatism that is an essential characteristic of sea social conservatism is a political philosophy whose primary concern is the maintenance of longestablished norms values and beliefs it places emphasis on a concern with moral and social values which many adherents of the ideology believe have deteriorated in todays modern society as a result of liberalism social conservatives in sea organise in support of duty and move to uphold traditional values and social institutions such as traditional family structures gender roles sexual relations and national patriotism social conservatives in sea also uphold traditional religious practices the antidemocratic and antiliberal social forces in sea have successfully outweighed democratic and liberal elements via laws and policies in civil society as a result political and ideological divides exist in this region and they have become more pronounced over the course of the most recent years as a case in point on december 6 2022 the indonesian legislature unanimously enacted a new comprehensive criminal code that criminalises extramarital sexual interactions the law is applicable to everyone in indonesia including international tourists recent modifications to the indonesian penal code are a clear reflection of the trend of rising social conservatism that is prevalent throughout sea there are trends that are suggestive of tension in this regard however only a few days before the indonesian law came into force for instance on november 29 2022 singapore decriminalised male sexual activity but concurrently the constitution in singapore was altered to preclude legal challenges to the conventional standards of marriage several public issues particularly those pertaining to public housing education and family planning are affected by the way marriage is interpreted in singapore as a result samesex couples cannot enjoy the rights and advantages of marriage including social security inheritance adoption common ownership of property and goods tax and benefits meanwhile the vietnamese government announced on november 11 2013 that it will no longer impose fines on anyone who conduct public samesex wedding ceremonies however such ceremonies are neither recognised by the law nor offered legal protection in spite of its rapid economic progress singapore is still often regarded as a conservative state that is especially stringent with some regulations violators of these laws face the possibility of being arrested or imprisoned the authorities even continue to use a centuriesold procedure called corporal punishment which consists of hitting a person with a rattan cane as a legacy of british colonisation caning is still employed as a form of disciplinary action in malaysia and brunei the province of aceh in indonesia which has a mainly muslim population is the only one in the country to observe islamic law and to publicly cane people for offences such as stealing gambling and adultery in aceh sharia law is strictly implemented which includes prescribing the outward appearance of society members via a dress code thus being modestly dressed in sea such as being covered from the waist to the knees for men and having the arms legs back and chest covered for women are typically regarded as essential for instance despite being a multicultural society malaysia has many local dress code traditions and expectations in malaysia it is strongly recommended that members of the public particularly tourists stay away from certain types of apparel such as singlets and short skirts meanwhile in singapore section 27a of the miscellaneous offences makes it illegal to be naked in public which includes being naked in private locations that are visible to the general public however despite the fact that going topless or nudist while sunbathing is considered impolite in thailand thailands legal system does permit clothingoptional resorts in a move consistent with this trend toward social liberalisation meanwhile on june 9 2022 cannabis in thailand was removed from the list of illegal substances weed tourism subculture vs counterculture this legal framework for cannabis dates back to the 1970s the narcotics act was enacted by thailand in 1979 the classification of cannabis as a class 5 controlled substance was determined however in 2019 thailand passed the narcotics act which legalises the use of cannabis for scientific and medical study therefore initiatives to use cannabis in research and development have been given the goahead to instigate the cannabis subculture in the year 2020 the thai food and drug administration announced that cannabis leaves and roots generated from recognised sources will not be matched the criteria for classification as type 5 narcotics these actions made it possible to legalise cannabis while setting some restrictions during the following year the fda registered approximately one hundred locations such as government entities and agricultural communities with state registrations to cultivate marijuana on june 9 2022 thailand made history by permanently removing cannabis and hemp from the list of category 5 narcotics this decision was highly significant enormous with regard to the tourism industry in thailand initially all aspects of the cannabis plant including possession manufacture distribution consumption and sales were legalised in thailand for medical use only however since the beginning of june 2022 numerous food and beverage companies around the nation have capitalised on the recent liberalisation of marijuana by stocking the shelves of convenience stores with cannabisinfused foods and beverages containing marijuanaderived ingredients it should be noted that while in order for food and drink products to be legally sold in thailand they must contain less than 02 percent tetrahydrocannabinol cannabisinfused food and drinks can be served including to tourists in cafes and restaurants provided the thc content of these products remains below the 02 percent threshold notwithstanding this point a recent study conducted at a renowned institution in thailand revealed that thirty percent of these items exceeded the 02 thc limit set by the government thc is the principal psychoactive component of marijuana as a result without a doubt the cannabis counterculture has begun to grow in thailand following the drugs legalisation it is plausible to argue that in global terms the cannabis subculture functions as a cultural subgroup inside the larger culture members of this group could hold beliefs and passions that are not shared by the larger culture around the world there are now neonlit signs featuring cannabis plants and cannabis is making its way into the food drinks and cosmetics industries this tendency is bolstered by the prospect of profit from weed tourism which is anticipated to be worth more than one billion dollars for thailand by 2025 the revenue from cannabis has been a lifeline for cities devastated by the restrictions related to covid which have wrecked thailands tourismbased economy cannabis in thailand has now been advertised as a vacation experience by the tourism authority of thailand which has published a series of guidebooks promoting places where tourists may visit organic cannabis fields and receive cannabis oil massages since june 2022 more than one million people have been granted permission to cultivate cannabis through the governments mobile phone application according to the thailand ministry of public health this number is anticipated to continue rising however throughout the rest of the sea drug prohibitions are stringent in singapore in 2022 itself five men were executed for drug trafficking offences human rights watch reports that since assuming office on june 30 2016 president rodrigo duterte of the philippines has waged a war on drugs that has resulted in the deaths of over 12000 filipinos largely the urban poor the philippine national police has been implicated in at least 2555 killings in a campaign that may constitute crimes against humanity it has been reposted that duterte and other senior officials have approved and incited those killings thus with the prominent exception of thailand the cannabis culture in sea remains a prominent counterculture the ideals and conventions of cannabis consumption behaviour diverge significantly between thai and other sea mainstream societies the thai societys tolerance towards cannabis appears to be strongly contradictory to sea mainstream cultural values this is not the first time thailand has legalised a subculture that contrasts with that of other sea nations in 2007 nat which stands for naturist association thailand co ltd was founded in 2011 chan resort became the first resort in sea to legally permit visitors to disrobe on the property in 2015 when the barefeet naturist resort in bangkok initially opened its doors visitors were not permitted to choose whether or not to wear clothing guests are required to be naturists or to be accompanied by a naturist at all times the nat has three thousand members as of 2016 including individuals from india australia hong kong the philippines myanmar thailand singapore and taiwan in 2022 thailand was home to eight resorts that did not restrict tourists to wearing clothing the resorts are well established around thailands major cities such as in bangkok pattaya phuket and chiang mai despite the pandemic thailand is a popular destination for naturists from other nations since the climate is good throughout the year the majority of nonwestern clothing optional tourists are not just from sea but also from australia india the middle east and china meanwhile in 2015 the thai parliament passed the gender equality act this law is intended to protect lesbian gay bisexual and transgender community members from discrimination based on gender identity and sexual orientation although thailand has a long history of tolerant attitudes towards lgbt individuals this is the first law that clearly guaranteed their rights as a result in 2017 bangkok was voted the second most lgbtfriendly city in asia due to its thriving lgbt community bangkok was ranked as the 61st greatest lgbt destination in the world despite the fact that samesex marriage remains outlawed the score was determined based on surveys conducted in 80 nations in which respondents ranked the lgbt tourism such as dating places nightlife openness safety and legal rights in each location as expected no other asean cities were ranked and listed on this survey meanwhile travelling to bangkok or other cities in thailand is not a challenge for asean community members the asean framework agreement on visa exemption which was launched during the 39th asean ministerial meeting on july 25 2006 in kuala lumpur was a significant initiative designed to boost and speed up intraasean and labour liberalisation this programme permits asean individuals including tourists travelling throughout the sea to travel visafree for 14 working days from the date of admission as a result of geographical distance and visa exemption tourists from other sea have been visiting thailand in great numbers thus sea tourists passing through thailand would have easy access to behaviours or substances including cannabis forbidden in their own countries research methodology the research objectives were to understand the effect of thailands subcultures on other sea states countercultures the primary research question was to investigate the effect of thailands subcultures on other sea states in the context of weed tourism particularly that is thailands recent cannabis culture as a result a qualitative research approach drawing on data and analysis were utilized qualitative data that was nonnumerical in nature such as text documents was compiled and analysed in order to gain a better understanding of ideas perspectives or experiences the method of digital ethnography was selected for the study of individuals in a realworld setting digital ethnography also known as mobile ethnography is a modern digitalfirst approach to conducting ethnographic research remotely in terms of data gathering the social and behavioural sciences rely heavily on ethnography which is also a common qualitative research technique secondary data collection was employed to collect data which was then transformed into knowledge that may be utilized to develop conclusions on the functions of societies and individuals this methodology also allowed researchers to observe responses from the sea states in their natural surroundings to participate in this study sea states were required to meet two inclusion criteria the consequences of the recent cannabis counterculture and cannabis law in thailand were the sole factor taken into account firstly only the views and opinions after june 9 2022 from the sea government authorities specifically government ministries and leaders were considered second only viewpoints from asean member states were examined consequently only the opinions of the governments of the 10 member states were considered the east timor governments views on the cannabis subculture in thailand were not included because east timor is not an official asean member state thematic analysis was conducted to investigate the recurring themes within the secondary data as it is a method rather than a methodology this approach is not beholden to a particular epistemological or theoretical stance unlike many other qualitative research studies thus this analysis makes it a very versatile strategy added a substantial advantage given the diversity of this research topic this qualitative data analysis was used to analyse primarily nonnumerical data such as audios videos and texts from government and official press websites as well as from the official asean website the researchers classified all the data systematically and then organised the codes based on similarities into larger and larger categories resulting in a hierarchical structure represented by the likes of code subtheme and theme the researchers followed braun and clarkes sixphase framework which included familiarising themselves with the obtained secondary data generating initial codes searching for common themes evaluating the themes identifying themes and writing up the results using voxco software the researchers analysed the selected reports and searched for salient patterns in the datas repeated themes findings since the 1970s asean governments have primarily employed strong punitive measures in an attempt to kerb drug consumption and distribution nonetheless on june 9 2022 thailand legalised the cultivation of cannabis and its consumption in food and beverages and removed cannabis from its list of prohibited drugs thailands new law aim to enhance its agriculture and tourism industries and allow the use of plant for medical purposes immediately following its introduction this new thai law was reported in the media of all ten asean member states hence the researchers reviewed and analysed the responses of the asean member states leaders and government representatives to the reports of the change in thai cannabis law with the objective being to address the primary research question the findings of this research indicate that weed tourism activities in thailand will help the inhabitants of this region to comprehend respect or perhaps even themselves adopt thailands subculture geopolitical factors have an intriguing effect on the cannabis culture in sea in terms of thailands subcultures mainland and insular states tend to hold opposing viewpoints mainland states the kingdom of cambodia khan samban the director of the industrial crops department at the ministry of agriculture said while cannabis cultivation will be still illegal here the government could consider lifting the ban it is an easy crop for planting and can grow in many areas the government would consider amending the law for special cases republic of the union of myanmar there has been no official remark from the military government of myanmar regarding the legalisation and usage of cannabis in thailand the narcotic drugs and psychotropic substances law in myanmar which was passed in 1993 regulates the use and possession of cannabis in myanmar cannabis is still prohibited in myanmar however this law was changed in 2018 to state that drug users are no longer considered criminals drug use has been decriminalised although possession of minor quantities has not some argue that this weakens the entire regulation because it is difficult to use cannabis without also possessing it lao peoples democratic republic similarly to myanmar laos government officials made no official statements regarding cannabis legislation in thailand however the lao ministry of health informed the thai ambassador to laos in a letter dated july 2022 that the kratom plant shall remained illegal in laos this includes cultivating possessing purchasing selling processing storing and importing or providing the plant to laos kratom is a herbal substance that has effects similar to those of opioids and may cause psychotropic effects it can also be addictive socialist republic of viet nam the viet nam government also issued no formal pronouncements regarding this topic even for medical purposes cannabis is outlawed in vietnam however the nonpsychoactive chemical contained in marijuana is permitted and readily distributed vietnam classifies marijuana as a controlled substance like heroin and cocaine as such it bears the same severe punishments as imprisonment or the death penalty recent reports indicate that police in vietnam do make arrests on recreational cannabis consumptionrelated offences however offenders including tourists only face a maximum of a usd100 fine and a harsh warning insular states malaysia the home minister datuk seri hamzah zainuddin in a speech read by home ministry deputy secretarygeneral datuk abdul halim abdul rahman stated malaysians traveling to thailand would be easily exposed to cannabisbased products in the form of food drinks and supplements sold there furthermore cannabisbased products in the form of food drinks and supplements may be smuggled into malaysia malaysia is concerned that some malaysians may become addicted to cannabis because they had unwittingly consumed such products republic of singapore the minister for home affairs and law kasiviswanathan shanmugam shared the point that freer availability of cannabis in thailand to which a lot of singaporeans go to and from where a lot of tourists come to singapore is going to present more challenges republic of indonesia the royal thai embassy in jakarta warn thai people not to carry cannabis hemp or products with cannabis or hemp ingredients into indonesia violators of the law could face a fine of at least 5 years to life imprisonment capital punishment or a fine of roughly 24 million baht negara brunei darussalam on 13 july 2022 the narcotics control bureau made a formal statement stating that people convicted of ingesting class a drugs face up to ten years in jail a fine of up to usd 15000 or both therefore ncb reminded brunei citizens and permanent residents who visit foreign countries that they must be aware of this penalty under bruneis law bruneian and its permanent residents caught ingesting drugs outside of the country are also subject to prosecution regardless of where the drugs were ingested chapter 27 of the misuse of drugs act of brunei criminalises the possession consumption and cultivation of cannabis distribution or possession of more than 500 grams of cannabis will result in the obligatory death penalty republic of the philippines the thai cannabis law has not as yet impacted on the legal position regarding drugs in the philippines there was no formal statement but the new president of the philippines ferdinand marcos jr has pledged to take a softer stance on illegal narcotics than his predecessor however the government made it clear that cannabis possession will remain illegal in the philippines in 2002 the comprehensive dangerous drug act was passed which classified cannabis as a dangerous substance possession and use of cannabis are therefore regarded as illegal in the philippines with possible punishments including life imprisonment or the death penalty according to the findings the mainland and insular states of sea are currently engaging with prepared to face the new cannabis law in thailand cannabis culture will continue to exist as a counterculture in all sea states for the foreseeable future however mainland sea states such as myanmar laos cambodia and vietnam may have the propensity to tolerate and observe thai cultural characteristics within their own territorial boundaries the degree of these states acceptability of cannabis use can be deduced from their official proclamations that have been disseminated through various media outlets however it does not appear that the insular sea states are prepared for the establishment of such subcultures and it is apparent that they will continue to categorise cannabisrelated activities as those belonging to countercultures there is a chance that the role played by politics and religions is the essential factor that requires further examination in future studies of this matter for example the philippines and vatican are the only two independent jurisdictions in the world where divorce remains illegal under their respective legal systems according to the philippines commission on women the family code enacted in 1987 authorises relative divorce or legal separation but still imposes no regulation on divorce per se according to human rights watch bruneis sharia law requires the death penalty for offences such as having sex with a nonspouse or having anal intercourse therefore with these strong markers of social conservatism in mind it would be difficult for these insular states to ease their cannabis regulations consequently in the future there may be significant geopolitical issues in sea as there could be differences between the two subregions as governments on the mainland may adopt a more relaxed and liberal attitude on their cannabis regulations while those on the insular may take the opposite posture therefore the asean framework agreement on visa exemption could be stalled or revised as sea states could face severely divided views on cannabis subculture and weed tourism in thailand which could also jeopardise asean and the regions stability and prosperity conclusion the sea region is divided into mainland and insular subregions the ten member states of the asean region have always been known for opposing social liberalisation and upholding traditional values thailand decriminalised cannabis in june 2022 permitting cannabisinfused foods beverages and medical use of the drug widely throughout thailand in contrast other sea nations prohibit the usage of cannabis in their states and consider cannabis use to belong to a counterculture in thailand this study assessed the impact of this law change on sea subregions this study addressed the question of whether thailands recent cannabis law could influence other sea nations due to the novelty of this research qualitative and digital ethnography were employed the approach included the study of content extracted topics from secondary government data the findings of this research suggested that mainland states may accept and apply their existing cannabis counterculture as a subculture however thailands cannabis subcultures and weed tourism in thailand shall remain countercultures in the insular states region given this point regarding the relevant geopolitical differences such as the acceptance and tolerance of cannabis culture between insular and mainland states it is stated that the issue could pose a future challenge to the prosperity of this sea region

southeast asia sea is geographically divided into two subregions mainland and insular this region consists of 11 states that consistently oppose social liberal changes and uphold traditional values conservatism in politics economy and society including the legal realm is always favoured in this region however recent developments in thailand could test the conservative beliefs and practices in this region in june 2022 thailand decriminalised the cultivation and consumption of cannabis this new law allows people in thailand to consume marijuana edibles marijuanainfused drinks and use marijuana for medical purposes this is not the first time thailand has liberalised its laws for example unlike other sea countries thailand does not regulate the use clothing in private spaces therefore there has been a significant increase in the number of clothingoptional resorts in thailand over recent years meanwhile in 2015 thailand became the first sea country to recognise and protect the rights of lesbian gay bisexual and transgender lgbt individuals such laws and tolerance have now become part of thailands practices and subculture but remain taboo in other sea states hence this research has investigated the impact of developments in thailands subculture on the sea subregions with a particular focus on cannabis law reform therefore this research addresses the primary research question in the context of weed tourism could thailands recent cannabis culture impact other southeast asian countries due to the infancy of this research a qualitative and digital ethnographical research method was chosen the thematic analysis was adopted from the secondary governmentpublished data by eliciting key themes the findings revealed that weed tourism activities would encourage the people in this region to understand respect or even practice thailands subculture themselves the mainland states may tend to accept and observe thailands cannabis subculture in their states however the insular states will not accept such subcultures and will always consider such activities as countercultural

introduction globally 83 of births in 2020 occurred with skilled birth attendance but coverage continues to be uneven around the world with significant discrepancies between regions with only 64 of births in subsaharan africa being attended to by sba 1 about 303 000 maternal deaths are registered annually with 99 being recorded in lowincome and middleincome countries 2 3 sba has been documented as an effective intervention for reducing maternal and neonatal deaths 4 5 skilled attendance at birth can reduce intrapartumrelated complications by up to 20 6 therefore ensuring increased utilisation of sba can substantially contribute towards achievement of the sustainable development goal 3 that aims at reducing the global maternal mortality ratio to less than 70 per 100 000 and neonatal mortality ratio of ≤12 per 1000 live births by 2030 6 7 8 a skilled birth attendant is an accredited health professional such as a midwife doctor or nurse who have been trained with adequate skills needed to handle uncomplicated pregnancies childbirth and the immediate postnatal period and in the identification management and referral of complications in women and newborns 6 besides the women losing their lives effects of maternal mortality and morbidity are also experienced at the household and community level 9 10 children left behind after maternal deaths have increased odds of mortality or other health challenges including undernutrition and the society loses resources when women die in their most productive years 9 in sierra leone pregnancy is associated with a 1 strengths and limitations of this study ► this is the first nationally representative analysis that explores the ruralurban correlates of skilled birth attendance in sierra leone ► we used the latest nationally representative sample from the 2019 sierra leone demographic and health survey hence findings are generalisable to women in sierra leone ► given the crosssectional nature of the data we could not establish the temporal relationship between the outcome variable and the independent variables ► since the data were collected from women who had childbirths within 5 years prior to data collection we anticipate recall bias in the process of collecting this data among the respondents open access in 17 lifetime risk of maternal death making it among the highest globally 6 despite several measures being implemented in the country utilisation of maternal health services such as utilisation of at least four or more antenatal care contacts marginally increased by three percent points between 2013 and 2019 while initiation in the first trimester decreased by 1 point 11 in 2017 the ministry of health adopted the latest 2016 who guidelines for anc recommending eight or more anc contacts during pregnancy 12 to date there are no data available about the progress made regarding the utilisation of eight or more anc contacts the latest sierra leone demographic and health survey only reported on the utilisation of at least four anc contacts 11 postcivil war and ebola epidemic sierra leone era has witnessed left a fragile health system having poor infrastructure and inadequate skilled health personnel who are irregularly paid low salaries 13 despite the governments efforts to improve maternal health with approaches such as exemption of user fees for maternal healthcare services 14 the country ranks among the top three countries with the highest mmr globally 3 6 15 furthermore the exemption of user fees is challenged by inadequate skilled health personnel increasing workload and inadequate supplies and equipment 16 17 secondary and tertiary care in sierra leone is provided by 14 district and regional governmental hospitals 17 at national level there are four tertiary referral hospitals which are all located in the western area urban district 18 the country has one of the lowest nurse densities in the world at approximately 02 nurses and midwives per 1000 people 13 although differences in the levels of utilisation of sba between sierra leones rural and urban women have been documented 6 11 there is a paucity of information on this topic as it is not adequately explored therefore it is important to further understand these factors when stratifying by ruralurban place of residence among women because this may be key to designing effective contextspecific strategies and interventions targeting rural and urban areas we aimed to determine the correlates of sba in sierra leone stratified by ruralurban place of residence methods data source secondary data from the 2019 sldhs was analysed for this study sldhs data collection occurred between may and august 2019 by statistics sierra leone with technical assistance from inner city fund international through the dhs programme study sampling and participants a stratified twostage cluster sampling design was used for the survey leading to 13 872 households 11 the 2019 sldhs final report contains a detailed description of the sampling procedures 11 19 women of reproductive age who had a live birth within 5 years preceding the sldhs were included in this secondary analysis originally a weighted sample of 15 574 women was included in the individual womens data set of which 7326 had given birth within 5 years prior the survey 3 as shown in online supplemental file 1 variables dependent variables sba was defined as delivery conducted by a doctor nurse or midwife 11 and was coded as 1 while unskilled birth attendance was coded as 0 independent variables the analysis included independent variables based on evidence from available literature and data 6 9 20 sixteen explanatory variables were included and categorised as shown in table 1 statistical analysis due to the multistage cluster study design used by sldh complex sample package of spss statistical software was used with the analysis plan designed to include sample individual weight strata for sampling errors design and cluster number 21 22 23 associations between independent variables and sba were assessed by cross tabulation and p values presented before the final adjusted model each independent variable was assessed individually for its association with sba using bivariable logistic regression and the crude or 95 ci and p values are presented and independent variables with a p≤025 and not strongly collinear with other independent variables were included in the final multivariable logistic regression model 24 in the final adjusted model adjusted ors 95 ci and p values were calculated at significance level set at p 005 online supplemental file 2 shows the strengthening the reporting of observational studies in epidemiology checklist sensitivity analysis was done with unskilled birth attendance as the outcome and the results are shown in online supplemental file 3 patient and public involvement patients were not involved however local authorities in the different regions were contacted before data collection a comprehensive report on the survey results was released and openly available on the dhs website 11 results table 2 shows a comparison of background characteristics of study participants rural areas had more participants compared with urban areas remarkable differences were observed in region with 11 of rural women residing in western region compared with 511 in urban areas furthermore 632 of rural women had no education compared with 355 in urban areas 348 in rural areas belonged to the poorest quintile compared with 04 in urban areas and 362 had exposure to mass media in rural areas compared with 697 open access in urban areas over 603 of rural women had big problems with distance to the nearest health facility compared with 258 in urban areas overall 883 of the women had sba sba was higher in urban areas at 949 compared with 842 in rural areas factors associated with sba tables 3 and4 presents the predictors of rural and urban sba our analysis revealed that region of residence exposure to mass media and distance to the nearest health facility have significant positive association with sba among women from both regions of residence in the rural areas the likelihood of being delivered by a skilled birth attendant was three times higher in the southern northern and six times higher in the eastern regions one and a half times higher among women who had been visited a field worker two times higher among women with postprimary education one and a half times higher among women with exposure to mass media twice higher among women not having big problems with distance to the nearest health facility while the likelihood was 08 times lower among women who initiated anc after the first trimester in the urban areas the likelihood of being delivered by a skilled birth attendant was five times higher in the the sldhs collected data on household asset ownership and calculated wealth index using principal component analysis 68 among rural women only 09 and 57 belonged to the richest and richer quintiles hence these were combined into one to have rich middle poorer and poorest quintiles in logistic regression among urban women only 03 and 30 belonged to the poorest and poorer quintiles hence these were combined into one to have poor middle richer and richest quintiles in logistic regression region northern eastern southern western and northwestern among rural women only 11 belonged to the western region hence in logistic regression western and northwestern regions were combined education no education primary education secondary and tertiary education among rural women only 05 of the women had tertiary education and only 71 in urban hence secondary and tertiary were combined to have postprimary in the logistic regression analysis household size less than seven members and seven and above members based on the dataset average of seven members per household sex of household head male or female marital status married and not married marriage included those in formal and informal unions while not married included the never married divorced separated and widowed religion muslims and christians and others problem seeking permission to access healthcare big problem and no big problem in the original sldhs questionnaire three responses had been suggested no problem no big problem and big problem however the no problem response was not reported by anyone difficulties accessing nearest health facility big problem and no big problem in the original sldhs questionnaire three responses had been suggested no problem no big problem and big problem however the no problem response was not reported by anyone open access southern 12 times higher in the eastern region one and a half times higher among women from households with less than seven members twice among women who had exposure to mass media and one and a half times among women who had no big problems with distance to the nearest health facility compared with those from the western and northwestern regions households with seven and above household members with no mass media exposure and those with big problems with distance respectively wealth index was imprecisely significant with urban women belonging to the richest quintile being more likely to have sba compared with those in the poor quintile discussion in this study we looked at factors associated with sba utilisation in sierra leone stratified by ruralurban place of residence overall 883 of the women had sba the overall urban rural and sba prevalence in our study shows 28 15 and 31 percentage point increases respectively compared with that of 2013 6 25 this shows a tremendous improvement in the uptake of the sba between 2013 and 2019 in sierra leone which could open access open access be attributed to the changes in healthseeking behaviour and transformation of the health systems witnessed after the ebola epidemic 26 27 the introduction of free maternal healthcare services in 2010 could also partly have contributed to the observed increase in sba utilisation 28 29 sba was higher in urban areas at 949 compared with 842 in rural areas higher sba utilisation among urban women has also been shown by ameyaw and dickson 6 and this could be partly explained by factors such as the huge negative effects of the conflict on the rural healthcare system high concentration of health centres and hospitals and healthcare workers in urban areas enabling easier access to maternal healthcare services 6 30 31 higher sba utilisation among urban women compared with rural women has been shown in several other studies 32 33 34 the mismatch between high coverage of sba and the persistently high numbers of maternal and perinatal deaths is not only unique to sierra leone this may be partly attributed to delayed seeking of childbirth care and inadequate quality of care provided by skilled birth attendants 35 36 37 available evidence from similar low resource settings in subsaharan points towards poor quality of services offered 29 38 the inadequate quality of care may be attributed to factors such as poor remuneration which demotivates health workers increased workload on health workers lack of essential drugs and low quality preservice and refresher training 36 37 in sierra leone preservice training for sbas produces three cadres of nursing staff namely maternal and child health assistants who train for 2 years state enrolled community health nurses spend two and half years in training and state registered nurses whose training lasts 3 years these cadres then have the option to undertake further midwifery training that lasts between 18 and 24 months depending on the nursing qualification and experience 39 40 however the quality of training is affected by factors such as poor student attendance delayed and low tutor allowances and poor schools infrastructure especially for rural training schools 30 40 region of residence exposure to mass media and distance to the nearest health facility had higher likelihood of sba uptake in both rural and urban areas household size was only significantly associated with sba in urban areas while being visited by a fieldworker level of education and timing of initiation anc were only significant in rural areas being a resident of the south the eastern and northern regions was associated with more odds of sba utilisation among rural areas compared with those in the western and northwestern regions which was a similar finding for urban women in the eastern and southern regions this is an unexpected finding since the western region has the highest concentration of skilled personnel and health facilities the most developed and is the most economically vibrant region and therefore has better quality social amenities compared with other regions 28 30 however the western areas have witnessed increasing numbers of urban poor who are experiencing high standards of living and inequitable distribution of social amenities hence negatively affecting their ability to access quality healthcare 41 42 furthermore the documented staff challenges in urban areas such as poor delegation favouritism and a lack of autonomy could partly affect quality of services in public health facilities which further limits utilisation of healthcare 28 30 the governments efforts to ensure better service delivery in the less developed regions that are far away from the developed western region could also have contributed to this observation 12 region has been documented to have an association with sba in other studies 43 exposure to mass media was associated with more odds of sba utilisation in both rural and urban areas mass media have been documented to improve health literacy open access by sensitising communities on the positive outcomes of timely healthcare seeking and utilisation hence leading to positive attitudes challenging negative social norms and improving health seeking behaviour 44 45 furthermore women who are exposed to mass media are more likely to be educated have discussions with their peers which interpersonal interactions contribute greatly in challenging negative norms that might affect health seeking and hence lead to positive health seeking behavioural change 46 47 hence enhancing mass media exposure can be used to provide targeted maternal health messaging that can lead to increase in the utilisation of sba 48 exposure to media has been shown in previous studies done in similar contexts to have a positive association with sba 6 49 50 rural and urban women who reported that distance to health facilities was not a major challenge had higher odds of sba utilisation our study observed that the mothers in rural areas and urban areas who had no big problem with distance to a health facility had 225 and 162 higher odds respectively of being attended to by a skilled birth attendant compared with their counterparts who had challenges of distance to the nearest health facility the strong association between distance to health facility and sba utilisation among the rural mothers compared with urban can be partly explained by the fact that rural areas of sierra leone have poor road networks compared with urban areas with most roads being only accessible by offroad vehicles or motorbikes this is further compounded by the lack of access to affordable transport and health facilities that far apart from each other which contributes to delays faced by women in rural areas 35 51 distance to health facilities has been shown to impede access to maternal child health services including sba in several other studies 9 52 53 unlike in urban areas being visited by a field health worker such as a community health worker among rural women was significantly associated with sba utilisation the high demand of chws in rural areas due to limited accessibility of healthcare because of shortage of health facilities and large distances needed to be covered by rural women 30 51 compared with easier access of health facilities in urban areas could partly explain the observed difference in association the increased sba utilisation among rural women who were visited by field health workers could be partly explained by the fact these field health workers equip mothers with knowledge on the dangers of using unskilled birth attendants and complications of pregnancies in addition to encouraging them to seek care within health facilities 54 being visited by field health workers has been shown to be associated with sba in several other studies 55 56 level of education was significantly associated with sba in rural areas but not urban areas women with postprimary education had more odds of sba utilisation compared with women with no education educated women are believed to easily understand counselling given from healthcare workers more health literate hence informed on obstetric danger signs which enables them to seek early maternal healthcare 48 educated women have also been shown to develop greater confidence be more conscious of their health and better abilities to make wise decisions about their own health hence better sba utilisation 6 9 furthermore higher levels of education have an influence on womens positive interpretation of mass media messages leading to positive healthcare seeking behaviour change 48 in predominantly patriarchal african societies and mainly in rural areas 57 men are the main providers with the highest decision making powers 58 women in rural areas are usually open access less empowered due to the more conservative societies in rural areas hence factors such as education that might increase womens status and decision making are more likely to have an impact on healthcare seeking 59 60 61 62 this might partly explain the significance of education in rural areas and the nonsignificance in urban areas our findings indicate the need for government to strengthen access to quality girl child education among rural areas to at least secondary school level level of education has been shown to be associated with sba utilisation among several other studies 48 63 delayed initiation of anc among rural women was associated with less odds of sba utilisation anc utilisation has been shown to be associated with several other studies 48 52 64 delayed initiation could partly reflect poor health seeking behaviour which is further observed by reduced odds of sba utilisation however there is need for further studies to explore the association of anc utilisation and sba given the fact that anc frequency was not significantly associated with sba but timing of anc initiation was besides the three factors that were significant in both rural and urban areas household size was the only factor that showed significance in urban areas women who belonged to households with less than seven members had more odds of sba utilisation compared with their counterparts this is in agreement with a study done in nigeria and india 65 66 although wealth index was marginally significant in urban areas women belonging to the richest wealth quintile had 25 odds of sba utilisation compared with their counterparts in the poorest households we hypothesise that families with smaller sizes tend to have less expenditure which enables savings that can be used for the direct and indirect costs involved in accessing healthcare 66 furthermore smaller sizes could be attributed to better maternal healthcare seeking such as modern contraceptives utilisation which is further translated into sba utilisation 66 lastly having smaller family size might lead to less time spent by women while doing household chores and providing care to other family members and increase their time to seek healthcare 67 however given the dearth of information regarding household size and sba utilisation we recommend further studies to explore this strengths and limitations the study used a nationally representative sample for the analysis and thus the results can be generalised to all sierra leone women since the data was extracted from dhs surveys we are confident that standardised procedures such as validated questionnaires were used in data collection to ensure the validity of the results this being a crosssectional study this creates a limitation in establishing casual relationships from the established associations in addition since most of the data was for women who had childbirths within 5 years preceding the survey we anticipate recall bias in the process of collecting this data among the respondents conclusion and public health implications in sierra leon sba utilisation has greatly improved in the last decade utilisation is higher in the urban compared with the rural areas region of residence exposure to mass media and distance to the nearest health facility had a significant association with sba uptake in both rural and urban areas household size was only significantly associated with sba in urban areas while being visited by a fieldworker level of education and timing of initiation anc were only significant in rural areas hence ensuring context specific policies and strategies is crucial to ensure effective sba utilisation generally maternal stakeholders need to focus on western region use of mass media for awareness and sensitisation and ensuring increased availability of affordable and accessible health facilities in both rural and urban areas in addition urbanspecific programmes need to focus on women residing in larger households and rural specific programmes need to focus on use of field health workers women educated to primary level and below and ensuring timely initiation of anc services further research is need to explore reasons why maternal mortality is high despite the high sba focusing on areas such as quality of care provided contributors qs conceived the idea drafted the manuscript performed analysis and interpreted the results im kk and mwm reviewed and interpreted the results reviewed the first draft and drafted the subsequent versions of the manuscript all authors read and approved the final manuscript qs is responsible for the overall content as the guarantor 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 not applicable ethics approval this study involves human participants and was approved by high international ethical standards are ensured during measure dhs surveys and the 2019 sldhs protocol was reviewed and approved by the sierra leone ethics and scientific review committee and the icf institutional review board besides the local authorities before implementing the survey and wellinformed verbal consent are sought from the respondents prior to data collection this data set was obtained from the measure dhs website after getting their permission and no formal ethical clearance was obtained since we conducted a secondary analysis of publicly available data note the sldhs report does not provide the irb approval number 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 may be obtained from a third party and are not publicly available all data are available from the demographic and health surveys website upon registration 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 understanding the ruralurban contextspecific correlates of skilled birth attendance sba is important to designing relevant strategies and programmes this analysis aimed to assess for the ruralurban correlates of sba in sierra leone setting the latest nationally representative sierra leone demographic and health survey of 2019 participants the study included a weighted sample of 7326 women aged 1549 years each of them had a live birth within 5 years prior to the survey 4531 in rural areas and 2795 women in urban areas primary and secondary outcome measure sba primary and predictors of sba secondary results sba was higher in urban areas at 949 95 ci 941 to 957 compared with 842 95 ci 838 to 859 in rural areas rural women resident in the southern northern and eastern regions with postprimary education adjusted or aor 18 95 ci 13 to 25 exposure to mass media aor 15 95 ci 11 to 19 not having difficulties with distance to the nearest health facility aor 23 95 ci 17 to 30 were associated with higher odds of sba urban women resident in the southern eastern region with households having less than seven members aor 15 95 ci 11 to 23 exposure to mass media aor 18 95 ci 11 to 29 and not having difficulties with distance to the nearest health facility aor 16 95 ci 11 to 25 were associated with higher odds of sba conclusion given the observed differences improving sba requires programmes and strategies that are contextspecific

significance clinical domains other than obstetrics have recognized the importance of care management interventions to reduce hospital emergency department visits while recent literature has identified clinical predictors of postpartum ed visits interventions to reduce unnecessary ed visits and improve postpartum health for highrisk women are limited this study reveals opportunities for early intervention to reduce the widening gap of maternal morbidity and mortality for introduction racial and ethnic disparities in maternal health are a public health crisis in the united states black women are two to three times more likely to experience severe maternal morbidity and three to four times more likely to suffer pregnancyrelated mortality compared to nonhispanic white women these elevated health risks exist across the pregnancy continuum and extend into the postpartum period black women are more likely to have an emergency department visit after delivery and black and latina women have a twofold increased risk of postpartum hospital readmission relative to white women postpartum ed visits and hospital readmissions are markers of the excess morbidity black and latina women experience and studies indicate that some instances of emergency service utilization following delivery are preventable the postpartum period presents a critical opportunity to improve outcomes given that 51 of maternal deaths occur within 1 day to 1 year after delivery recent valuebased payment models have focused on moving care upstream and centering intervention on providing incentives to increase adherence to the 6week postpartum visit however these interventions may have missed the mark as many women experience health problems long before the 6week time point resulting in increased emergency department visits in fact studies indicate that 60 of all maternal ed visits occur prior to 6 weeks postpartum understanding trends in postpartum ed utilization is central to addressing disparities as a marker of poor maternal health future morbidity and pregnancys longterm impact on the health and wellbeing of new mothers and their families clinical risk factors for postpartum complications and ed usage have been extensively described yet the current body of literature lacks the patient perspective on what brings women to the er and whether opportunities for intervention existed along their journey over the last decade research has focused on understanding the role of social determinants of health the conditions in which people are born grow live work and agein relationship to health outcomes however increasing evidence argues that addressing sdoh alone does not completely improve outcomes for women of color because it fails to recognize the larger systemic context that serves as the primary driver of social inequity newer approaches suggest investigating the structural determinants of health defined as the cultural norms policies institutions and practices that define the distribution of sdoh as the root cause of health disparities and a primary driver of sdoh the historical allocation of greater resources to white communities while disproportionately depriving communities of color is an important lens to consider in maternal morbidity and mortality outcomes because it allows us to understand how racism classism and sexism intersect to affect the lives of women of color identifying key factors that lead to increased rates of postpartum ed visits can inform quality improvement efforts however a more thorough investigation into the patient lived experiences driving ed visits especially for disadvantaged women of color is needed the objective of this study is to explore the postpartum experiences of publiclyinsured women of color to identify additional risk factors that may contribute to postpartum emergency room usage and identify potential opportunities for intervention methods we used purposive sampling to recruit postpartum women into four focus groups in the summer and fall of 2020 all women were eligible to participate if they spoke spanish or english ≥ 18 years old delivered an infant between june 1 2019 and may 1 2020 at mount sinai hospital and had medicaid coverage for their delivery eligible participants were identified using either an epic query or outreach to the ambulatory clinic by posting irb approved recruitment fliers in the waiting room all participants verbally gave their informed consent by phone with use of a witness prior to inclusion in the study and received a copy of the consent form via mail or email participants also completed a brief anonymous demographic survey via email and mail participants were offered a 100 gift card and roundtrip metrocard for compensation of their time upon completion of the focus group raceethnicityconcordant moderators led the focus groups three english focus groups were conducted in july and august 2020 and one spanish focus group was conducted in october 2020 due to covid19 health and safety concerns the focus groups were held virtually using a hipaa compliant platform approval of this study was obtained by the program for the protection of human subjects at the icahn school of 1 3 medicine at mount sinai school this study was conducted in accordance with the coreq criteria for reporting qualitative research a moderator guide containing openended questions was used by the moderators to ensure consistency among focus groups and techniques such as reflection were used to clarify statements the moderator guide was developed by the research team based on prior research and published literature the same questions were asked in each focus group and were only slightly modified to follow the natural flow of the conversation each focus group lasted approximately an hour in length the focus groups were both video and audiorecorded and transcribed in their entirety the spanish focus group transcript was professionally translated into english and bilingual members of the research team verified the accuracy of the translation following the focus groups the research team debriefed about initial thoughts and impressions the moderator then wrote detailed notes summarizing each focus group including verbatim quotes from the transcripts we used a combined inductive and deductive approach to analyze the data first we developed deductive codes based on the teams impressions from the focus groups and the moderator guide topics iterative review of the transcripts and coder triangulation were used to thematically analyze the data members of the research team individually reviewed the transcripts and then met to create an inclusive master themes list two independent readers then coded the transcripts and a third reader reviewed the coded transcripts for interrater agreement disagreements were then discussed and resolved dedoose software was also used to facilitate data management and retrieval results eighteen women participated in one of four focus groups majority of participants selfidentified as blackafricanamerican and were over the age of 30 of eighteen participants five women had an er visit within 30 days of delivery reasons for er visits included preeclampsia postpartum cardiomyopathy and infection four major themes and 13 subthemes were identified that described womens postpartum experiences the four major themes included lack of access to and communication with a medical team lack of preparation importance of social support and participant recommendations for improving quality of care each theme is discussed below tables 45 6 and 7 include the themes and representative quotes from participants lack of access to communication with medical team participants reported varying degrees of accessibility and communication with their medical team following delivery some women reported no problems with scheduling appointments other participants particularly women who had postpartum complications identified hardships 1 3 in accessing prompt care following delivery many women described feeling like a bother or pain in the butt to their doctor when calling to ask questions as one woman explained its hard getting in contact with someone when youre going through something sometimes you call and they tell you we are going to send the message and the doctors going to call you back within x amount of days but sometimes they dont call you back and its like i have this thing going on id rather be seen fg2participant with ed visit participants also spoke about their concern with not having a single team to watch over them prenatally during delivery and after birth due to being medicaidinsured most participants had rotating providers throughout their pregnancy course and postpartum for one participant who experienced an adverse health event inability to identify a single provider made the emergency room seem like the nextbest option to receive the immediate care she needed women also described having rotating providers as a barrier to building trusting relationships with their physician participants described being a part of a huge system that prevented development of emotional connections to their doctors and instead relying on visiting nurses and midwives for support additionally some women reported racism and bias in their interactions with healthcare providers throughout prenatal care and during delivery which dampened their communication and desire to reach out to them prompts about racism and bias sparked a robust conversation in the spanishspeaking focus group with one woman remarking when asked directly about racism and bias some participants described providers as very kind and the services they received as excellent others emphasized the structural barriers they experienced due to being lowincome and medicaidinsured such as lengthy clinic wait times and financial disadvantages that made it difficult to access care one participant compared her experience being medicaidinsured with being privately insured stating the first time i gave birth i had insurance through work…but i lost my insurance and this time i delivered with medicaid…i never felt like i had a team of people watching even while i had the gestational diabetes it was a total experience from the last time because i had a specific doctor that only looked at me fg2 participant with ed visit lack of preparation for postpartum period a general response among all focus groups was feeling unprepared for what to expect following delivery some participants specifically emphasized being illprepared for the emotional aspect while others spoke about underestimating the lifestyle changes of bringing home a new child one participant stated nothing can really prepare you for what is about to go down fg3 participant without ed visit participants who had experienced a postpartum complication tended to recall the fear they felt during the postpartum period and beyond by using words such as terrifying and scary when recounting the postdelivery experiences with which they felt unequipped to deal women stated that they did not receive enough health education about what to expect or look out for during the postpartum period which contributed to feelings of women both who did and did not have an ed visit expressed difficulties in retaining information immediately following delivery women repeatedly described it as a blur and therefore advised against verbal education during clinic or hospital visits as the main educational tool it was very awkward and i didnt want to speak to that man after that ii i feel like a lot of women dont get services because of financial reasons or dont have the insurance that covers those types of things services should be offered to women and let them decide if they would like to decline iii i contacted the doctors so much in the hospital that someone spoke to the social worker and said i should see someone else like a psychiatrist or something participants also spoke about competing demands at the time of delivery such as other children or wanting to return home from the hospital that made it difficult to focus on the information that was being provided importance of social support to postpartum success the value of social support spanned all focus groups women either described feeling grateful for the support they received or reported feeling overwhelmed because support was lacking one participant spoke directly about the challenges of asking for help as a new mom stating there is no longer a village to help with your child fg1 participant without ed visit some participants stressed the importance of identifying a close support person during pregnancy to prepare for unexpected events in the postpartum period women discussed how their partners mothers mothersinlaw sisters and older children helped them in the first few weeks or months after coming home from the hospital most participants spoke about the important role of partners in coping with new responsibilities during the postpartum period for women who needed to go to the er partners played an essential role as family caretakers however not everyone had a husband or a partner to help them for example one woman mentioned that she split from her partner right after the baby was born and another had a husband who lived in another country other women expressed disappointment of unmet expectations when family members were not supportive or able to help on how to be a parent i feel like the support system is very very important in order to raise a child have a child and take care of the child even if you went to classes it is very difficult so have a good support system subtheme 32 role of partners i w hen we came home my husband was here… we were doing it together like we were a team he was helping a lot with the baby ii my husband also took me to the emergency room it was just him who was with me and he was in charge of rushing home to see my eldest children and rushing back to the hospital and to be with me just him subtheme 33 unmet expectations i i live with everyone at home my mom my dad and my siblings and at that time when i gave birth id have liked some of my family to help me the day my child went to sleep maybe i could go to sleep too… but for some reasons they had to work each of them had to do their things they… didnt do it ii certain expectations that i had when they didnt happen that was really disappoint ing participant recommendations for improving quality of care women in each focus group were asked to provide direct feedback on how postpartum care could be improved in this section we provide a highlevel summary of the identified opportunities for intervention that were consistent across focus groups several of our participants mentioned that enhancing health education by providing adapted material formats for both themselves and to share with caregivers could be helpful particularly in printed form to take home or an easily accessible electronic backup in case the printout gets lost one participant expressed a desire for more health education about possible warning signs women in our focus groups spoke about the need for health care providers to engage caregivers and family members from the start although partners and family members played an important support role for many of our participants they were not always knowledgeable or helpful according to one woman maybe even if it is a very severe case like the one i had maybe if those things would have been listed maybe my husband would have read it and kept it fg2 participant with ed visit aside from family members one participant mentioned seeking support from peers who experienced a similar postpartum complication another woman agreed that creating informal peer support groups of women who are going through the same experience can be helpful and indicated that participating in a focus group gave her a different perspective one participant described a positive experience with being part of a group of women treated in the same clinic who were expecting around the same time however the continuation of such connections into the postpartum period remains unclear in closing remarks multiple participants added that providers should just listen to women more discussion our study identified the following factors that influenced womens postpartum experiences access and communication with their medical team perceived level of preparedness for the postpartum period and social support network following delivery while some women had good communication with their providers many women reported barriers due to rotating providers and racismbias generally table 7 participant recommendations for improving quality of care subtheme 41 enhancing health education i …maybe even if it is a very severe case like the one i had maybe if those things would have been listed maybe my husband would have read it and kept it ii pay attention to moms postpartum providing resources or information right before you give birth or while they are in the hospital this is what you need to be careful of a list of things that you could use or that may use could be life changing critical for mom iii come up with the right kind of resources whether its pamphlets whether it is an online app subtheme 42 engage caregivers i …in case you are ill the family already knows what you have and you feel that support because the doctor… already told them that she needed that support on this this and this or for example when you have an appointment that your relative doesnt stay outside but that they may enter with you and listen to your opinion ii its a good initiative to do at least a kind of talk in order to involve the family member at the beginning and near the end of the pregnancy so that they can understand that there is a new member coming into the family that is that everyone must collaborate that everyone must be supportive because sometimes as a new mother as it is my case i didnt know if i am doing well with the baby or i am feeling very tired or i need someone to tell me i am going to stay with you tonight to watch your baby i do think that family members should be more involved directly from the center itself so that family members feel more engaged than if i tell them myself subtheme 43 support groups i i felt like i had enough support at home but to be connected to other women who are actually going through it because to be honest its hard for me to find anyone in new york that has a group like that and it wouldve been nice i guess to be connected with someone who has experienced it or is going through it right now ii so i did… my doctor visits with a whole bunch of other girls who were expecting around the same time so i was supposed to give birth in june so my doctor was really really available when it came to emailing and answering questions if i didnt ask her id ask my nurse if it wasnt the nurse then i would look for the mommy the mommy the little groups that were of women pregnant at the same time as well to ask them questions subtheme 44 listen to women i a doctor in the room would not listen to me i kept telling him i dont want forceps he got frustrated ii one thing doctors can do is listen more a lot of simple thing s but a lot of doctors are not doing it all women felt a level of unpreparedness for the postpartum period due to ineffective education methods this lack of knowledge often resulted in fear for women who experienced warning signs prompting ed use social support networks were essential to postpartum satisfaction and greatly influenced womens ability to juggle the changing responsibilities of bringing home a new baby our results are consistent with previous studies that have found that primary care accessibility health education and social support are critical factors to decreasing emergency service utilization and preventing adverse health outcomes among vulnerable populations however our study adds that addressing these factors is particularly important in reducing postpartum morbidity and mortality among publiclyinsured women of color due to the baseline systemic inequities that exist as a consequence of racism classism and sexism to our knowledge this study is the first to draw directly on the narratives of black and latina women to identify nonclinical risk factors that may be important for postpartum ed utilization although we expected to find notable psychosocial differences between women who visited the emergency department and women who did not each group had comparable experiences and shared similar concerns instead our results indicated that the upstream structural factors of their experience due to being lowincome publicly insured women of color disproportionately affected the women who developed health complications during the postpartum period many of the concerns including inaccessibility of care low levels of health literacy and insufficient support reflect the historical systemic structural and political forces that have limited the ability of communities of color and in this context specifically women of color to lead healthy lives as pointed out by dr whitney laster pirtle in her paper on racial capitalism the systems of racism and capitalism have disadvantaged racially minoritized and economically deprived groups for centuries and will continue to harm their lives even in the presence of interventions that focus on alleviating inequality at the individual and community level while our study highlighted possible opportunities for proximal intervention that will be discussed we recognize that true eradication of the stark disparities in maternal health outcomes will require multiple additional interventions aimed at addressing the policies and practices that uphold structural racism and drive poorer outcomes for women of color based on our findings we provide the following recommendations for intervention to reduce morbidity and mortality for publiclyinsured women of color during the postpartum period 1 improving continuity of care extensive studies indicate that a regular and usual source of care can improve health outcomes particularly for vulnerable populations postpartum care is both essential for obstetric outcomes and can serve as a vital link between pregnancy and wellwoman care policies and strategies to improve continuity of care should focus on teambased approaches that encourage coordination of services for women 2 incorporating early postpartum visits prior studies have shown that women at increased risk for postpartum emergency department use may benefit from earlier scheduled postpartum visits by providing earlier opportunities for care our findings suggest that there may be an increased ability to catch serious complications early before the patient needs to go to the ed 3 adapting teaching materials due to high rates of er use within 1week of delivery interventions focused on discharge planning and postdelivery education among obstetric patients may reduce er visits while recent studies have called for increasingly standardized discharge instructions to prevent unnecessary ed use our findings suggests that educating women on warning signssymptoms during the delivery hospital stay is not optimal in addition to the standard providerpatient education accessible short videos for postpartum women and their family members about what to expect in the postpartum period and the warning signs that should prod them to contact their medical team are critical to accessible patient education 4 using evidencebased methodology to reduce providers implicit bias addressing structural racism requires a multipronged approach from the systemslevel down that is rooted in equity frameworks however some progress can be achieved with providerlevel training on recognizing implicit biases and providing accountability structures that encourage providers to address racism examples of accountability structures include providing openly available standardized assessments that allow patients to document their treatment quality which ultimately should be linked to models of care that are associated with payment this study had two main limitations the first limitation is a small number of participants due to covid19 we altered our recruitment strategy and focus group setting from inperson to virtual consequently we anticipated that we may experience difficulties meeting our recruitment targets due to factors such as varying rates of technology access and fluctuating availability of participants however during thematic analysis we concluded sufficient themes were saturated and provided rich information on which we were able to draw recommendations additionally our study was conducted at a single academic institution in an urban setting and should be further investigated in other contexts such as nonteaching and community health settings in summary this study offers evidence for understanding postpartum ed visits as a metric that can be useful in assessing quality improvement by identifying risk factors for postpartum ed visits and implementing early intervention the excess burden of morbidity and mortality experienced by lowincome underserved women can be reduced however future interventions should focus on addressing the structural forces that shape the contextual experience and influence women of colors ability to lead healthy lives conclusion our study provides an important perspective into the postpartum experiences of publiclyinsured women of color that can be helpful in identifying areas for intervention to reduce the need for postpartum emergency department usage our focus groups elucidated that some risk factors are structural in nature and addressing the patientlevel factors is not enough addressing some of these factors will require highlevel policy interventions however some proximal interventions addressing structural elements of care delivery such as enhancing continuity of care to increase healthcare access adapting teaching materials to improve preparedness and engage caregivers and training providers to reduce implicit bias may also be beneficial data availability the data underlying this article are not publicly available to protect the privacy of study participants code availability the data that support the findings of this study are not publicly available due to them containing information that could compromise research participant privacyconsent author contributions eh conceptualized designed and supervised the study eh tj ab kg and th contributed to the implementation of the study th jp and lg facilitated focus groups th kg and ab developed code and completed data analysisinterpretation author th wrote the manuscript with support from kg ab and tj all authors reviewed and approved the final version of the manuscript ethical approval

the purpose of this study was to explore the postpartum experiences of publiclyinsured women of color and identify how postpartum care can be improved to reduce hospital emergency department usage after delivery methods we conducted four focus groups with 18 publiclyinsured women who primarily selfidentified as black andor latina and gave birth between june 1 2019 and may 1 2020 we used inductive qualitative analysis to identify prominent themes from focus group discussionswe identified four domains 1 lack of access to and communication with a medical team 2 lack of preparation 3 value of social support and 4 participantidentified opportunities for improvementthis study describes the postpartum experiences of publiclyinsured women of color with the objective of identifying areas for intervention to reduce postpartum emergency department usage our findings suggest that focused efforts on enhancing continuity of care to increase healthcare access strengthening patientprovider communication by training providers to recognize unconscious bias increasing postpartum preparation by adapting teaching materials to an online format and engaging womens caregivers throughout the pregnancy course to bolster social support may be beneficial

introduction depression is one of the most common mental disorders 1 adversely affecting peoples wellbeing physical and mental health and life expectancy 23 estimates of its lifetime prevalence vary widely across countries 1 the prevalence of depression is more common in women 1 those with less education 4 and a lower socioeconomic status 5 depression is also related to social functioning for example lower relationship satisfaction 6 higher divorce rates 7 and adverse parenting performance 89 importantly the causality of these associations is unclear for instance is a lower relationship satisfaction the consequence or the source of depression further social environments have diverse effects on depressive trajectoriesthey can play a protective role or serve as a mental health risk factor 10 positive assortative mating or homogamy can be observed for sociodemographic psychological and physical characteristics 11 12 13 even though the evidence is mixed 14 importantly couples where both are depressed may be more likely to divorce 15 while actor effects are better predictors of relationship difficulties than partner effects the interaction of the actor and partner effects is important as well 6 homogamy between spouses can arise through various mechanisms 16 namely partner preferences for selfsimilarity geographical andor social proximity convergence or secondary assortment 17 testing homogamy however has predominantly relied on crosssectional data this is problematic because data on couples similarity at onetime point indicates only a little about the causes of their homogamy and nothing about their longterm similarity from the perspective of interdependence theory 18 interacting partners affect each others experiences one might expect partners mutual influence especially in relatively plastic traits over time in other words the unit of analysis should be couples instead of individuals depressive symptoms can change over time for many reasons previously four classes of aging individuals were found with different patterns of longitudinal depressive symptoms consistently low consistently high increasing and decreasing depressive symptoms 1920 thus we may also expect that some couples have dynamically changing longterm dyadic patterns of depressive symptoms tracking spousal trajectories in depression is important to disentangle the dynamics and etiology of depression in a holistic perspective considering the most important social factors importantly we expect that not all couples will show the same trajectories which can explain the difficulties in confirming the underlying mechanisms of assortative mating differences in longitudinal depression trajectories can be explored by advanced analytical techniques here in a sixwave prospective cohort study the survey on health ageing and retirement in europe we tested the trajectories of assortative mating in depressive symptoms in longterm ageing couples and its impact on their wellbeing physical health and relationship stability using the probabilistic growth mixture modeling approach couples were divided into classes based on their longitudinal trajectories of depressive symptoms instead of using the classical correlation approach on the undivided total sample this way we could identify distinct classes of couples having differing longitudinal dyadic trajectories of depressive symptoms 21 results altogether 11136 couples made up the analytical sample homogamy was detected for age education and childhood socioeconomic position after controlling for childhood socioeconomic position we still found homogamy for education in addition homogamy was revealed for wellbeing at baseline number of limitations in instrumental activities of daily living number of chronic diseases extraversion agreeableness conscientiousness neuroticism and openness the dyadic growth mixture modeling suggested four classes of depressive symptoms class 1 was composed of consistently low depressive symptoms in both partners class 2 was composed of couples with decreasing depressive symptoms class 3 was composed of only women having consistently high depressive symptoms while men had consistently low depressive symptoms class 4 was composed of couples with increasing depressive symptoms in both sexes although in class 2 both men and women had a decreasing level of depressive symptoms men started at a higher level at baseline than their female partners and their rate of decline was greater than their partners in class 4 mens depressive symptoms were lower than womens at baseline but mens symptoms increased more sharply homogamy in the demographic variables only negligibly differed between the classes descriptive statistics of the classes are provided in table 2 and further details of the analysis are in the supplementary information when compared to couples that were consistently low on depressive symptoms both men and women had lower baseline wellbeing within the couples with mutually decreasing depressive symptoms as well as within the couples where both partners had increasing level of depressive symptoms only women had lower baseline wellbeing within the couples in which only women had consistently high depressive symptoms but men had consistently low level of depressive symptoms results were similar when tested for the total number of chronic diseases and limitations in instrumental activities of daily living the prevalence of bereavement was about 34 times higher in classes 24 than in the nondepressed reference class 1 the class 4 1437 p 0001 and class 3 411 p 0043 couples had higher chance of breakup than class 1 couples see further differentiating factors between the classes in table 2 and the detailed results of the multinomial regression in supplementary table s8 discussion depression affects various aspects of peoples lives here we explored romantic couples in relation to their mutual trajectories of depressive symptoms and how those trajectories were associated with relationship stability bereavement and wellbeing in a large sample of couples from europe we identified four fig 1 dyadic latent trajectories of depressive symptoms across four classes of couples measurements taken every 2 years between wave 1 and wave 7 except in wave 3 the scale of the depression scores ranged from 0 to 12 mens and womens mean depressive symptoms were presented in solid and dashed lines respectively 95 confidence intervals were shadowed in grey classes of couples based on their dyadic longitudinal depression trajectories most couples were homogamous in their low levels of depressive symptoms followed by a class where only women had high depressive symptoms 783 of couples with increasing symptoms and 718 of couples with decreasing symptoms further we observed that couples were strongly homogamous in age level of education wellbeing and childhood socioeconomic position and were moderately homogamous in physical health and personality notably the couples with increasing depressive symptoms had the same direction of change but different rates of change and different endpoints of mean depressive symptoms the couples with decreasing depressive symptoms also had the same direction of change but they had different starting points converging to similar ending points using the traditional nomenclature 11 we may call the second group convergent but the first group could be both labeled divergent and convergent even though the direction of change was the same in both partners in both classes their levels of depression at the end of data collection were different the traditional nomenclature of couples divergence only considered couples having similar starting levels and different ending levels in a characteristic over time however importantly we added another dimension to categorizing couples joint longitudinal changes the direction of change we argue that true divergence would mean having different directions of change over time according to this rationale we did not identify any class of couples truly divergent in depressive symptoms why is couples assortment in depression important evidence suggests at least partial genetic background together with familial effects and especially with unique environmental effects in depressive disorders 2223 further the offspring of parents who were concordant in affective disorders were at higher risk for depression than children with only one affected parent 24 thus spousal similarity can rise the prevalence of depression in the offspring because of both genetic and environmental factors and their interactions 25 knowing the different patterns couples show in their depression trajectories it would be possible to better explore how different relationships affect their offsprings mental health when both partners had increasing depressive symptoms they had the highest prevalence of bereavement and relationship dissolution during subsequent assessment in comparison to the other classes perhaps unsurprisingly importantly although mens rate of increase in their depressive symptoms was higher than womens both had lower wellbeing and worse physical health than the nondepressed class 1 a reasonable explanation could be that their diminishing health puts too much weight on these couples jeopardizing their relationship stability however one would need to have a more detailed picture of their daytoday lives including their psychological coping and living circumstances to be able to better plan possible intervention programs for these couples couples in the increasing and decreasing depression classes have a certain synchronization in the direction of their depressive symptoms however in both classes men had higher depressive symptoms in almost all waves than women interestingly in the class where womens depressive symptoms were consistently high men were not affected by their partners symptoms this is in accordance with recent findings that women were more susceptible to the emotional contagion of sadness than men 26 apart from the lack of emotional contagion in male partners other underlying factors may have been responsible for example different manifestations or types of depressive symptoms in each class the most common class consisted of both nondepressed homogamous partners remarkably on the other hand there was no class consisting of both partners with consistently high depressive symptoms we speculate that people with mutually high depression probably do not initiate a relationship with each other or these couples are not stable and their relationship quickly dissolute however we cannot rule out the latter possibility from these data as couples should be followedup from the initiation of their relationships future directions future research should investigate whether initial assortment and preference for low level of depressive symptoms is responsible for homogamy in having no depressive symptoms alternatively part of these couples started heterogeneously but after an adjustment period they both converged to have low depressive symptoms presently these possibilities cannot be tested because our sample only consisted of established couples and we have no data available about their depressive symptoms before their relationship started or from the beginning of their relationship in addition our observations were limited to the study being collected in waves at 2year intervals hence daytoday mood changes could not be detected but instead our study extracted traitlike longterm patterns to better understand the mechanisms of these trajectories one should investigate in more detail the daytoday dyadic dynamics within the couples including a more detailed analysis concerning the specific time of bereavement and relationship dissolution this would allow researchers to explore who affects depressive symptoms which is especially interesting in couples with increasing and decreasing depression targeting couples with similar directions of change would unfold the underlying shared environmental factors affecting both partnerseven if the effect is differing in degrees between the sexes limitations and conclusions evidence for homogamy in affective disorders is mixed 24 there were methodological differences across previous studies which may be responsible for that this study is based on a crossnational longitudinal and representative sample such data are unparalleled in relationship research and couples data although we did find some differences between the classes apart from their depressive symptoms and wellbeing we did not predict them and thus they deserve more attention in the future as already mentioned above the twoyear time lag may be considered too large to observe moodrelated fluctuations thus our findings apply only to traitlike longitudinal patterns of change further we know little about important aspects of their relationships and mental health which imposes constraints on the conclusiveness of our results the couples were already established when the project started and their overall low rates of relationship dissolution limited our ability to observe the effects of depression on relationship stability although these couples came from 16 european countries with varying cultural and economic backgrounds they still share significant similarities in being western educated industrialized rich and democratic 27 societies as they were on average about 61 years of age we cannot generalize these findings to younger couples either in sum we showed different patterns in couples longitudinal trajectories of depressive symptoms by defining four different classes we suggest a new approach when considering assortative mating longitudinally we detected factors which were specific for each class such as wellbeing physical health relationship dissolution and bereavement rates consequently the different classes of couples might need different intervention approaches lastly we demonstrated that the classification approach and longitudinal data are useful both from the perspective of clinical practice and social sciences as they can differentiate unique longitudinal patterns of couples plastic characteristics the study has an interesting setup for the future it suggests that we tend to treat all couples as the same which obscures important differences identifying betweencouple differences is a new frontier of research not all couples are the same and not all factors will differ from couple to couple and not all factors which differ will matter materials and methods participants data for the analysis came from a prospective cohort study share which was previously described in detail 28 briefly share is a multicentric multidisciplinary longitudinal study that was initiated with the aim to assess health social network and economic conditions of communitydwelling individuals in europe and israel the first wave of share was conducted in 2004 followed by five subsequent waves in 2year intervals participants were sampled based on probability selection methods to be eligible to take part individuals must be at least 50 years old speak the official language of the country and not have lived abroad or in an institution at baseline data are collected using computerassisted personal interviewing in the participants homes in case the participants have a spouse the spouses were also invited to take part irrespective of their age therefore the share study is an optimal data source to study trajectories of depressive symptoms in couples this study was carried out in accordance with the declaration of helsinki share has been repeatedly reviewed and approved by the ethics committee of the university of mannheim all participants provided written informed consent data were pseudoanonymized and participants were informed about the storage and use of the data and their right to withdraw consent analytical sample we restricted the analysis to individuals who participated in share with their spouses and each had at least three measurements of depressive symptoms irrespective of from which wave the data came inclusion of at least three measurements enabled us to study trajectories of depressive symptoms from 206723 individuals included in the share database 139556 people completed at least one interview from them we identified 125532 individuals who took part in share with a spouse therefore there were 62766 couples we excluded 546 samesex couples and 36746 couples that did not have at least three measures of depressive symptoms leaving the final analytical sample of 11136 couples this sample size is sufficient to perform growth mixture modeling on data of six waves 29 mean age of men was 6231 and of women was 5921 flowchart is presented in supplementary fig s1 trajectories of depressive symptoms to assess depressive symptoms share uses the eurod scale a tool that was originally developed to compare symptoms of depression in older adults across europe 30 and has been used in multiple studies 31 32 33 the measurement with eurod was conducted in all waves except for wave 3 participants were asked whether they have experienced 12 symptoms during the last month for each symptom they received one point creating a scale ranging from 0 to 12 points with higher values suggesting more depressive symptomatology couples dyadic trajectories of depressive symptoms were extracted using dyadic growth mixture modeling in mplus version 87 this approach combines the latent classification methods and latent growth modeling which can thus differentiate latent trajectories of depressive symptoms the couples that followed similar dyadic longitudinal trajectories at a high probability were grouped into the same latent classes the final classification model selected for publication was performed according to the recent guidelines 21 see the supplementary information for all details of the performed analyses following interpretation and supporting criteria the 4class model was selected for publication the 4class model showed the following patterns of dyads class 1 consistently low depressive symptoms in both members of the dyad class 2 decreasing level of depressive symptoms in both men and women class 3 only the women have consistently high depressive symptoms but the men have consistently low depressive symptoms and class 4 increasing depressive symptoms in both members of the dyad see fig 1 the figure was created in r studio version 141717 in a subsequent analysis the latent classes were regressed in a multinomial regression on the covariates using the 3step method breakup during the followup period as categorical distal outcome was predicted by the latent class variable using the dcat method 34 mplus syntaxes can be obtained from the first author upon request covariates five sets of covariates were used in five respective models to study which factors were associated with the trajectories of depressive symptoms the first set included the following demographic variables age sex region education 35 childhood socioeconomic position 32 the number of children and grandchildren and the type of participants residence area the second set comprised the following health variables wellbeing 36 number of limitations in instrumental activities of daily living 37 chronic diseases and drugs for depression a subsample of individuals who participated in the 7th wave had available information on the third set of covariates the big five personality traits measured by the tenitem personality inventory 38 the fourth model included the death of either men or women during the study 20 the fifth model included a variable breakup which was defined as a transition from being in a couple with the studied spouse to being single or being with another partner irrespective of whether the original partners got back together information about covariates was acquired at baseline which is the wave data on eurod was first available except for the variables for drugs for depression death and breakup covariates of both sexes were used except for the number of children and grandchildren as these were too strongly correlated between men and women we included this only for women to avoid collinearity means and proportions were compared between classes in spss version 26 competing interests the authors declare no competing interests additional information supplementary information the online version contains supplementary material available at correspondence and requests for materials should be addressed to zsófia csajbók reprints and permission information is available at reprints publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the occurrence of depression is influenced by social relationships however most studies focus on individuals not couples we aimed to study how depressive symptoms of couples evolve over time and determine which characteristics are associated with their distinct trajectories a multicentric cohort sample of 11136 heterosexual couples mean age 6076 from 16 european countries was followed for up to 12 years share study information on depressive symptoms measured by eurod scale was collected every 2 years dyadic growth mixture modeling extracted four distinct classes of couples both nondepressed 7691 only women having consistently high depressive symptoms while men having consistently low depressive symptoms 808 both having increasing depressive symptoms 783 and both having decreasing depressive symptoms 718 couples with increasing depressive symptoms had the highest prevalence of relationship dissolution and bereavement in comparison to the nondepressed class individuals with any depressive symptoms were less psychologically and physically well our results suggest that distinct mechanisms are responsible for couples various longitudinal trajectories of depressive symptoms

introduction health and risk communication are critical to prevent the spread of the severe acute respiratory syndrome coronavirus 2 health and risk communication are critical to prevent the spread of the severe acute respiratory syndrome coronavirus 2 also when it comes to the roll out and effectiveness of vaccines yet it brings with it challenges and complexity 1 only when individuals have an accurate understanding of their risk of getting infected by or dying from the coronavirus disease 2019 will they be able to take responsibility and engage with the range of prevention practices and technologies available 1 furthermore studies have also shown that some migrants have an increased risk of contracting infection with covid19 as well as suffering severe consequences from it 2 3 4 including psychosocially 5 it is therefore essential that information about covid19 is made accessible to all population groups including migrants giving them an equal chance to find effective ways to protect themselves from infection and engage with guidelines concerning preventive measures in their country of residence 6 7 8 9 however migrants are often left behind in health risk communication efforts 610 a review of public health communication during the first months of the covid19 pandemic revealed that fewer than half of european countries had online covid19 advice in at least one major migrant language 10 in denmark official information about covid19 in english was not published until the end of march 2020 approximately two weeks after the first national lockdown 11 information about covid19 has since been made available in other languages 1213 other sources of news also failed to consider other languages for example live press conferences frequently held by the prime minister and health authorities were broadcasted without subtitles or translation 13 as a consequence and as noted by the world health organization aparttogether survey many refugees and migrants report relying on social media or news about covid19 from their country of origin to keep themselves informed 14 failure to consider migrants linguistic diversity in health risk communication responses leaves them underserved and vulnerable 15 and ultimately put migrants at higher risk of sarscov2 transmission 3 for example a report from the danish institute for human rights interviewing ethnic minorities with poor danish language skills during the covid19 period showed that some were uncertain about the risk of transmission of the disease as well as the authorities guidelines which sometimes led to extreme selfisolation and concern 16 a small but expanding body of literature is beginning to highlight the consequences of the linguistic challenges faced by migrants in this time of crisis for instance research from nepal 17 and the netherlands 18 has found language barriers to be associated with numerous consequences such as stress anxiety difficulties in accessing relevant services and the spread of misinformation among different migrant groups 17 18 19 furthermore not addressing migrants linguistic diversity does not just leave migrants underserved and vulnerable to infectious diseases such as covid19 it undermines the broader pandemic response much current knowledge however is based on quantitative data commentaries or editorials we have little empirical understanding of how migrant groups qualitatively experience their access to health and risk information concerning covid19 furthermore much of what we do know relates to the information barriers migrant groups face in accessing health and risk communication whilst little has been done to explore the tactics they adopt to overcome these barriers we therefore take inspiration from de certeaus 20 notion of tactics to explore the everyday acts and occurrences that migrant groups adapt to attain some control or make do in an information and communication setting deemed constraining by drawing on the concept of tactics we will be able to not only highlight the challenges experienced by our participants but also disentangle their actions and the supportive structures they form part of against this background we ask what are the tactics adopted by migrants in denmark when facing the challenges of accessing information on covid19 materials and methods we drew on data from a qualitative interview study that aimed to investigate the various impacts of the covid19 pandemic for migrants living in denmark the study forms part of the international aparttogether study which is a collaboration between who the un system and a consortium of universities 13 informed oral consent was obtained from all participants guaranteeing that they would be anonymized we used pseudonyms when referring to the participants throughout this paper study location and participants the study took place in denmark during the spring of 2020 following the first wave of the covid19 pandemic like many other countries the danish government implemented a nationwide lockdown of all nonessential activities however at the time of the interviews most activities had temporarily reopened 20 recruitment of the migrants used in this study took place in may and june of 2020 migrants who had filled out the aparttogether study survey and who had indicated that they would be willing to participate in an interview were contacted only respondents who had answered the survey in english or danish were contacted interviewees were contacted through either email or a text message depending on the contact information provided after a few days a reminder was sent to interviewees who had not yet answered our first request we recruited migrants of any age interviewing a total of 18 migrants living in denmark the migrants included four men and 14 women they came from various countries within and outside of europe many of the migrants had lived in denmark for a year or less and there was a range between four months and seven years for all migrants data collection and analysis in may and june 2020 the first author conducted 18 semistructured interviews with the migrants due to the covid19 restrictions imposed by the danish government at the time of the interviews as well as the general risk of gathering all interviews were conducted virtually a description of the study was provided to the participants followed by obtaining an oral consent all interviews were conducted in english and lasted between 31 and 76 min the interviews were steered by a topic guide structured around five different themes corona and social distancing in your everyday life experiences and sensemaking worries and vulnerabilities social support and coping strategies and the response of the authorities and civil society the conversations surrounding health risk communication are the center of this article all 18 interviews were audiorecorded and subsequently transcribed in their full length in our efforts to disentangle emerging themes we coded and thematically organized the interview transcripts in accordance with the steps outlined by attridestirling 21 this was done with the support of nvivo 12 a qualitative data analysis software a total of 112 codes emerged from this process however we do not intend to present all the emerging themes in this paper instead we focus on the 28 codes that relate to health risk communication challenges and tactics the remaining codes covered themes such as worries about their financial situation wellbeing of their relatives and loneliness in preparation for this paper the 28 selected codes underwent a second round of organizing codes that related to each other were grouped into basic themes if the basic themes shared similar issues they were then rearranged into what attridestirling refers to as more interpretive organizing themes in the following analysis we will present and unpack the different themes derived from our thematic network analysis results throughout the interview narratives it was clear that many of the migrants faced several challenges when it came to accessing the health risk communication coming from the danish authorities in response to this however many of them found other channels of communication challenges i just want some clear answers throughout the interviews many of the migrants expressed that it was difficult to navigate the authoritys response to covid19 this included how and where to find health and risk information or making sense of the information they found either because it was in danish or imbued with cultural reference points for instance one common issue among the migrants was not knowing which and when restrictions were put in place this is illustrated by leah who had been living in denmark for only nine months in the following quote she describes her inability to follow the regularly press briefings held by the danish authorities in the spring of 2020 at the height of the first wave of the pandemic it has been really hard to figure out like when danes know eg timing of press briefings like that the prime minister is going to make a speech because it will happen at seemingly completely random times and then like all the sudden we find out oh yeah she has been speaking for half an hour and we turn it on but like there was no way to figure out yeah i never i still dont know how people are finding out when she was going to say important things i was always like a bit behind its probably because we are not counted as well but there is a lot of things that is about danish citizens and not about foreigners these accounts can be read as examples of recently arrived migrants feeling left out of the response due to their migrant status and lack of proficiency in the danish language besides being a great source of frustration among several of the migrants this sense of not being counted as heather puts it resulted in confusion and uncertainty about how best to navigate the pandemic response another common barrier to the migrants ability to navigate the pandemic response was linguistic difficulties many of the migrants did not speak danish making it difficult for them to understand much of the covid19related information coming from the danish authorities matej who had just started learning danish provided an example of his inability to follow the danish news so most of the time i feel like that most of the information is in danish and i started to learn danish recently but i am not fluent yet faiza who had been in denmark for less than a year and did not speak any danish yet also described how information from the danish authorities are not accessible for migrants information is not that clear i mean it is not eligible for people who are like us immigrants despite faiza knowing how to navigate the news flows she was still feeling left behind due to linguistic barriers many of the migrants interviewed did not feel that they were addressed in a way that was understandable to them and this was especially true for those migrants who had not been in denmark for very long or had moved to denmark alone because of their unfamiliarity with the danish system coupled with their inability to understand the danish language many of our participants were unable to understand the messages and health advice coming from official sources eg the regular press briefings like faiza they were lost in translation shortcomings by the danish state to make health risk information available to migrants in a timely manner were however partly addressed by other structures such as workplaces or language schools this was experienced by a small handful of our participants for instance irene who had come to denmark only a year ago explained that the language school that she was enrolled in not only provided danish lessons but also valuable covid19related information in the beginning of the pandemic when it started to sort of get momentum the whole pandemic in school we had a class that was completely dedicated to you know this corona is looming wash your hands you know sneeze in your elbows so like this sort of they basically also explained the basic things about you know personal hygiene and safety for others the workplace was a way to stay updated on what was going on with regards to changing covid19 rules and regulations this was exemplified by bogdan who regularly received essential information about covid19 from his manager our general manager would send us emails keeping us posted with whats going on most of the time actually all the time we knew whats going on and they would tell us you know when we gonna know more from the authorities were gonna let you know however for most of our participants such backup support was unavailable requiring them to actively seek out information tactics seeking to be in the know to get information about covid19 in denmark the migrants employed various tactics tactics can be understood as the formation of new daily practices amongst people in marginalized positions as a result of their absence in more formal dominant and strategic responses either to get by or to display resistance 19 in this case the marginalized positions are those of migrants in denmark who experience exclusion from the authorities channels of communication they therefore turn towards opportunities to receive information about covid19 provided outside the established frameworks of communication one tactic was to use a tool to translate for example press briefings held by the authorities here exemplified by linh and everyone was just watching the news and again i dont speak any danish but i just used the translator on my web browser to try to see if what the authorities say at least when they are on tv or the newspaper other tactics that the migrants employed on their own included reading online news in english or their native language or accessing news from their country of origin beyond searching for information on their own some migrants also relied on their close social networks such as family members or friends who spoke danish faiza who had a danish boyfriend described that he translated the most important news about covid19 so its difficult and my boyfriend is happy to translate it if relevant he translates it to me but then i would like to process it on my own you know some migrants also used their broader social network to stay updated with the aid of social media here exemplified by blanca who was a part of a whatsapp group with her friends also living in denmark at the time for example they regularly shared covid19 related information with each other when it comes to information from denmark we what we had to do or didnt do we we had a whatsappgroup with our friends here in copenhagen and some of them have been here for many years so they would send links with important information and every time that mette the danish prime minister talked they would just send a whatsapp so hey that is kind of like the summary so they kind of like made it work for us as the accounts show faiza and blanca made active use of their social networks to access and share information however even though both were able to mobilize their social network to get relevant information regarding covid19 they also expressed a desire to assess the information on their own without relying on the help of others or digital tools in our interviews information sharing about covid19 also happened in much more structured transnational networks several of the interviewed migrants explained how they actively used larger groups or communities on social media platforms that targeted migrants living in denmark this was well articulated by ana who did not speak any danish and did not have any danishspeaking relatives and friends to help her with translation of covid19related information in the following she reflects on how she stayed updated using facebook so it is a facebook group and there are some people there that right after the government announcements they translate everything into bullet points what is most important so mainly i would follow all the guidelines from there ana continues elaborating on how the group supported her in accessing covid19related news the facebook group actually helps quite a lot because there are some people that they have been through the struggle of the language and they know how difficult it is to actually have access to news etc so you have a lot of support of people that have been living on the country ehh for many many years and they are actually there to support you and give you information having just arrived in denmark ana has not had time to adapt to her new surroundings therefore the facebook group was particularly important for her to stay updated on the covid19 response in denmark for newly arrived migrants who still needed to establish strong social networks the group constituted an important access point for covid19related information including knowledge about measures introduced by the danish authorities and ultimately being able to follow guidelines as they relate to the danish context the use of such social media networks can be seen as an example of how the sudden reorganization of established spaces because of covid19 was tactically utilized by migrantsproviding them with important information about covid19 discussion we set out to explore the challenges and tactics adopted by migrants when accessing covid19 information our findings show that being away from their country of origin in a time of crisis and having no or only limited knowledge of the danish system and language some migrants find themselves excluded from the covid19 response most of the migrants participating in our study noted that much of the information available at the start of the pandemic was in danish and that it was difficult to navigate the news flows having little knowledge about the danish language and customs many of the migrants were unable to keep up with the changing restrictions and guidelines and the rationale behind these our data suggest that this was especially the case for migrants who had only been in denmark for a short period of time and who had come here alone those migrants who had stayed in denmark for several years appeared to face fewer challenges in navigating health risk information about covid19 the feeling of not being included in the responseor repeatedly accessing information with much delayled to uncertainty and frustration among many of our participants whilst the danish authorities and nongovernmental organizations eventually made essential health and risk information available in multiple languages it was difficult for the participants to keep up with changes often announced in press conferences held in danish our participants therefore relied on adopting various tactics to access and share information these included the use of translation tools searching for news in their country of origin and on social media platforms as well as engaging with different digital migrantnetworks helping each other navigate the pandemic in denmark in different ways digital tools emerged as critical enablers of tactics in accessing and sharing health and risk information outside of established structures and spaces this finding resonates with previous observations a study by park et al 22 exploring the experiences of migrants living in the republic of korea at the time of the mers outbreak describe digital tools as weapons to survive an emergency when living in a foreign country they found that digital tools were used to receive and share information among migrants in their closer social networks 22 in our study however information sharing also happened in much larger online social media groups and communities illustrating new tactical practices social media thus acted as a key gateway to receive health and risk information about covid19 when official information channels were inaccessible despite social media platforms being a muchused alternative source of information on covid19 among the migrants in this paper studies suggest that social media platforms also have the potential to disseminate inaccurate information 2223 furthermore it has been suggested that increased use of digital tools to get covid19related information and the use of many diverse platforms can lead to information overload increasing the risk of important information to be ignored or forgotten 24 while digital tools were important for the migrants in accessing health and risk information about covid19 the tactical use of such tools often also involved fellow migrants or other people in general even though digital tools enable access to information these digital tools are only relevant because the migrants we spoke to were part of compassionate social networks characterized by information sharing and support relying solely on the help of others however to access vital health information might leave them vulnerable to disruptions in information flows or misinformation nonetheless given the absence of the danish welfare state to cater for the health and risk information needs of migrant populations in the early and critical weeks of the pandemic digital tools proved critical in helping our participants to access essential health and risk information when there was no alternative our findings are constrained by two methodological limitations one we did not have access to language interpretation this meant that we could only recruit participants who either spoke english or danish as many of the participants did not have english or danish as their first language important nuances of their experiences may have been lost two we recruited participants and conducted the interviews through online and digital means requiring a certain level of digital literacy and access to digital tools it is therefore likely that we have recruited more resourceful migrants missing out on the experiences of those who are most vulnerable future research ought to include more disenfranchised migrant populations whilst our findings highlight the practical implications of social media platforms in helping our participants to access information about covid19 they also point to the need for offline alternatives to reach more vulnerable migrant groups council estates with significant migrant populations could recruit trusted covid19 ambassadors for different cultural language groups and support them go doortodoor making covid19 health risk testing and vaccine information available conclusions this paper demonstrates the agency and resourcefulness of migrants in overcoming the specific challenges some migrants face when it comes to their ability to access and understand health risk communication in the country they reside in understanding and recognizing the role migrants can play in health risk communication responses is key to support them during this pandemic and in the future there is a need to consider migrants resources when developing future information strategies including involving and engaging migrants in the process data availability statement the data are not publicly available requests to access the data used in this study can be sent to the corresponding author informed consent statement informed consent was obtained from all the migrants involved in the study appendix a codes basic themes google translate information and news are in danish danish media are trustworthy webpages in english

health risk communication plays a crucial role in preventing the spread of infectious disease outbreaks such as the current coronavirus sarscov2 yet migrants are far too often forgotten in health risk communication responses we investigate the challenges and efforts made by migrants in denmarkin the initial months of the pandemicto access information about covid19 we draw on 18 semistructured interviews conducted in may and june 2020 all interviews are thematically coded and analyzed our analysis reveals that many of the migrants faced several challenges including accessing information in a language understandable to them and navigating constant streams of official news flows issuing instructions about which actions to take however we also note that the participating migrants found numerous creative ways to address some of these challenges often aided by digital tools helping them access crucial health and risk information this paper highlights that migrants constitute an underserved group in times of crises they are vulnerable to getting left behind in pandemic communication responses however we also identify key protective factors social resources and agentic capabilities which help them cope with health and risk information deficits national governments need to take heed of these findings to inform future pandemic responses

when the government of indias expert committee on tribal health requisitioned for an estimate of the infant mortality rate for the tribal population in india the office of the census and sample registration system was unable to provide the same the nation had not cared to measure death rates in tribal children the committee for its report 1 had to depend on indirectly estimated rates based on the census 2011 and the national family health surveys 1 to 4 but the generic term tribal people incorporates within it 705 different tribes each having unique culture lifestyle and hence with a different child mortality rate the great anthropologist verrier elwin had long ago documented the life and culture of various major tribes in india 1 who would provide us their imrs in the present issue of indian pediatrics verma sharma and saha three researchers from the national institute of research in tribal health provide us exactly that 2 from the census of india data they have estimated the imr under5 mortality rate and life expectancy at birth for scheduled tribes from seven states rajasthan gujarat maharashtra madhya pradesh chhattisgarh jharkhand and odisha 2 they selected the tribes with population size large enough indentifying 123 tribes which account for 9497 of the total st population in the respective states using the demographic methods of indirect estimation pioneered by prof brass of the london school of tropical medicine and hygiene they estimated for the first time the imr u5mr and leb for these 123 tribes 2 they deserve kudos for this contribution these estimates reveal three diversities between the total population and the st population of india between the seven states and within each state between the tribes since what the authors have estimated the imr u5mr and leb are literally the estimates of life and death they matter what these different statistical numbers reveal are huge inequalities for the opportunity to survive the most fundamental human right these researchers estimate that whereas the imr for the total population of india in 200607 was 65 per 1000 live births it was 76 for the total st population in the country but hidden within this number 76were huge diversities the imr for these 123 tribes varied from the lowest 48 for the gamit tribe in maharashtra to the highest 124 for the birhore and bharia tribes residing in chhattisgarh jharkhand and madhya pradesh seventy six additional infants died in these later two tribes per 1000 live births similarly the u5mr among these 123 tribes ranged from the lowest of 57 in one tribe to the highest of 203 in another it was lowest for the total st population in maharashtra and highest in madhya pradesh the estimated leb for these 123 tribes ranged from the lowest 51 years to the highest 72 years two major limitations of these firstever estimates are one they are not actual measurements over a period of time but have been indirectly estimated from a crosssectional data the census of india second they pertain to the year 200607 in a way already outdated but they make a beginning of making estimates for the individual tribes hopefully the estimates based on the next national census will arrive sooner the two landmark reports of the lancetlowitja global collaboration on the health of the indigenous and tribal populations 3 and tribal health in india the report of the expert committee on tribal health of the government of india 4 have e d i t o r i a l c o m m e n t a r y e d i t o r i a l c o m m e n t a r y e d i t o r i a l c o m m e n t a r y e d i t o r i a l c o m m e n t a r y e d i t o r i a l c o m m e n t a r y volume 58 january 15 2021 editorial pointed out that globally as well as nationally the indigenous and tribal people suffer worse health status and chances of survival compared to the general population in the countries regrettably india had the second highest imr for the tribal people in the world next only to pakistan now verma sharma and saha show that even within the tribes there are large disparities between the states and within the states so what do we make of this one the policymakers need to appreciate the importance of segregated measurement for the tribal people as a whole and for each individual tribe the expert committee on tribal health has underscored this need and some movement in the academia can be seen after that will the ministry of health and family welfare and the ministry of tribal affairs show more action second the tribal development plans the tribal subplans and the health plans of the states should now move further and develop the tribe specific plans birhore tribe whether in chhattisgarh jharkhand or madhya pradesh has the highest child mortality each tribe has different challenges hence needs separate attention and solutions third the pediatricians and policymakers need to assert that the tribal mothers and children receive near complete coverage with the proven health care interventions such as the anc institutional delivery homebased neonatal care immunization breastfeeding and nutrition and finally treatment for pneumonia diarrhea and malaria but the coverage will improve only if measured and monitored separately for tribal children niels bohr was absolutely right tribal children lives matter measure them

any of us will be surprised to know that as many as 104 million tribal people live in india more than the national populations of 90 percent of the countries how do tribal children in india live and more importantly die how many why what can be done these questions bother every pediatricians conscience sometime or other

introduction numerous studies have been published to date about emergency remote in higher education during the covid19 pandemic 1 2 3 4 consequences for higher education institutions were devastating at a broad range of levels from a human and also an economic perspective 5 up to this date we find reports from all continents and a huge diversity of countries from east to west and north to south eg pakistan 6 turkey 7 united states of america 8 russia 9 south africa 10 new zealand 11 india 12 and united arab emirates 13 among many others even multinational comparisons 14 both largescale even global 1 15 16 17 and smallscale qualitative studies 18 have been undertaken certain studies have focused on partial subjective perspectives of the educational participants either from the instructors side 9 or from the students 10 some studies have contributed to a better understanding of particular pedagogical techniques and tools in the elearning context 1920 while other researchers focused on mental health risks 8 and emotional coping strategies 21 with our study we want to contribute to this massive body of knowledge that should help us all together to be better prepared to overcome likely new erhe situations in the future in spanishspeaking countries there are also a great deal of studies 22 23 24 25 26 we find for example navarro and colleagues study 26 addressing instructors related variables in the successful perception of erhe while others 21 focus attention on the students perspective each of these studies however 2126 addresses different issues such as digital teaching competence on the instructors side and emotional coping strategies on the students side they do not contemplate the very same issues for both instructors and students so that their results can be considered cumulative in a certain way but not contrastive to each other to our knowledge studies comparing students and instructors perspectives are still very scarce and of a limited scope regarding participating samples 2728 in that sense our study responds to a current need providing a comparable perspective of both participants sides conceptual considerations regarding he and erhe globally considered he institutions already had adopted and mainly integrated information and communication technologies for teaching and learning by 2020 however this was not necessarily the case worldwide up to the pandemic he institutions in latin american countries functioned predominantly traditionally facetoface 29 hence the emergency forced the he institutions in these countries to cope with unexpected challenges at the highest velocity and all instances of the educational community had to adapt themselves to this new situation debattista 30 offers good practice principles for instructional design such as encouraging studentfaculty interaction promoting interpeer cooperation facilitating active learning offering prompt feedback emphasizing time on task communicating high expectations to the learners and respecting and catering to diverse talents and ways of learning certainly these principles do not differ much from facetoface quality teaching and learning practices previous literature on elearning and blended learning points to the need for specific socalled technopedagogical design 31 in other words teaching and learning processes in the virtual context require specific instructional decisions to promote and enhance learning chances as ict by itself does not warrant positive learning processes 32 33 34 even the assessment processes must be subject to particular design in the elearning and blended learning contexts 35 as some underline managing time is probably the biggest challenge in the online setting 36 last but not least human interaction must be taken care of in the virtual learning context 37 in order to promote quality learning all of these instructional decisions were compromised in the emergency context as the global study of aristovnik and colleagues reported 17 the student population from latin american countries had less favorable studying conditions and more basic infrastructure such as fragile and unstable access to the internet compared to richer countries in the northern hemisphere in the case of instructors the lack of the socalled digital competence that is the ability to plan and manage teaching and learning situations mediated by elearning components was probably the biggest problem to tackle globally but especially in those places where ict elearning components were not yet common ground 38 studies prior to the pandemic situation already reported students difficulty in communicating with peers in the elearning context 3940 as the literature claims the online interaction between instructors and students feels easier for the students themselves compared to the need to interact with peers in a constructive manner in other words peer interaction for learning purposes in the synchronous and asynchronous space does not happen spontaneously with ease and benefits from pedagogical guidance 4142 however as some studies report 43 there might be some connection between students interaction quality and achievement during erhe which underlines the importance of this pedagogical guidance regarding teaching previous results report the extraordinary demands that the erhe put on the instructors need of redesigning teaching and assessment strategies and coping with the loss of immediate students feedback in classroom interaction among other issues 44 with respect to the variety of components of the pedagogical process many studies coincide in pointing at assessment quality as the most important challenge during erhe 45 46 47 48 49 which includes a set of challenges from proctoring measures to prevent students dishonesty to providing useful feedback and promote meaningful learning from the competencebased perspective of current curricula our study specifically pursues the following goals • to describe the erhe process during 2020 in three latin american countries comparing instructors and students perspectives since teaching and learning processes cannot be understood only from a single perspective • to identify some variables of erhe affecting students and instructors perceptions of learning we will particularly look at sex and educational cycle in the case of students as the main personal variables likely to affect subjects experience • to identify improvement needs for future experiences of erhe considering the previous analyses materials and methods a nonexperimental quantitative design was employed to analyze the perceptions of students and instructors regarding the remote teaching and learning process this research is of correlational scope and the methodological approach used was a crosssectional survey instruments in line with the theoretical framework related to successful virtual education experiences prior to the pandemic two instruments with similar characteristics were designed for online administration one targeting students and the other aimed at instructors both instruments addressed the same dimensions and aspects in order to fulfill the comparative purpose of our study 50 four evaluators with experience in educational psychology and psychometric analysis evaluated the indicators derived from the literature review the evaluators followed an evaluation guideline that aimed to assess the relationship between each indicator and the theoretical variable associated with effective practices in distance education the dimensions analyzed were empathy between instructors and students teaching organization collaborative work quality of assessment and perception of learning additionally they evaluated the quality of the indicators of each dimension in relation to comprehension length and formal aspects for each indicator the evaluators provided a score ranging from 1 to 5 to represent its relationship with the theoretical dimension the four evaluators achieved an intraclass correlation index of 089 the student questionnaire consisted of 65 items while the instructor questionnaire contained 56 items both instruments included likerttype items rated on a fivepoint scale the questionnaires included four openended questions for subjective evaluation and reflection on the participants experience to gather qualitative aspects that could enhance the information regarding internal consistency both questionnaires exhibited satisfactory characteristics cronbachs alpha was calculated for each of the ten questionnaire scales for students the reliability of the lowest cronbachs alpha score was 079 the highest was 082 and the average was 081 for instructors the lowest cronbachs alpha score was 072 the highest was 083 and the average was 077 table 2 shows these dimensions and the internal reliability of the questionnaire for each set of participants data collection contact with study participants was established through university authorities in chile argentina ecuador mexico and colombia with which we had academic links participation was obtained from universities in chile ecuador and mexico countries located in latin america that share various similarities in terms of language culture and indigenous heritage likewise they face social and economic challenges like inequality poverty and the need to improve their education systems the survey was made available online using google forms the questionnaires were distributed during the second semester of lockdown in 2020 a period of emergency teaching and learning students and instructors were invited to participate from their respective universities which centrally sent out the surveys and invitations to participate voluntarily and anonymously via institutional email through the institutional email we were able to obtain almost 95 of the sample for this study additionally the snowball sampling technique was employed participants who completed the survey shared it with their peers in other universities thereby expanding the surveys reach to the largest possible number of practicing university instructors and students through this technique 100 of the sample presented in this article was completed in this way the sample encompassed a wide range of cases within the accessible population from different disciplinary areas considering both public and private universities within each participating country the ethics committee of universidad del desarrollo approved this research in june 2020 the approval certificate ensures compliance with all ethical safeguards of scientific research such as confidentiality anonymity voluntary participation the right to withdraw from the study or choose not to answer the absence of risks associated with participation and the competence of the research team this certificate of ethical approval was provided to the universities invited to participate in the study the questionnaire used in the study included informed consent which explained the research objectives and the ethical safeguards involved the ethical standards and codes of conduct followed included those of the american psychological association the code of ethics of the chilean college of psychologists as well as chilean legislation on scientific research and the 1975 declaration of helsinki revised in 2000 data analysis plan analysis of variance was used to test for statistically significant differences between groups and multiple linear regression was conducted to develop explanatory models the reliability analysis of the scales was carried out using cronbachs alpha coefficient all these analyses were performed using r version 430 results this study specifically aims to describe the erhe process during 2020 in chile mexico and ecuador both from instructors and students perspectives comparing participants experiences and perceptions of the quality of the teaching and learning process tables 3 and4 show the global results for both the participants perspectives students and instructors in the following subsections we will address the concrete results for each research goal students and instructors report that the weakest aspect of education is the quality of the assessment of learning this difference between assessment and the rest of the studied dimensions is significant for students 136563 p 0001 and instructors 85399 p 0001 on the other hand students evaluation of remote education is more critical across all domains than instructors evaluation of their erhe experience students rate all analyzed dimensions significantly lower than instructors remote education process during 2020 both from instructors and students perspectives in chile mexico and ecuador the results of the three latin american countries studied in relation to the dimensions of empathy didactic organization collaborative work quality of assessment and perception of students learning are presented in the following subsections we will also analyze whether there are differences in these dimensions according to the gender of the participants and the disciplinary areas in the case of the students we will also report whether there are differences according to the level of education they are studying it is important to note that there are significant differences between chile mexico and ecuador in relation to the technological and physical resources present at the beginning of erhe 1827 p 0001 when making comparisons between student groups through the tukeyhsd test results show that students from ecuador report having fewer physical and technological resources for remote education while mexican students are the ones who have the best conditions on the other hand students studying degrees related to the area of education and biological sciences report having the least physical and technological resources for erhe compared to the rest of the degrees 1868 p 0001 there are no significant differences for students by gender 071 p 050 or the cycle they are studying 003 p 097 regarding instructors there are no significant differences about empathy in erhe table 5 presents results concerning the first dimension instructor empathy versus students perceived empathy we found significant differences in the perception of empathy between chilean students and those from mexico and ecuador 11780 p 0001 also when making comparisons between groups through the tukeyhsd test chilean students report perceiving lower empathy from their instructors during the pandemic moreover there are significant differences by gender 686 p 0001 female students perceive greater empathy from their instructors significant differences also exist by cycle with intermediatelevel students reporting lower perception of empathy from their instructors 1358 p 0001 intermediatelevel students differ from both initialcycle students and finalcycle students furthermore there are significant differences between disciplines 3841 p 0001 students in the education and social sciences fields perceive greater empathy from their instructors while students in engineering and biological sciences perceive less empathy from their instructors interestingly in all three countries students in the education and social sciences fields are the ones who report having the most empathetic instructors 1664 p 0001 ecuador f 571 p 0001 mexico f 494 p 0001 regarding the instructors there are no significant differences between countries 160 p 020 however there are significant differences by gender 304 p 0002 female instructors perceive themselves as more empathetic than males on the other hand there are significant differences between disciplines 509 p 0001 instructors in education majors perceive themselves as significantly more empathetic than instructors in the field of biological sciences about didactic organization in erhe table 6 presents results regarding the second dimension of the questionnaires didactic organization significant differences are observed in the experience of students from the three countries 7228 p 0001 when making comparisons between groups through the tukeyhsd test it is observed that chilean students report the remote educational process with lower didactic organization while ecuadorian students report a better perception of this variable there are significant differences by gender 616 p 0001 female students perceive the didactic organization of their virtual classes more positively additionally there are significant differences by cycle 1990 p 0001 intermediatelevel students report a more negative perception in this area there are also significant differences by disciplinary area 1117 p 0001 with students in education majors reporting a better experience in this variable and students in engineering fields reporting the lowest regarding teaching strategies students report that the most frequently used ones in erhe are technological expository written response dialogic and traditional expository the least used strategies were collaborative and gamification approaches there are significant differences in the perception of students from chile mexico and ecuador regarding students participation 4730 p 0001 when making comparisons between groups through the tukeyhsd test chilean students have the most negative perception regarding the instructors we found significant differences between chile and the other two countries 649 p 001 chile has a lower mean there are no significant differences by gender nor are there significant differences by discipline area furthermore through a chisquared test of independence teaching strategies reported by the instructors were compared it was found that chilean instructors report significantly fewer dialogical activities than other instructors 600 p 004 and fewer written response activities 2225 p 0001 ecuadorian instructors report the most technological expository activities 175 p 042 and traditional expository activities 393 p 014 finally mexican instructors report the most significant collaborative activities 996 p 001 collaborative work in erhe table 7 presents the results of the third dimension collaborative work we found significant differences between ecuadorian students and the rest of the countries 11500 p 0001 when making comparisons between groups through the tukeyhsd test results show that ecuadorian students report a higher presence of collaborative work than the others also there were differences by gender 573 p 0001 with women reporting a higher experience of collaborative work additionally there are significant differences between academic cycles 1689 p 0001 intermediate cycle students express a significantly lower level of collaborative work on the other hand there are also differences among students from different disciplines 2128 p 0001 students in the field of education significantly differ from other areas reporting higher levels of collaborative work regarding the instructors there were significant differences between chile and the other two countries 1753 p 0001 the chilean sample has the lowest scores there are also gender differences 390 p 0001 with female instructors having a higher perception of the implemented group work there are no significant differences between disciplines 018 p 097 quality of assessment in erhe table 8 shows the results of the fourth dimension of the questionnaire quality of assessment perceived by students and instructors we found significant differences between chilean students and students from ecuador and mexico regarding the assessment of learning 18490 p 0001 using the tukeyhsd test it is observed that chilean students have the lowest score indicating the most negative opinion regarding the quality of education on the other hand mexican students are the ones who show the best appraisal we found significant differences between men and women 614 p 0001 with female students having a more positive perception of the quality of assessment of learning also there are significant differences between academic cycles 1229 p 0001 students in the initial cycle presented a more positive opinion than the other two cycles finally there were differences between students from different disciplines 5654 p 0001 students in the fields of engineering and biological sciences have a significantly more negative opinion of the quality of assessment compared to students in the education field through the anova test significant differences are observed between chile and the other two countries in the case of instructors 3179 p 0001 when making comparisons between groups using the tukeyhsd test we noticed that chilean instructors have the lowest mean in other words they have the most negative opinion about assessment in erhe there were also significant differences by the gender of the instructor 271 p 0007 with female instructors having a generally better opinion of the quality of assessment additionally there are significant differences by disciplinary area 339 p 0005 with instructors from educationrelated fields reporting a better experience in this variable and those from engineering areas reporting the lowest using the chisquared test of independence we observed that chilean instructors report higher use of openended items than the rest 481 p 009 and ecuadorian instructors significantly use more closedended items 6562 p 0001 there are no significant differences in the use of performancebased tasks among instructors from different countries 179 p 041 on the other hand female instructors report fewer closedended responses and more openended responses and performancebased tasks instructors from the education area significantly use more openended items and performancebased tasks while instructors from biological sciences use more closedended items perception of students learning in erhe table 9 presents results concerning the fifth and last dimension of the questionnaire perception of learning during erhe we found significant differences between chilean students and students from mexico and ecuador 19030 p 0001 chilean students show a significantly lower score in their perception of learning additionally there are differences between mexico and ecuador and in favor of ecuador there were also significant differences between men and women 668 p 0001 women had a higher perception of learning there were also significant differences between cycles 2858 p 0001 intermediate cycle students perceive significantly lower learning finally there are significant differences between discipline areas 1354 p 0001 the perception of learning differs among students in education and healthrelated careers on the one hand and students in engineering and biological science fields on the other the former group perceived achieving higher learning outcomes regarding instructors appraisal there were significant differences between chile and the other two countries 3725 p 0001 when comparing the groups using the tukeyhsd test it is observed that chilean instructors reported a lower mean in other words they perceive that their students learned significantly less than the students from other countries comparing the other instructors perspectives there are no differences by gender predictive model to explain perception of student learning from the perspective of both the instructor and the student multiple linear regression was performed to create explanatory models of student learning perception as viewed by both instructors and students themselves table 10 displays the outcomes from the teachers standpoint while the students perspective is presented in table 11 table 10 shows that the participating instructors perceived that their students learned more in the erhe education when the instructional organization of their synchronous classes was effective the evaluation methodologies employed were reliable the students were not in the intermediate cycle and they did not belong to engineering or biological sciences undergraduate areas table 11 exposes that the participating students perceived more learning in the erhe when the instructional organization of their synchronous classes was felt effective instructors displayed empathy towards their students and peer collaborative work exercises were conducted additionally this trend was observed among female students who were not in the intermediate cycle noteworthy for instructors pedagogical variables explain their students learning however for students in addition to instructional aspects the instructors empathy and collaborative work carried out in classes are relevant these variables encompass undeniable socioemotional components discussion due to the pandemic the implementation of remote education in 2020 was developed in an emergency in this study we intended to describe chilean ecuadorian and mexican students and instructors evaluations on several aspects of the teaching and learning process paying attention to sex and educational cycle in the case of students in order to be able to identify needs of improvements for future cases initially educational institutions were concerned with internet access providing equipment to enable connections and creating physical spaces to facilitate the distance learning process however these basic conditions were not assured many students faced challenges due to the lack of access to electronic devices and a stable internet connection as evidenced by the previous studies 1316 in these three national contexts participating in our study many instructors had to learn on the fly how to use technologies for an online teaching and learning process initially this remote education was a transfer adaptation or exact copy of facetoface education there was no time for special preparation as instructors gained experience nevertheless it became increasingly clear that a different approach was needed 303336 the first point of discussion of our results is that students and instructors perceptions differ regarding the same aspects and this pattern is consistent across the three studied countries in general instructors tend to have a more favorable perception than students in the five dimensions examined empathy didactics collaborative work assessment and learning students as recipients revealed themselves as more critical than instructors and showed more disagreement with erhe these findings align with those of 15 who demonstrated that many students reported a loss of quality in online education compared to facetoface education this also corresponds with the findings of 6 who highlighted that students faced challenges in staying focused on online assignments and exams due to distractions additionally they missed the facetoface interactions with instructors and classmates which impacted their ability to ask questions and receive realtime feedback which reminds us of the need to carefully design even the smallest details of interpeer interaction to facilitate a successful learning experience 37 on the other hand one issue on which instructors and students agree is that the area of assessment of learning is the least successful assessment remains the achilles heel even more so in online education contexts as pointed out by 26 the assessment system generates mistrust among all participants on the one hand there were concerns about the possibility of dishonest practices which raises doubts about the academic integrity of students indeed there were doubts about whether the grades obtained by students truly reflect what they have learned this is associated with the research findings of 9 where they identified several problems in assessing online learning one of the main issues they found was the lack of adequate tools and methods for assessing online learning instructors also pointed out that it is challenging to assess student participation and engagement online as well as the authenticity of work submitted electronically additionally instructors mentioned that the absence of facetoface interaction with students hinders effective feedback and assessment of learning prepandemic literature already warned about the need to take specific measures for assuring learning assessment in the online context 35 thus guaranteeing that the online space goes beyond a medium of delivery of students solved assignments or a means of testtaking but evolves into a safe space for effective feedback in this regard studies have shown 48 the importance of moving towards more authentic contextualized and challenging assessments where students are required to apply knowledge make decisions and demonstrate performance this entails incorporating more frequent performancebased tasks and the use of openended items instructor feedback plays a key role in remote education as it allows for monitoring of learning and encourages student selfregulation unfortunately the main preoccupation of instructors during erhe was in proctoring measures the good news is that remote education has allowed some progress to be made a systematic review by 49 analyzed how the covid19 pandemic affected assessment in he the study found that traditional methods such as paperandpencil examinations have become less common while projectbased assessments have become more popular additionally it showed that online assessment methods can be more efficient and effective than traditional methods the crosscountry comparison also reveals certain trends in general both chilean instructors and students tend to be more critical of their experience in emergency remote education compared to ecuadorian and mexican participants chilean students in particular perceive less empathy from their instructors and have a more negative perception of remote educations didactics and assessment moreover chilean instructors are the ones who perceive most that their students learn less and they also consider themselves less dialogical in their teaching compared to their peers in ecuador and mexico in contrast in the ecuadorian sample students despite having the least technological conditions for remote education perceive greater empathy on the part of their instructors instructors stand out for engaging in more tutoring activities finally mexican students are the ones who have the most technology for erhe and are most likely to engage in performancebased tasks for assessment instructors stand out for engaging in more collaborative work activities it is important to mention that in chile the pandemic occurred immediately after the social upheaval experienced since october 2019 this meant that many university students had their first experience of remote education during a time of social unrest without the necessary conditions and the results were not very positive therefore the erhe pandemic possibly started with a negative predisposition due to previous experiences and also because of the emotional impacts caused by the political and social polarization during those times our second goal pointed at differences between participants views considering sex differences and study experience in the case of students regarding sex we found noteworthy results in most of the dimensions assessed females both students and instructors tended to make more positive evaluations of erhe than their male counterparts we found no previous study that could help us interpret these results we would want to underline them the previous worldwide study of aristovnik and colleagues 15 did not throw significant differences between students by sex which might indicate that differences could be linked to latinamerican cultural particularities in addition to sex regarding study experience there is a negative trend in the evaluations of erhe by students in the intermediate cycle compared to students in the initial or terminal cycle this could be interpreted based on the experience and comparison that thirdand fourthyear students make between facetoface and remote education during crucial years of their professional training such a comparison cannot be fully made by students in the initial cycle since they lack enough university experience and can hardly compare to other kinds of study practices at he and students in the final cycle take it less seriously as they are close to graduating from their degree course regarding comparisons between disciplines there is also a trend that has been previously discussed by 25 students studying educationrelated careers tend to share a more positive evaluation of the various dimensions of erhe the opposite occurs with engineeringrelated careers which tend to have a more negative view the additional difficulty of communicating mathematically in the online context could help understand these results 31 it would be interesting to delve into what factors contribute to women in general and students studying educationrelated careers in particular having a more positive impression of the implementation of erhe similarly understanding why engineering students male students and those in their third and fourth year of studies have a more negative evaluation of this process future studies could be carried out to further investigate these aspects the results of this research enable us to identify areas for improvement in future experiences of erhe as was our third goal particularly generalizable to the latin american context for instance the instructional design should be modified to be more dynamic more dialogic and to give greater prominence to students attention should also be focused on the instructorstudent bond including aspects like containment visibility and dyadic relationship as it has a significant impact on learning particularly during emergencies additionally it is crucial to ensure clarity in instructions and to consider the needs of the learner as discussed in the article by 14 there is a need to enhance dialogic collaborative gamified and technologybased teaching activities especially considering that didactics and dialogic interaction are two variables that significantly predict remote learning according to 43 additionally it is known that communication between students and instructors was negatively affected during erhe which had an impact on the quality of learning as stated by senanayake and colleagues 13 technologybased remote education is here to stay offering many opportunities and positive aspects in terms of learning and outreach prior to the pandemic ref 40 explored students perceptions of learning regardless of the course delivery method and online environment the results indicated that perceptions of facetoface learning were higher than those of online learning in terms of social presence 37 social interaction and satisfaction however there is always a place for contrasting views in previous studies some students even felt very comfortable with online learning as it gave them the opportunity to be innovative through the use of computer technology on the other hand bustamante and colleagues 18 identified benefits of erhe such as the flexibility and accessibility of online learning students reported greater ease in accessing learning materials and organizing their study time enabling them to learn at their own pace and on their own schedule additionally some students mentioned that online education allowed them to save time and money by avoiding daily commuting to the university instructors also reported greater flexibility in lesson planning and the possibility of reaching a wider audience it is therefore necessary to gain a deeper understanding of how students perceive and react to erhe as the perception and attitude of students and instructors are critical to motivation and learning the pandemic has had a significant impact on the lives of he students and instructors around the world students reported higher levels of anxiety stress and depression during the pandemic negatively affecting their emotional wellbeing learning and quality of life 15 future research on remote education should consider these aspects conclusions and practical ideas remote education can have significant benefits and opportunities for both students and instructors if we learn from the experience of erhe during the pandemic the possibility of saving time on transportation having greater flexibility in the educational process studying at ones own schedule and pace and promoting a more sustainable education are certainly benefits in todays world and for the future however technologybased he cannot be reduced to these logistic aspects we know that the instructional design of erhe should be different from facetoface education logistically it becomes necessary to consider for instance shorter synchronous classes and ensure students have the minimum and basic conditions for internet access and technological devices for distance learning emotional aspects are also crucial there is a focus on the importance of stronger connections between instructors and students as well as among students themselves as facetoface interaction and social relationships are missed additionally showing empathy towards students in their new learning process is essential pedagogical aspects cannot be overlooked instructors must strive for increased student participation and dialogue prioritize the curriculum and clarify what is essential undoubtedly implementing assessment is a priority students need meaningful and realistic assessments that allow them to apply their knowledge it is equally important to provide opportunities for feedback from instructors to clarify doubts learn from mistakes and reinforce their successes both students and instructors perceive instructional organization as a crucial variable for explaining learning in this sense technology should be at the service of learning and the user transforming learning not just transferring the facetoface classroom powerpoint to the online environment to achieve this we must pay attention to the protagonists of the teaching and learning process students and instructors in order to respond to instructors need for professional development and to the learners perspective and learning needs data availability statement access to data shall be offered by the authors by request author contributions conceptualization ar and vv methodology vv validation vv and ar formal analysis vv resources vv data curation vv writingoriginal draft preparation ar and vv writingreview and editing ar and vv supervision ar project administration vv funding acquisition vv all authors have read and agreed to the published version of the manuscript informed consent statement informed consent was obtained from all subjects involved in the study

the covid19 pandemic forced higher education institutions all around the world to revise their praxis and update tools and numerous procedures this study offers a comparative analysis of three latin american students and instructors perspectives on a selection of both the pedagogical and emotional aspects of higher educational life that were affected the report is about the participants perception of others empathy their evaluation of the organization of teaching and learning and of collaborative learning experiences their appreciation of the quality of learning assessment practices and eventually their perception of learning an exploratory study was carried out based on survey research in likertscale form responded to by 2742 students and 926 instructors significant differences were found among subsamples with chilean students and instructors having less favorable views in all dimensions compared with their mexican and ecuadorian counterparts also differences were found with respect to educational levels discipline areas and participants gender this study contributes with a doublesided view of both protagonists perspectives students and instructors to reinforce the importance of instructional design instructorstudent bond meaningful and realistic assessments that allow for the application of knowledge and opportunities for feedback in postpandemic virtual education

introduction given the inequalities in health status that continue to prevail in european societies it remains crucial to develop effective policies in response people in lower socioeconomic groups die at younger ages and suffer from a higher prevalence of health problems such as chronic conditions mental health problems and disabilities 1 in europe two types of health disparities create concern the disparities among social groups and those among member states for instance a 2010 report from the world health organization compared the life expectancy rates of european member states that joined the eu before and after 2004 the report discovered that for those joining after 2004 the life expectancy was 56 years lower 2 this alarming situation has made improved health a key priority of the europe 2020 strategy to promote at smart and inclusive growth in the inclusive growth goal the ec highlights the need to develop a major effort to combat poverty and social exclusion and reduce health inequalities to ensure that everybody can benefit from growth 3 health disparities are particularly worrisome among vulnerable and socially excluded groups such as the roma who have been the focus of our research as various international institutions have reported it is crucial to acknowledge the blatant exclusion that the roma people experience within the european union particularly regarding health specifically their estimated life expectancy is ten years shorter than that of the general population 4 the european commission and the who report that this statistic is directly related to the exclusion of the roma from society 5 researchers have traced the health disparities among different social groups to a range of socioeconomic factors including differences in educational level attained occupational class and income gender and race also play significant roles 6 the associations between these factors are also important for instance low income affects educational attainment 7 in addition inadequate housing poor nutrition and healthrelated behaviours 8 and other factors such as social ties in the local community 910 are all powerful determinants of the poor health conditions that affect millions of people around the globe the whos regional office for europe in its first report on the social determinants of health and the health divide discusses the most relevant social determinants that impact individuals health childhood living conditions education working conditions and employment welfare and social protection poverty communities and health systems the who has repeatedly noted that the rates of infant mortality are higher among the children of mothers with no education especially in certain countries for such women in bolivia for instance the rate is greater than 100 deaths per 1000 live births 11 a 1999 who report stated that the poorest and least educated people not only live shorter lives but also are more likely to suffer from disabilities 12 in particular the educational attainment of mothers has been found to determine child mortality ratesmaking female education an urgent focus in reducing infant mortality 13 available healthrelated data on rates of premature mortality show that the rates are significantly higher among people with lower levels of education lower occupational classes and lower income 1 thus educational level is a key factor influencing health conditions international institutions such as the who and the oecd have provided evidence for this direct relationship 111415 indeed education is positively associated with a variety of social outcomes such as better health 16 health among the roma people the european union acknowledges that the roma people are one of the most marginalised social groups facing deep social problems related to low levels of education high unemployment inadequate housing poor health and wideranging discrimination 17 in particular they face serious health situations because of their disadvantaged social position in addition many researchers note that few rigorous systematic data are available on the roma communitys health condition 18 19 20 the data on roma childrens health statuses are inconsistent due to the challenges of monitoring ethnic groups in europe but fragmented evidence indicates high levels of maternal and child mortality and morbidity 521 furthermore data from the european survey on health and the roma community 22 show a high dependency rate among the roma in europe 62 not economically active people for every 100 active ones as opposed to 487 for the eu27 moreover the available data support the fact that the socioeconomic situation of the roma affects their health conditions along this line the undp 23 report that hunger is a problem in the poorest roma communities of the roma surveyed by the undp in southeastern europe 53 reported going hungry in the previous month compared with 7 of the nonroma living in close proximity to these roma settlements the roma population has also shown a high prevalence of chronic diseases such as migraines hypertension and arthritis dental problems and difficulties with vision and hearing are also widely reported again the european survey on health and the roma community lists factors that explain the poor health conditions of many european roma citizens among them are a lack of resources poor housing conditions inadequate employment opportunities and difficulty gaining an appropriate level of education the roma also have inadequate access to prevention services over 25 of roma children do not adhere to vaccination schedules and 40 of women over 15 have never been to a gynecologist for reasons other than pregnancy or labor 22 in contrast particular cultural traits among the roma can function as health assets among other traits solidarity within the community strong family bonds and cultural norms and traditions surrounding health might help explainand improvethe health conditions of the roma people 2425 there is a lack of quantitative data specifically associating the health statuses of the roma with their educational levels however the general association between low educational level and poor health status is especially threatening in their case as the rates of exclusion that the roma face in education among other areas are particularly alarming one study that focused on the roma population over age 15 in a selection of european countries with significant percentages of roma people found that 44 of roma individuals had not completed primary school and only 24 had at least a secondary education moreover young roma have a higher prevalence of risk factors for certain diseases linked to lifestyle and low educational status 26 thus educational factors are recognized as having a significant impact on basic health indicators such as perceived health status one of the few sources providing data about health conditions and education among the roma is the report on the health situation of the roma communities 27 which indicates for instance that 15 of roma participants over age 14 who have finished postsecondary school suffer from chronic diseases compared to twice that many among those who have no formal education researchers have found that among other social factors reduced inequality correlates with better health status and life expectancy 28 which is essential to overcoming the alarming health conditions in roma communities 29 in this context studies have revealed the need to more strongly emphasize social inequalities 30 and to promote multisectoral policies that aim to reduce poverty by improving educational levels 31 to reduce the health disparities among the roma communities and other ethnic minorities and vulnerable groups in this regard the academic community along with the council of the european union and the european commission emphasize that substantial and effective efforts must be made to reverse the educational exclusion facing many roma people across europe to help reduce the health inequalities they experience 1732 health condition and educational level not surprisingly peoples health improves when efforts are made to improve healthcare systems and to address other socioeconomic factors that have impacts on health particularly education 33 indeed the european commission and other institutions highlight education as one of the four pillars of the social and economic integration of the roma they describe the potential of education to improve health and the impacts that healthrelated behaviors have on educational attainment 17 studies addressing the role of education in improving health have analyzed this relationship from the perspective of the educational level attained 1116 34 35 36 given this focus studies tend to neglect other important educational interventions or activities that could influence health although opportunities for lifelong learning have been recognized as helping to determine individuals health conditions 37 no systematic analysis has been conducted on how adult educational interventions could impact adults health conditions in oecd countries 38 this research gap in turn indicates a potential gap in the way education interventions are analyzed do they consider the relationships between education and healthwellbeing indeed it is widely accepted that education can directly influence health greater knowledge contributes to better health the influence might also be indirect better jobs and higher incomes promote better health these potential relationships are described in the who levelling up report on european strategies for tackling social inequalities in health 37 this report suggests that other educational elements might also play key roles in reducing health hazards but those elements cannot be identified in analyses that focus exclusively on individual educational levels that is although the literature clearly shows the relationship between education and health quality other factors related to involvement in educational activities might also be influencing those health improvements for instance a study on ways to overcome educational inequalities found that active participation and community engagement in decisionmaking in schools can help reduce healthrelated problems 39 for all these reasons then further research is needed on the associations between education and health outcomes especially accounting for groups at various socioeconomic levels 38 such research could reveal educational actions that can improve the health of particular vulnerable groups with low levels of education such as the roma community addressed here in this article we address this need and explore the particular ways in which two successful actions that are focused on encouraging roma people to participate in their local schools are improving health statuses the integrated included project defined sas as evidencebased actions in various social areas that are universal and transferable and have been effective in addressing social inequalities and fostering social cohesion 40 methods data collection the analyses presented here stem from the included integrated project the largest research project on schooling funded by the 6th european commissions framework programmes for research 40 the projects general goal was to identify educational strategies that either contribute to social cohesion or lead to social exclusion to this end the project conducted a comprehensive and integrated analysis of european school systems educational reforms and educational practices that increase educational success the project also explored the impacts that educational inclusion has on other areas of society such as employment housing health and political participation the study was designed to focus on specific vulnerable groups to analyze the actions and policies that could promote their inclusion through education in the context of this larger project 26 casestudies of successful schools were carried out in different european countries to select the cases starting with data available from governmental sources we selected those that most closely met three main criteria schools that were located in low ses areas with a significant presence of the vulnerable groups defined within this project obtained better educational results on standardized tests than average schools in similar contexts and had high levels of family participation the findings we present here are part of a fouryear longitudinal case study 39 of a school located in la milagrosa a ghetto neighbourhood in the city of albacete in southern spain with a majority roma population this neighborhood is characterized by high levels of poverty data from the spanish ministry of education social policy and sports reflect that in 2008 35 of the inhabitants of this area were social welfare recipients 7 were illiterate and 79 had not completed elementary levels of education all of the included research including this case study was carried out through communicative methodology 41 which is based on thinking from contemporary social scientists including the communicative rationality as understood by habermas 42 and the process by which humans construct knowledge through dialogue which mead calls symbolic interactionism 43 this methodology was developed to create the conditions for egalitarian dialogue between researchers and the individuals they are studying such dialogue breaks with the traditional interpretative hierarchy this dialogue makes it possible to integrate existing knowledge from the academic community with the life worlds of the social actors using a communicative process that continues throughout the research from the design of the research to the interpretation of the final results 44 the new knowledge created through this process is relevant to the actors involved and thus is more useful for throughout society this approach is especially valuable in research with vulnerable communities such as the roma people whose voices have traditionally been excluded from academic research preventing studies from having a more relevant and useful impact 45 to conduct the longitudinal case study the project team collected both quantitative and qualitative data more specifically each yearly round included 13 standardized openended interviews 13 communicative daily life stories to endusers one communicative focus group with professionals working in the local project five communicative observations and two questionnaires completed by the endusers in particular the data from the fourth round which are analyzed here consisted of 19 communicative daily life stories conducted with roma people along with nine openended interviews as in most qualitative works the participants were selected following the criterion of purposeful sampling 46 selecting the cases according to the stratification based on the previous knowledge in order to select those cases which could help better to respond to the research question these techniques were the most appropriate for this research since the aim was the comprehension of the meanings that actors gave to their actions and how they transferred the abilities and knowledge acquired through their involvement in the educational field to other contexts of their daily life such as health and care the research followed the criterion of credibility transferability dependability and confirmability which as has been widely argued by qualitative methodology experts are the base to ensure the validity of the results 4748 the data gathered in the phase presented here relates to selfreported health perceptions which according to literature is a good predictor of objective health status 49 50 51 as well as qualitative perceptions of education professionals and the other community representatives interviewed nevertheless future research could benefit from triangulation of this information with other sources such as measures obtained from health records and qualitative research conducted with professionals of the primary care unit of the area the voices of the roma families and members of the la milagrosa community are central to this study most of these participants have low incomes and little education beyond the primary level they are all neighbors in the la paz school community and when they first became involved in the school some were literate these roma adults had dropped out of school many years earlier if they had attended at all additionally few had jobs in the formal labor market and they faced serious economic challenges including how to feed their children the community had experienced such a critical level of social exclusion that some had become involved in the vicious circle of drug abuse and dealing among other illegal activities however the transformation of the school into a learning community improved the situation of the whole community in a range of very important ways the included project was based on an analysis of successful educational actions which are defined as the actions that contribute to school success and living together in other words seas contribute to overcoming school failure and early dropout as well as overcoming the risk of exclusion in other areas such as employment health housing and political participation the seas identified have been shown to lead to positive progress in the results in every context in which where they have been implemented and therefore they have already been transferred to other schools and communities to improve school success and social cohesion success is measured in terms of reducing early school dropout and absenteeism as well as in terms of the results obtained by students on the standardized tests administered by the department of education of castilla la mancha which evaluates ten competencies including linguistic communication mathematics knowledge and interaction with the physical world cultural and artistic competences treatment of information and digital competence social studies and citizenship learning to learn autonomy and personal initiative emotional competences and english data analysis using communicative methodology to include the voice of roma endusers the research team collected qualitative data so that it was possible to identify and analyze the impacts that the sas had on students educational levels and on the health conditions of those participating in the activity and of others in the wider community in this article it is analysed one sa educative participation which is described below and its impact on the health of the roma community in this neighbourhood the voices of the endusers are presented here to explore the relationships between education and health that developed among this roma community we look at how and how much educative participation helps improve the health of roma people the accounts analysed here have been selected because they illustrate well the analytical themes that represent the findings discussed the use of the communicative methodology was critical in both developing the data collection process and conducting the analysis the communicative approach requires that the research subjects participate throughout the entire project various elements guaranteed this participation one such element was the advisory committee comprising members of the social group that is the subject of the researchin this case representatives of the roma community and has the functions to provide feedback at different stages of the research on various materials to analyze the literature review to define the fieldwork techniques so that they would tap as much community knowledge as possible and to review the final report highlighting the evidence gathered the analysis revolved around two dimensions namely the exclusionary and transformative dimensions in analyzing a given situation of exclusion those using the communicative methodology identify the obstacles to reversing the situation along with elements that could help to promote change the transformative elements are key parts of this methodology recommendations for ways to transform the situation can draw from both the existing evidence and the reflections and contributions of those who are experiencing the exclusion results and discussion the included integrated project identified several sas in different domains that are helping reverse the social exclusion of vulnerable groups importantly the results of this project have also informed this article describes the ways in which family and community educative participation at la paz school had impacts on improving the roma endusers health overall we found that the participation of roma families and community members in interactive groups and family education both identified as seas 52 fostered specific cultural values among the roma that support better health moreover they transferred some of their learning in the seas to other contexts both elements helped to improve not only their own and their families health conditions but also the general level of health in their community roma cultural values as assets improving health through educative participation two cultural traits of the romafamily cohesion and mutual care and protectionplay key roles in their health conditions for the roma the value of family includes great respect for the elderly and authority care for ones family members and the observance of cultural family norms such as those related to mourning and kinship solidarity 53 importantly the roma understand family not as the nuclear family but rather as the extended family and even the broader community as they organize their lives they include all people whom they consider to be near their kin and whom they identify with their homes their culture and their way of doing things thus care and relationships also extend to a wider idea of family more similar to that of community this conceptualization of community or extended family is illustrated by aroa a 25yearold roma woman who has siblings and cousins in la paz school she explained in her narrative that everybody knows each other in the neighbourhood and if they are not cousins they are nephews we are all relatives here thus the roma people have a strong sense of identity and belonging to the broad and diverse roma ethnic group they share identity traits such as the family and communitybased ways of organizing the networks of solidarity established within these groups and the value attached to dialogue and the word 54 all of these values arise from their longstanding experiences of discrimination their centurieslong opposition to injustice has become a unifying force instead of a divisive one contributing to their cohesion and survival as an ethnic group all of these experiences have led the roma people to be aware of and care about not only their personal wellbeing or that of their closest family but also that of the other members of the community regardless of others actual roles as kin this sense of common identity motivates the strong bonds of solidarity that the roma develop among themselves a factor that can also help to improve their health this trait is clearly illustrated in the words of luis a 42yearold roma father in the neighborhood if we roma can be identified by something it is by this unity with this strength as people even more so we are there in the moments of illness 100 for instance if someone needs blood and if i meaning the community cant donate we buy it somewhere and we provide it and we ask each other if my blood is good or if yours is and if we are 100 people the whole 100 are tested to save the one person this is a point that i believe identifies us very much very very much the analysis of the ways that roma families and community members participated in interactive groups and family education at la paz school showed that this involvement helped these families to gain access to more resources and promoted relevant skills among them moreover it enhanced particular roma cultural strategies and values that helped them extend these health improvements to the whole community the next sections explore in more depth how their educative participation helped reduce some of the health inequalities in the community and therefore enhanced their health overall the included project identified educative participation as one of the three types of participation that had the greatest impacts on childrens academic achievement 55 educative participation means that members of the students families as well as others in the community either become involved in instrumental learning activities with the children or participate in education programs themselves among these activities interactive groups and family education were considered seas because they helped improve childrens academic outcomes and were transferable the analysis of the educative participation of roma families and community members at la paz school showed that this involvement enhanced particular roma cultural strategies and values that helped them extend health improvements to the whole community interactive groups have been found to be a successful form of heterogeneous ability grouping and reorganization of human resources within the classroom such groups allow all the students to perform better academically and they improve coexistence when a teacher implements interactive groups the classroom is organized into small and heterogeneous groups of students each with an adult who promotes supportive interactions and dialogue among the students the classroom teacher manages the classroom and provides extra support when necessary 52 in this strategy family members or neighbors come into the classroom to support the teacher and participate in the childrens learning family education activities are addressed to adults and include literacy subjects that are part of basic primary and secondary education and a wide set of courses that train individuals for work in such areas as childcare care of the elderly and monitoring playgrounds and school cafeterias the implementation of interactive groups and family education in la paz started in the 20072008 school year educational results have improved since its initial implementation according to the diagnostic tests conducted by the regional government of castilla la mancha in all schools as is shown in figure 1 the variations in the pupils matriculation provide further evidence of school success moreover absenteeism for the 20062007 school year was 30 and it reduced to 10 the following school year when members of families and the community come into the la paz classrooms that are organized into interactive groups they are in charge of encouraging supportive interactions among the children in addition through the family education in la paz the roma people acquire instrumental competences this also affects their childrens success in school 52 56 57 58 in this regard the evidence has long shown that family involvement in educational activities has a positive impact on childrens academic performance it changes their schoolrelated behaviors and improves their achievement thus family education enriches interactions among those of different cultural and educational backgrounds making that diversity an asset that can further improve both academic results and the coexistence among children of different backgrounds among the other impacts are the increased interactions between family members and the school as family members follow up on or ask for help with the childs school activities through both interactive groups and family education roma parents become active agents in their childrens learning in turn they feel increasingly useful selfconfident and rewarded for their work 59 such participation also helps to create networks of trust among participants which later translate into increased trust in the use of various social services such as health care 60 the focus here is how such family and community participation in schools can become a space to support health improvements among the roma source selfcompilation based on registration data and standardized tests elaborated by the department of education of the government of castilla y león increased emotional wellbeing through educative participation i feel much happier much more satisfied and even more valued… because i wake up with a purpose luis initial involvement at the school was not his own decision he started volunteering at his childrens school while he was still in prison to comply with the requirement for community service however his participation in interactive groups at the school radically changed his life when he was released he offered to continue as a volunteer at the school luis experience is like that of many romani parents at la paz as the school opened to the community through its process of becoming a learning community many opportunities became available for the local roma people who had until then lived at the margins of society luis did not simply participate in the classroom in the interactive groups he became a relevant resource in several ways improving the learning processes of all of the children in the community as well as his own his participation in appropriate educational activities such as the interactive groups made him feel valuable and useful the roma people were interviewed agreed on this point as soon as they became involved in the schools daily educational activities they became happier and more motivated and active in the regular activities of their daily lives in addition other people observed luis improvement including the teachers his relatives and the children luis explained to be appreciated by someone is nice to be appreciated by many people and children and not only children but teachers even though the appreciation of the children is important too because before you got up without a purpose now you get up with another you know with another perspective new routines habits resources and even sources of motivation have all improved the lives of these roma participants and are directly impacting their personalities ways of thinking expectations for their future and that of their families and ways of communicating these attributes also affect their health and wellbeing as described by luis well as i said it is because of coming here as i said the way of talking the way of thinking the way of relating to another person now i have a rhythm i come in the morning in the evening but i truly like it for these roma parents the very act of participating in activities in which they see their children learning becomes a trigger that increases their emotional wellbeing it creates meaning that improves their selfesteem rosario a roma mother of six children who was in jail for dealing drugs explained this when talking about her involvement in interactive groups you could see how children learned how useful you felt… teachers ask your opinion in the classrooms you are like if you were also a teacher they ask you to do something with the children and then you feel useful you feel well you feel valued and now even more they also see that being involved in activities in which they help future generations learn improves their own selfesteem because they feel useful and see themselves doing something good for others in contrast with some of their past personal experience in this vein when discussing the impact of her involvement in the schools educational activities rosario explained that it had helped her as well as the children now she feels that she is a better and more useful person it has helped me a lot because in addition to helping my children i am also learning as its stuff that you have forgotten and also i personally feel very useful and i feel i am a better person when i come here this involvement by roma adults in the interactive groups or family education activities has given new meaning to their daily lives they now do something that they know is positive both for themselves and for others in the neighborhood and this leads them to see more worth in themselves for many in la milagrosa these motivations to collaborate have helped to prevent mental illness in the forms of depression and drug or alcohol abuse raising awareness about health issues in addition to feeling more motivated and important in others lives these roma adults also indicated that participating in the schools educational activities made them more aware of health problems in the community and the need to intervene when they are involved in the classroom the mothers become more aware of health conditions among their own children and the other children leading them to improve their own attitudes about health the teachers especially noticed this impact as in the example below monica a teacher from la paz school explained how family members participation in interactive groups had an impact on hygiene conditions in my class yes i do because the mothers see it they see how many children come in very clean and then theirsyou know so yes they themselves notice for instance one came and said check their heads because theres lice …and when they are in class participating they see this even more thus the educative participation of these roma adults has made them more aware of healthrelated issues such as hygiene along with auditory visual and dental problems among the children similarly people interacting within the interactive groups and family education environments constantly raise and discuss various issues related to childrens health now roma family members can acquire important information that they did not have before they also learn new strategies and resources to improve the communitys health for instance they discuss childrens vaccinations and ways to prevent and treat head lice and they share information on dental and eye care during informal interactions with teachers students and other family and community members thus family participants learn about healthrelated topics while they acquire new instrumental competences in various other fields including math languages and science perceiving themselves as learners they adopt a different attitude as they hear details about health care or illness becoming more interested and more active agents in both the educational arena and their families health now when they go to the doctor they do not simply comply with instructions they want to know and understand what the terms mean and why the doctor prescribes one treatment over another luis explained i go to the doctor or to my daughters doctor and i get information with all the details if there is anything that i dont understand well theyll have to explain it well because im interested in it for example i might not know a particular disease or they would say you have to go to the otorhinolaryngologist and i would have said yes yes… i was ashamed to ask and id said yes and then once i was in the street i would tell someone that they had told me to go to the otolary something and they would say but will you go there and id be but where and now maybe i say ear throat and nose specialist because they have explained it to me because i have asked about it i have asked him and what is that about what is it for what function does it have and i dont feel ashamed to ask in sum the data analysis demonstrates the ways in which educative participation has a positive impact on the roma health both because individuals acquire new skills and competencies and because they have generated more confidence in this new learning environment caring for the familys health dolores is 26 years old and is participating in a family education course to earn her certificate in secondary education she explained that since she became involved in the school she has paid more attention to the health of her four younger brothers she dropped out of school when her youngest brother was born her mother fell into a deep depression and dolores had to take care of both her mother and brother and assume the household tasks now as she takes care of the family she establishes healthy routines and habits which she sees as her responsibility when dolores began to participate at la paz she maintained her family responsibilities but still engaged in other activities that benefited both her and her relatives other roma women told similar stories their domestic routines changed as soon as they became engaged at the school now they can better organize their everyday lives to make optimal use of their time they participate at the school assume family responsibilities and also take good care of themselves there must be time for everything to get ready to take care of oneself to feel well… and not be the typical roma with the bun and the slippers and the housecoat no that has to change that was in earlier times in the first century in the second century… one must become independent and go ahead on your own as well i used to say that women had to be at home washing the windows and staying with the kids and nothing else but look at me four months ago… i dont recognize her and some tell me you used to say that and i respond well i used to say that last year but this is already a new year and now dolores is not the same anymore one has to update importantly these transformations show the positive impact on families health qualities these women take home all that they learn through their new interactions at the school dolores talks about her familys nutritional habits especially those of her younger brothers to whom she is now much more attentive in a joking way talking about healthy eating habits im an artist in that im worse than my mother the kids are disgusted by me because of the vegetables and i say mummy prepares boiled things no fried stuff because the kitchen ends up greasy and we dont eat well does she really call herself mummy shes their sister i try to get my brothers not to eat chocolate pastries and now in school the same vegetables and now with the fruit very well milk no they want nesquik chocolate milk well none of that youll eat what we have dont ask me for funny things im not going to buy them… i try i try with the vegetables as the adults spend time in the educational environment hear of issues related to health and acquire important new skills and competencies they begin to detect and prevent their own health problems along with those of family members in addition they bring the knowledge that they acquire in the school to other areas of their lives particularly their homes the importance of family care and cohesion among the roma along with communication and an emphasis on dialogue helps to reinforce the learning that takes place at the school other members of the community know that if they need help with or advice about personal or health issues they can rely on support from those who participate in the school for instance aroa who is becoming more literate through her participation in la paz explained how she helped her aunt who is still illiterate to understand what the doctor said in a letter to her as seen here the strong family bonds among the extended roma become a channel through which information flows from the person involved at the school to the rest of the family including those who have no children at the school such as grandparents the emphasis on family wellbeing and the relevance of dialogue and communication ensure that what one person learns will flow to others in the household given this phenomenon the conversational topics within the family change with time and they expand to include health concerns luis explains how this occurred in his family well i just go there and tell them everything from an anecdote about some child to the discussions with them all around the clock from when i get up until i fall asleepit is all talking about school besides i like to tell my wife my children… while we eat i explain to them this and that has happened to me its a joy at home… we used to communicate as well before we talked but it was more like there was nothing to talk about family education courses in la paz serve two purposes first the roma participants acquire literacy skills and other competencies that they can use to capitalize upon their existing knowledge gaining skills for instance in assertiveness and communication to more effectively respond to doctors instructions or the pamphlets that come with medications second they transfer their newly acquired knowledge about health issues to their families where others then use it to make more appropriate decisions about their own health the following quote from luis illustrates how within an adult education course participants also obtain access to specialized health knowledge which has a positive impact on their families even the podiatrist has come to the adult learning school because maybe you think that you need to get surgery on your foot and then this man tells you that your shoes are not right and maybe you dont need any surgery well this man told us that we have to walk like this and that and i went to see my kids and i told my daughter walk walk and i said you have to walk like this as he showed us about the movement and so on and after seeing the podiatrist i came home and i said lets see whether my daughter has this curve to her feet but if you dont have this information… well then thats it along the same lines rosario who is involved in interactive groups and family education in la paz explained how she is taking better care of her children she says the same is happening in other families and that people are changing in deeply transformative ways her involvement even helped her to overcome her addiction to drugs which led to deep changes in her own life and those of her family members by being involved in school for instance there are mothers whose children came to school very scruffy and by coming here to the interactive groups you change your image completely you take better care of them this has happened to me there was a time when i was very bad i was on drugs i was in a center for nearly seven months and at that time i did not take care of my children on the contrary they got up on their own got dressed and came to school later on when i left the center and i was well it was me and my husband and i have not fallen back into drugs thanks to the school coming to school getting involved for me it is very important very important overall through such involvement these roma people have begun to care more about their own health conditions and those of their families their participation has deeply transformed their lives and future prospects at different levels not only do they capitalize on the knowledge they acquire and share it to benefit their families with transformed attitudes and increased confidence they can also better address health issues and develop more informed relationships with healthcare staff their particular cultural values with the prevailing relevance of family traditions and norms play significant roles as they improve their own healthrelated habits and those of their family members importantly these cultural values help to extend the benefits of this participation beyond themselves to their families and even beyond their closest kin as shown in the following section caring for the health of the extended roma community because interactive groups and family education emphasize dialogue among all participants they can take optimal advantage of the elements of roma culture such as unity and group cohesion which in turn improves roma health for instance when one roma adult learns that any child in the school has a health problem she or he reacts quickly talking with the childs parents or other relatives to find a solution that will improve the childs wellbeing for example because of her involvement in an interactive group aroa was able to identify why miriam a roma girl in the classroom was nervous and fidgety every morning aroa observed miriams behavior and asked her about it why are you so nervous and miriam answered because i dont have chocolate milk for breakfast my grandmother gives me coffee because she doesnt have chocolate milk so then… i will of course its the girls health she is just 8 or 9 years old and drinking coffee the grandmother was misinformed when aroa came to understand why this girl was so nervous she spoke with the mother about the problem she had noticed as a member of the roma community aroa shared more cultural codes with the mother than the teacher did so she and the teacher decided that she rather than a school employee would raise the issue with the mother in talking with the mother aroa was able to inquire more about the girls health she then learned that miriams younger sister only five years old also had this unsettled behavior because of her inappropriate breakfast aroas intervention was invaluable it led to both girls joining the morning class a school initiative in which children from families in need receive healthy breakfasts before starting the school day aroas account vividly exemplifies several relevant elements grounded in roma culture that are positively associated with improving health conditions and overall care among the roma community we see her concern about the fidgety girl and how she addresses the issue with both the girl and her mother through open and confident communication this roma commitment to the health of others in the community serves to increase the trust among other roma parents who are less involved in the school they feel relieved that their children are taken care of by the women who volunteer there aroa expressed that she could see that other roma participants were also committed to the wellbeing of other children in the neighborhood she also realized that even though she had no children of her own in the school she was more concerned with the other childrens health and wellbeing because of her involvement in interactive groups and family education about health i am more interested… i remember it and i see it when i arrive at the school i see that they are also interested in the health of children i do not have children myself but i have other relatives in school and i see that and whether i want it or not i also get it there too its transmitted i mean i also want to be interested in them being family mother or whatever these mechanisms have allowed the roma people to transfer their new knowledge and skills about health beyond the school and the family to the rest of their community the experience of increased solidarity among various community members enhances relationships among all the neighbors as they encourage each other to adopt new positive habits juana another roma mother explained how the environment had become friendlier as families in the neighborhood cared more for each other yes yes there are fewer conflicts yes because the mothers come to the school they maybe have a coffee become more friendly trust each other more and when you are on the street you say hi soandso maybe before we didnt say hi to each other and now we do and are you going to school or have you gone or why didnt you go today this stuff in addition this positive social control has extraordinary consequences for some of the participants as solidarity and community care have led them to engage more deeply vanessa a local teacher explains another side of rosarios story her life changed through her participation in the interactive groups encouraged by community members and the teaching staff this change deeply affected her health habits and routines as well as those of her family and well we kept on encouraging her saying come on just come one day and try if you like it you can offer your ideas… and from the moment she came she liked it and she keeps on coming everything improved in school her kid is much better both in learning and behavior at home she has started to organize herself her house is now cleaner now she has habits and routines that allow her children to get around and look for work she is also pursuing training herself getting involved in the education of her children and taking more care of everything one thing led to another… these womens stories show the deep changes in their lives as a result of their involvement in the interactive groups and family education which then led to changes in their families and the community indeed they recommend that other roma become involved at la paz as an effective way to improve their childrens futures as well as their own circumstances and their families health for example when a friend of aroas was depressed aroa urged her to become involved a girlfriend of mine has had deep depression and i have tried to encourage her to take a course in the school or be a volunteer in the school to keep her mind busy with something meaningful also increasing the impact on the community is the fact that a wide variety of roma adults from the neighborhood are involved in the interactive groups and family education when health issues arise they are granted a kind of authority among roma children and youth that even the teachers do not hold this authority another cultural element also helps to improve health habits the teachers understand how this can be an asset and use it to improve the health of all the children luis explains this clearly they caught one or two kids in the schoolyard with a cigarette and they said to me look luis what if you talk to them as a roma and as a man they will not shout at you or swear at you so i did talk to them yes yes if it had been the teacher female they wouldve told her whatever but if its me theres almost no need to say a word they would get quiet no swear words no yelling nothing this vignette illustrates yet another finding by spending more time in the school with the children the roma adults become able to identify problems among the children that their families often do not notice or cannot control the cultural emphasis on community members as authorities increases the value of having roma adults present within the school they can exert positive social control while reinforcing the bonds of trust among roma boys and girls and the roma adults conclusions researchers have taken individuals educational levels as positive indicators of their health conditions assuming that people with no or little education are less likely to be healthy 1661 this association makes even more sense for vulnerable groups such as the roma who receive far less formal education on average than the mainstream population 26 the results that have been presented here indicate that educative participation is a successful action that has a positive impact on the health conditions of roma people with little education the analysis of this roma community has shown that participating in such sas can lead to improved health even among people as vulnerable as the roma moreover we found that the positive impact on health by involvement in these activities transfers to other domains including the prevention and early identification of mental illnesses such as depression and anxiety and health issues arising in early childhood such as those related to hygiene dental health and hearing among many others additionally participating in these sas can help people acknowledge and overcome drug abuse the participants provided a wide range of reasons to explain this improvement some of these reasons are applicable to other social groups for example nearly anyone will feel more vitality and motivation for living when they engage in a meaningful and socially useful activity however given the extreme health inequality facing the roma our focus here has been on the explanations that are most applicable to this ethnic group the roma participants spoke of strategies relevant to their cultural tradition that were enhanced by their educative participation the experiences of aroa luis rosario dolores and juana illustrate how roma people even those with little formal education can build on particular cultural norms and traditions that are supported in the context of this sa to improve their healthpromoting habits when roma participants in the school feel that the childrens health is also their concern and responsibility they become even more involved in their own personal care and in identifying health problems whether physical or psychological that affect their children or other peoples children in doing so they gain knowledge and resources about health that others in the community may not have however because the interactive groups and family education foster family and community communication which are also key roma values these roma adults transfer their new knowledge to others in the community we also found that when these people faced new health problems the solutions they generated were based on their own cultural values and strategies such as involving members of the extended family and engaging in dialogue with their children and families direct communication and open dialogue appear to be the core of communitybased problem resolution among the roma people due to the strongly rooted value within roma culture that helps reduce health hazards and increase healthpromoting behaviors both their deep emphasis on family cohesion and their strong sense of belonging to the same ethnic group are reinforced when roma people participate in communitybased learning spaces such as interactive groups and family education participants in these sas use strategies grounded in roma cultural values which ultimately benefit not only their own families but also the extended roma community importantly these two educational actions interactive groups and family education share two key principles that overlap well with the health improvements in the roma community the goal of optimizing participants instrumental learning and an emphasis on egalitarian dialogue in which anyone is welcome to contribute to the dialogue regardless of their social or academic status the two principles work together to enrich the bonds of solidarity within the extended roma family and beyond in turn this solidarity helps participants transfer what they learn about health in the school to other spaces reaching the broader roma community future research is needed in order to complement the data obtained particularly it would be interesting to contrast the information obtained with available health records of the population of la milagrosa as well as with fieldwork conducted with primary health professionals of the area evidence that educative participation can effectively improve health conditions among the roma people is a positive contribution to the goal to reduce the health inequalities from which they suffer thus in addition to simply helping people gain more education these other educational interventions can help them to overcome health inequalities furthermore our findings emphasize the need for researchers to include the voices and cultural strengths of the roma and other vulnerable cultural and ethnic groups when designing educational interventions that aim to improve their health conditions finally policies intended to reverse the health inequalities facing the roma people must be grounded in empirical findings such as those provided by the roma community in la milagrosa in albacete in this community people have transformed their healthrelated behaviors regardless of their educational levels through the implementation of evidencebased sas future works addressed at the development of health policies for roma will benefit from the findings of this research conflict of interest the author declares no conflict of interest

on average the roma in europe can expect to die 10 years earlier than the rest of the population given the health conditions they experience eufunded research has informed on successful actions sa that when implemented among the roma provide them new forms of educational participation which have a direct impact on improving their health status regardless of their educational level the findings from this research unanimously endorsed by the european parliament have been included in several european union recommendations and resolutions as part of the eu strategy on roma inclusion to analyze these sa as well as the conditions that promote them and their impact on reducing health inequalities communicative fieldwork has been conducted with roma people from a deprived neighbourhood in the south of spain who are participating in the previously identified sa the analysis reveals that these sa enable roma people to reinforce and enrich specific strategies like improving family cohesion and strengthening their identity which allow them to improve their overall health these findings may inform public policies to improve the health condition of the roma and other vulnerable groups one goal of the europe 2020 strategy for a healthier europe

introduction for men who have sex with men and transgender women disclosure of samesex sexual practices can be a critical step toward engaging healthcare services to appropriately prevent and treat hiv and other sexually transmitted infections disclosure of a concealable and stigmatized sexual identity may lead to improved healthcare outcomes by allowing msm and tgw to express personally relevant information garner social support and influence societal views disclosure to family members can lead to acceptance support and identity formation that can lead to positive psychological adjustments and in turn may promote adherence to safer sex practices and medication including preexposure prophylaxis or antiretroviral therapy for hiv disclosure to healthcare providers is necessary to receive anatomically appropriate screening for stis and to inform the frequency of such screening while samesex sexual practices have become culturally more acceptable in many western countrieswith associated positive gains in human rights for msm and tgwthe same has not been observed in many parts of the developing world including subsaharan africa where there can be dire consequences for being identified as homosexual including stigmatization assault imprisonment and even capital punishment therefore disclosure of samesex sexual practices often occurs at substantial risk to the person making the disclosure exposure to these negative consequences of disclosure may create a hostile and stressful social environment thereby worsening mental and physical health in subsaharan africa two of the most commonly reported manifestations of stigma related to samesex sexual practices are enacted or experienced stigma which refers to behavioral expressions of stigma such as physical violence blackmail and denial of healthcare services and perceived or anticipated stigma which refers to a fear or expectation that enacted stigma may occur such as fear of seeking health care in 2014 legislation passed by the nigerian government recommended harsh punishments for msm and tgw and persons perceived to be promoting homosexuality following the passage of this law msm and tgw reported increased fear and avoidance of healthcare services in 2017 nigerian police raided an event organized to promote hiv testing in lagos and arrested men who were accused of engaging in samesex sexual practices a crime punishable by up to 14 years in prison prior research has shown that blackmail and beatings due to samesex sexual practices are commonly experienced by nigerian msm and tgw and are linked to increased risk of genitourinary diseases this could be partially explained by stigma leading to higher risk sexual behaviors such as increased condomless sex and decreased engagement with healthcare systems we have previously proposed a model whereby disclosure of samesex sexual practices can lead to increased hierarchical classes of stigma then suicidal ideation then condomless sex with casual sex partners and finally increased risk of hiv and other stis understanding disclosure patterns of samesex sexual practices among msm and tgw communities in subsaharan africa is therefore critical because these communities are marginalized stigmatized and have an exceptionally high burden of hiv and other stis nigeria is the most populated country in subsaharan africa and its residents account for almost one out of every ten people living with hiv around the world and about 10 of new diagnoses annually in some communities of nigerian msm and tgw hiv prevalence as high as 4466 has been reported the disproportionate burden of hiv among msm and tgw is driven partially by physiologic factors such as the increased transmissibility of hiv via condomless anal as compared to vaginal sex and partially by social and cultural factors such as the suboptimal quality and coverage of preventive healthcare services available to msm and tgw a structural approach to managing the stigma associated with samesex sexual practices including any stigma resulting from disclosure thereof is necessary to optimize quality of care in swaziland a structural stigmareduction intervention package has been implemented that encourages disclosure as a means of increasing uptake of evidencebased and rightsaffirming care for msm and tgw that includes couples counseling provision of condoms and condomcompatible lubricants anal cancer screening and laboratorybased sti diagnosis while the nigerian healthcare system is stratified into tiers operated at the local state and federal levels with inconsistent harmonization there is increasing recognition at some levels of the importance of engaging msm and tgw to curb the spread of hiv support in nigeria is shifting toward nongovernmental organizations that deliver health care in safe spaces like trustrv368 to address specific needs of msm and tgw in these analyses we separated disclosure out from previously explored stigma classes to identify the proportion of participants who disclosed their samesex sexual practices and evaluate whether disclosure could be an avenue for intervention to promote engagement with msmand tgwfriendly clinics we also further explored the relationships between disclosure to a family member andor hcp with condom use stigma and discrimination method measures upon enrollment data on participant demographics and sexual behaviors were collected by a trained interviewer using a standardized questionnaire a study physician performed a medical examination and recorded each participants medical history participants underwent counseling and testing for hiv and other stis hiv status was determined using a parallel algorithm of rapid tests with determine ® and unigold ® kits and a third tiebreaker with hiv12 statpak if needed all testing was performed according to package inserts enrollment evaluations were scheduled across two study visits approximately two weeks apart participants were categorized based on their responses to two questions have you disclosed to any member of your family that you have sex with other men or that you are attracted to other men and have you disclosed to any healthcare worker that you have sex with other men or that you are attracted to other men age gender identity sexual orientation education occupation and marital status were each assessed by selfreport participants were asked to describe the frequency of condom use during insertive anal and receptive anal sex using the categories always almost always half the time almost never and never they were also asked whether they had ever experienced a variety of potential indicators of stigma and discrimination such as fear of accessing healthcare services avoidance of health care and refusal of health care due to their msm and tgw status these indicators reflect types of perceived and experienced stigma related to samesex sexual practices that have been previously observed in western and southern africa data from clinical evaluations and participant interviews were collected on paper case report forms imported into an electronic database using teleform and verified for accuracy by a dedicated staff member statistical analyses separate analyses were conducted to compare groups reporting disclosure of samesex sexual practices to a family member andor a hcp demographic characteristics condom use and experiences of stigma were compared between these groups using pearsons chisquared test or fishers exact test for categorical variables and t test for continuous variables in separate models for disclosure to a family member and to a hcp poisson regression with robust error variance was used to estimate the relative risk of disclosure and 95 confidence intervals associated with prespecified factors of interest such as age gender identity sexual orientation education marital status city and enrollment year multivariable models included all prespecified factors of interest a twosided type i error less than 5 was considered statistically significant to help evaluate separate effects of disclosure to either a family member or hcp as well as the impact of overlapping disclosure to both a family member and hcp comparisons were repeated across all four possible combinations of disclosure disclosure to neither a family member nor hcp disclosure to a family member only disclosure to a hcp only or disclosure to both a family member and hcp a single multinomial logistic regression model was used to generate adjusted rrs and 95 cis for factors associated with each of these categories as compared to the nondisclosing reference group for all analyses missing data were carried backward from the scheduled 3month followup study visit if available or were categorized as unknown analyses were performed using stata 142 results demographics and disclosure of samesex sexual practices a total of 2591 participants were enrolled between march 2013 and may 2019 including 34 who did not answer questions about disclosure of samesex sexual practices and were excluded from these analyses of the remaining 2557 participants included in these analyses 1885 were from abuja and 672 from lagos the median age of participants was 23 years with interquartile range 2127 years samesex sexual practice disclosure among participants was generally uncommon with only 925 reporting some sort of disclosure including 192 who had disclosed only to a family member 541 only to a hcp and 192 to both a family member and hcp demographic and other characteristics of the study population stratified by disclosure of samesex sexual practices to a family member andor hcp are shown in table 1 and supplemental table 1 factors associated with disclosure of samesex sexual practices in unadjusted analyses disclosure of samesex sexual practices to a family member was more common among transgender women more highly educated participants participants living with hiv or with unknown hiv status participants in lagos and during specific years of enrollment participants who selfidentified as bisexual and were married or living with a woman were less likely to disclose to family after adjusting for all evaluated factors higher education level recruitment at the lagos clinical care site and living with hiv were each independently associated with an increased likelihood of disclosure to family as compared to participants with gayhomosexualother sexual orientation those reporting a bisexual orientation were less likely to disclose samesex sexual practices to a family member in unadjusted analyses disclosure of samesex sexual practices to a hcp was more common among older participants those with otherunknown gender identity more highly educated participants participants living with hiv or with unknown hiv status participants in lagos and during specific years of enrollment after adjusting for other factors older age otherunknown gender identity higher education level recruitment at the lagos clinical care site and living with hiv were each independently associated with an increased likelihood of disclosure to family participants who were married or living with a woman were less likely to disclose to a hcp in both the unadjusted and adjusted models the multinomial logistic regression model revealed similar trends older age was associated with greater likelihood of membership in one of the two groups that disclosed to a hcp factors associated with increased likelihood of all three combinations of disclosure as compared to nondisclosure included higher than senior secondary education recruitment at the lagos site and living with hiv sexual behaviors and condom use participants who disclosed their samesex sexual practices to a family member had a slightly younger age of coitarche with male partners which occurred at a mean age of 165 years compared to 173 years among those who had not disclosed to family no significant difference was observed in age of coitarche with female partners between participants who had and had not disclosed their samesex sexual practices to family compared to participants who had not disclosed their samesex sexual practices to a family member participants who had disclosed were more likely to report always or almost always using condoms during receptive but not insertive anal sex participants who disclosed their samesex sexual practices to a hcp had a slightly older age of coitarche with male partners which occurred at a mean age of 176 years compared to 170 years among those who had not disclosed to a hcp no significant difference was observed in age of coitarche with female partners between participants who had and had not disclosed their samesex sexual practices to a hcp compared to participants who had not disclosed their samesex sexual practices to a hcp participants who had disclosed were more likely to report always or almost always using condoms during both insertive and receptive anal sex similar inferences were drawn from comparisons across groups defined by all four possible patterns of disclosure participants who disclosed samesex sexual practices to a family member only were more likely to report condom use during receptive but not insertive anal sex participants who disclosed samesex sexual practices to a hcp with or without concurrent disclosure to a family member were more likely to report condom use during both insertive and receptive anal sex as compared to participants who did not report any disclosure experiences of stigma compared to those who had not disclosed to a family member participants who had disclosed their samesex sexual practices to a family member were more likely to report fear of seeking health services and avoidance of healthcare services but were no more likely to be denied healthcare services because they were msm and tgw furthermore those who had disclosed samesex sexual practices to a family member were more likely to have felt afraid to walk around experienced blackmail and experienced assault because they were msm and tgw when compared to those who had not made a similar disclosure similarly compared to those who had not disclosed to a hcp participants who had disclosed their samesex sexual practices to a hcp were more likely to report fear of seeking health services and avoidance of healthcare services unlike disclosure to a family member disclosure to a hcp was associated with a significantly increased risk of being denied healthcare services fig 2 indicators of perceived and experienced stigma due to samesex sexual practices stratified by disclosure of samesex sexual practices to a family and b healthcare providers bar height represents the percentage of study participants who reported each indicator of stigma upon enrollment pearsons chisquared test was used to compare the proportion of participants reporting each stigma indicator stratified by disclosure status statistically significant differences between groups are shown in bold vs 5 χ 2 2546 p 01 participants who had disclosed samesex sexual practices to a hcp were also more likely to have experienced both blackmail and assault because they were msm and tgw when compared to those who had not made a similar disclosure similar inferences were drawn from comparisons across groups defined by all four possible patterns of disclosure disclosure to a family member was not associated with denial of health care but denial of health care was more common in both groups that had disclosed to a hcp a similar pattern was observed with sexual violence disclosure to a hcp was not associated with fear of walking around but more participants in the groups who disclosed to a family member reported this fear other stigma indicators were generally increased among participants who had made any disclosure as compared to the nondisclosure group discussion disclosure of samesex sexual practices to a family member or hcp were each relatively uncommon among nigerian msm and tgw in this study in each case disclosure was associated with a larger proportion of participants reporting condom use consistent with results from prior studies suggesting that disclosure enhances social support improves quality of health care and improves treatment outcomes in msm and tgw populations however these apparent beneficial effects were countered by strong relationships between disclosure and stigma which may have discouraged utilization of healthcare services disclosure of samesex sexual practices among nigerian msm and tgw in this study was generally less common than has been observed in settings with less criminalization and stigmatization of homosexuality the disclosure rates of about 15 and 29 to a family member and a hcp respectively among msm and tgw in this study were substantially lower than the rates of about 75 and 56 respectively which have been reported from south africa where msmfriendly legislation exists in contrast research from countries with laws that criminalize samesex sexual practices among men generally shows much lower rates of disclosure including disclosure to a family member by 46 of msm and tgw in cameroon to hcp by 31 of msm and tgw in swaziland and disclosure to a hcp by only 17 of msm and tgw participants in a large crosssectional study in malawi namibia and botswana in addition to criminalization cultural and societal factors may also contribute to disclosure practices and should be considered when designing affirmative and targeted populationbased hiv and sti prevention intervention in china a country without antihomosexuality laws but with extralegal consequences for samesex sexual practices the overall disclosure rate to hcp was found to be only 16 in the african context cultural stigmatization has created barriers to msmand tgwfocused healthcare services that are compounded by criminalizing legislation that creates fear of arrest and brutality stigma was associated with disclosure of samesex sexual practices to both family and hcp in this study participants in this study reported both perceived and experienced stigma because they were msm and tgw including specific stigmarelated barriers to healthcare engagement notably although denial of health care was generally uncommon msm and tgw who disclosed their samesex sexual practices to hcp were substantially more likely to be denied health care the stigma and discrimination experienced by nigerian msm and tgw are in some ways legitimized by nigerias antihomosexuality legislation which has resulted in increased stigma that acts as a barrier to disclosure of sexual practices similar to the observation in this study samesex practice disclosure among msm and tgw in swaziland was found to be associated with stigma and fear of seeking healthcare services in gambia studies show several associations between disclosure of samesex sexual practices by msm and human rights abuses such as physical assaults arbitrary arrests and threats of decapitation while important decriminalization of homosexuality does not eliminate social and cultural sources of stigma as the first and only african nation to legalize unions between samesex couples south africa is one of subsaharan africas most legislatively accepting countries however msm and tgw still experience significant stigma discrimination and poor reception from hcp in south africa a study that evaluated the impact of decriminalizing laws in south africa botswana malawi and namibia found that human rights abuses such as police harassment and denial of housing persisted despite legislative changes but blackmail and fear were diminished legal and social change must occur in tandem in order to optimally promote community acceptance decrease stigma and encourage disclosure of samesex sexual practices to family and hcp this could possibly improve healthcare engagement and access to appropriate preventive health services in this study certain key factors were found to be associated with disclosure of samesex sexual practices among msm and tgw increased educational level was strongly associated with disclosure to both family and hcp underscoring the general importance of education possibly facilitating disclosure the reasons for disclosure being more common among participants living in lagos are uncertain both lagos and abuja are large urban centers with reports of discrimination and human rights abuses affecting msm and tgw understanding the social behavioral and environmental factors that positively influenced disclosure in lagos could inform hiv prevention approaches samesex practice disclosure to either a family member or hcp was associated with more condom use a prior study from china similarly found that nondisclosure was associated with riskier samesex sexual practices among gay and bisexual men despite the potential positive relationship between disclosure and condom uptake samesex sexual practice disclosure was also associated with increased perceived and experienced stigma prior data suggest that knowledge and attitudes of hcp are key barriers to disclosure of samesex sexual practices training hcp to demonstrate awareness through a patient management algorithm that incorporates proactive inquiry about sexual practices could reduce fear of disclosure and improve care and treatment outcomes tailoring interventions to the needs of individuals and communities who are less likely to disclose their samesex sexual practices may improve results national recognition and support of nongovernmental organizations that provide communityengaged care to msm and tgw in safe spaces may help to optimize the gains from disclosure while minimizing stigma there were a number of strengths and limitations of these analyses the respondentdriven sampling technique enabled the enrollment of a highly marginalized and hardtoreach population of msm and tgw the use of standardized questionnaires enabled the collection of detailed information regarding study population demographics samesex practice disclosure and associated stigma however potentially sensitive and stigmatizing data collected via selfreport may suffer from a number of biases including response and recall biases the population included in these analyses was recruited in two large urban centers in nigeria and may not be representative of populations in other areas recruitment at trusted community health centers specially staffed to create safe spaces for msm and tgw may have biased the study population toward a greater likelihood of disclosure although this bias was mitigated by the respondentdriven sampling methodology that reached participants who had not previously accessed these facilities only individuals who could provide informed consent in english or hausa were eligible for this study potentially biasing the study population toward inclusion of individuals with specific educational geographic or ethnic backgrounds associated with these languages there was some overlap of disclosure groups potentially confounding interpretation of the individual effects of disclosure to either a family member or a hcp however almost all inferences were robust to sensitivity analyses that recategorized participants into four mutually exclusive groups representing all possible patterns of disclosure to a family member andor a hcp the primary dichotomous analyses were retained to enable easier visualization and interpretation of the relationships that were confirmed by the sensitivity analyses while we have provided theoretical pathways through which the factors evaluated may be associated with disclosure of samesex sexual practices the crosssectional nature of these analyses limits our ability to infer any causal relationships these analyses did not distinguish between voluntary and involuntary disclosure of samesex sexual practices this study revealed a complicated relationship between disclosure and samesex sexual practices by nigerian msm and tgw cultural and behavioral implications of disclosure must be considered in designing interventions to engage msm and tgw in healthcare and hiv prevention services this study corroborates prior work indicating that interventions to encourage disclosure must be accompanied by larger campaigns to educate communities create safe spaces to access health care decrease stigmatization and promote policies of acceptance improved disclosure practices within safe spaces may enhance engagement of msm and tgw in healthcare and hiv prevention services compliance with ethical standards conflict of interest the authors declare that they have no conflict of interest disclaimer the views expressed are those of the authors and should not be construed to represent the positions of the us army or the department of defense or the department of health and human services 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 all participants provided written informed consent prior to enrollment the study was reviewed and approved by the ministry of defence health research ethics committee abuja nigeria walter reed army institute of research institutional review board silver spring maryland usa and the university of maryland irb baltimore maryland usa the investigators have adhered to the policies for protection of human subjects as prescribed in ar70 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 iveco mmons orglicen sesby40 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

disclosure of samesex sexual practices by men who have sex with men msm and transgender women tgw may facilitate appropriate healthcare engagement including risk assessment for hiv and other sexually transmitted infections stis and negotiation of condom use with partners however disclosure may also generate stigma in these crosssectional analyses msm and tgw were categorized based on selfreport of disclosure to family members and healthcare providers hcp at enrollment into the trustrv368 study of comprehensive hiv and sti care programs in abuja and lagos nigeria multivariable poisson regression models with robust error variance were used to estimate relative risk of disclosure with 95 confidence intervals pearsons chisquared test was used to compare condom use and stigma indicators by disclosure status of 2557 participants who answered baseline questions about disclosure 384 150 had ever disclosed to a family member and 733 287 to hcp including 192 75 who disclosed to both higher education prevalent hiv infections and residence in lagos were each associated with increased likelihood of disclosure to family and hcp older participants were more likely to disclose to hcp but not family participants who made a disclosure to family or hcp were more likely to report condom use during anal sex as well as perceived and experienced stigma that included healthcare avoidance blackmail assault and sexual violence as compared to participants who had not disclosed improved disclosure practices within safe spaces may enhance engagement of msm and tgw in healthcare and hiv prevention services

introduction family caregivers are considered as the backbone of the longterm care and support system 12 family or informal caregivers offer voluntary and unpaid physical practical and emotional care andor support to a person with a disability in the home environment 34 the german situation recent figures from the he german federal statistical office show that in germany 76 of all care to those with care needs is provided by family caregivers in their home environment 5 three to five million german family caregivers provide unpaid care to 45 million persons in need 6 most of these family caregivers are female between 4085 years old and still in employment when younger than 65 years 7 family caregiving can be extremely stressful especially in longterm care situations eg when caring for a family member suffering from alzheimers disease or a stroke 89 caregivers often experience a reduced quality of life social isolation loneliness stress fatigue exhaustion frustration as well as a sense of helplessness 10 11 12 a lack of choice of being a caregiver lack of support as well as financial strains and unfamiliar bureaucratic workload may also provoke caregiver burden 613 ideally family members need to be prepared and educated before they take up their new role as informal caregiver 1415 in germany the official conditions for caregiver support are embedded in a law that supports the hospital discharge management and the präventionsgesetzprävg 16 currently different stakeholders provide different forms of caregiver support 67 for example health insurances provide online support eg a caregiving coach 17 or group support eg caregiving courses 18 communal services offer personalized caregivingand environmental counselling however these services are uncoordinated unsatisfactorily utilized 1920 or planned too late during the caregiving trajectory 21 especially in case of a sudden incident such as a stroke the organization of tailored family caregiver support should start already within the hospital or rehabilitation setting ie before the patient is discharged acknowledgement of the prospective role of family members as part of the patient care trajectory together with welltimed personalized support might also prevent the socalled revolving door phenomenon 2022 context of the study the rhinemaasclinicum is a large hospital located in wuerselen northrhine westphalia germany with a strong hierarchical organizational structure the rhinemaasclinicum has a large geriatric department with 64 acute geriatric beds and 28 rehabilitation beds spread over three wards in 2016 1550 patients on average 827 years old were admitted treatment care and medical support is provided by around 70 professionals with a strictly patientcentered approach staff members at the rhinemaasclinicum treat family caregiver issues in an unstructured haphazard manner the needs of family members as prospective caregivers at home are insufficiently acknowledged although care professionals recognize the value of family members in the care trajectory of their patients family caregivers have been shown to play an unnamed but critical role in the geriatric health care system forming a socalled shadow workforce 23 they are an important source of information for geriatric care professionals being the ones able to supply key pieces of medical information about their elderly care receiver in a timely manner 23 however they often experience strain especially coresident caregivers and run the risk of getting depressed 24 in a large metaanalysis it was shown that receiving support formal or informal was related to better caregiver health 25 supporting them will secure the care to geriatric patients in the home environment after hospital discharge 26 recent recognition of the importance of the family as prospective caregivers for geriatric patients prompted the rhinemaasclinicum to join an academic research team from maastricht university the netherlands in setting up a participatory health research project to prepare the implementation of a new support programme for family caregivers called vade mecum 2728 vade mecum aims to sustain health and wellbeing and prevent social exclusion and health inequality of geriatric patientcaregiver dyads at the core of the concept is a new job profile a hospitalbased care employee with a special assignment to guide educate and support family members of geriatric patients in becoming an informal caregiver 27 a first step in designing a better system of geriatric care in the rhinemaasclinicum is to identify the statusquo and needs of geriatric care professionals to support them aim of the study before full implementation of the new family caregiver support concept in the rhinemaasclinicum a preimplementation step is necessary to gain insight in the statusquo activities and needs of the multidisciplinary team regarding family caregiver support because of the haphazard way of engaging with family caregivers of geriatric patients by individual care professionals little is known about how and what is needed to best deliver that support in a more organized way and to inform the hospital management on the best way of implementing the new holistic support concept in this article we report on both the process and the results of a phr study on actual state and needs of the mdt at the core of the phr approach is the delegation of decisionmaking power regarding the research process from academic researchers to a coresearch team consisting of members from the mdt this coresearch team will be formed at the start of the study and is responsible for choosing the research design participant profile data collection methods data analysis and reporting the actual research question will be articulated by this coresearch team during the phr process materials and methods research strategy for this preimplementation step a participatory research strategy is a preferred choice phr has a longstanding tradition in public health research 29 and is viewed with increasing interest by researchers decisionmakers and practitioners worldwide as a strategy to overcome the gap between academic researchers and professionals working in practice 30 one of the principles of phr is a power shift in the conduct of research from academic or expert researchers to those stakeholders in the field that possess insightful knowledge and experience 3132 in addition to the generation of new knowledge this approach also aims to empower those involved in the research process 3334 coresearchers learn methods of scientific knowledge production and use the process to understand their own reality whereas academic researchers understand the real needs of a practicedbased phenomenon 35 engaging members of the mdt as cocreator of new knowledge creates ownership of the outcomes 36 formation of the research team roles research activities three categories of researchers were involved in this study academic researchers a critical friend and coresearchers the ar was responsible for facilitating and stimulating the phr research process as external impulse provider contributing with scientific technical and managerial knowledge drafting the research plan and monitoring the progress and guaranteeing a constant communication flow the ar started the study by contacting all members of the mdt and explaining the participatory strategy during the research process a critical friend supported the ar a cf is a trusted professional who is able to ask proactive questions and give collegial feedback 37 the cf in our study was serving as listening ear stimulated reflection and continuous professional development of the ar 3839 in our study members of the mdt were participating as coresearcher with researchers from outside the setting members of the mdt are the ones with experiential knowledge in the setting have ideas about relevant research questions the acceptability and appropriateness of the research methods and the interpretation of the findings in principle all members from all professional groups of the mdt working at the geriatric department of the rhinemaasclinicum were eligible as member of the coresearch team provided that they have contact with family caregivers research experience was not necessary the head of the department a medical doctor served as gatekeeper the coresearch team together with the ar and cf set the research agenda formulate the research question decide on which qualitative research methods to be used to collect the data formulate selection criteria and recruit key informants in their peer group collect the data perform the data analyses report the outcomes and carry out all other necessary research activities to answer their research question 4041 the proceeding of this process is reported in the results section part 1 phr process and in table 1 documenting and reflection a research management plan was developed to keep track of all research aspects and choices and document who did what on what level of participation the ar outlined six phases beforehand orientation settingup planning data collection analysis and reporting according to the key principles developed for utilizing participatory methodologies in the cocreation and evaluation of public health interventions 42 the ar took lead in the preparation organization planning and communication of the project as the iterative research process progresses and the roles change contributions activities and expected or planned outcomes will be inserted in the management plan to document the emerging study in each phase the participation grades of the coresearchers will be determined and graded by using cornwalls participation typology which ranges from 1 cooption 2 compliance 3 consultation 4 cooperation 5 colearning to 6 collective action 43 to evaluate the experiences with the phr approach and critically reflect on the benefits and limitations of this research methodology within the setting a brainstorming session with mind mapping will be carried out in the final meeting when the coresearchers are still together as a group regular meetings between the ar and the supervisor were organized to discuss important research issues and the progress of the subsequent steps but also ways of ensuring rigor of the study 4445 the cf assisted the ar on keeping a reflective mindset while the ar kept record of reflective talks with the cf all research choices activities and reporting in this manuscript were guided by the standards for reporting qualitative research 46 ethical considerations this participatory project aimed to assess the statusquo and needs of hospital personnel regarding support of family caregivers of geriatric patients in preparation of their new to develop working practice participation as coresearcher or participant in one of the indepth study parts was on a voluntary basis no incentives were offered verbal informed consent was obtained from all individual study participants in the professional peer groups before data collection the head of the department enabled participation during working hours and facilitated the research activities ethical approval was given by the hospital management approval from an ethics committee was not necessary mutual respect equality and inclusion democratic participation active learning making a difference and personal integrity were the ethical principles accompanying the entire phr project 47 additionally the following ethics in practice principles were respected beneficence respect for autonomy justice and nonmaleficence 48 some fragments of the project up to the phase of data collection were published earlier 27 ¶ cr coresearchers § from 47 results first in part 1 the phr process will be presented per phase accompanied by the management plan next both outcomes will be presented and finally reflections on the research process will be addressed the project started in february 2017 and ended in march 2018 the phr life cycle started with the literature exploration explorative talks with professionals and a 2day field visit by the ar a list with topics was constructed to guide the first meeting with the prospective team members within the geriatric department settingup the second phase started with an impulse lecture to raise interest to conduct a phr study and by doing this to improve the caregiver support within the geriatric department members of the various professions in the geriatric department were invited as coresearchers careful attention was paid to ascertain representation of all levels of the hierarchical system within the hospital two medical doctors two case managers two social workers two therapists and four nurses took part as internal stakeholders the ar with the cf completed the research team in the first workshop the team was asked to reflect on their daily challenges in the interaction with family caregivers systemrelated problems as well as caregiverrelated problems were brought up additionally communal support offers were perceived as fragmented uncoordinated and lacking a holistic approach caregivers were occasionally involved as partners in the hospital care process but mainly for purposes of patient care caregiver burdens or needs were not assessed systematically at any time during the patients hospital stay coresearchers also reflected on their own expectations and goals of the new support concept they expected to allocate more time to support caregivers tuned to caregivers individual needs scheduled in the normal working hours to benefit from task simplification to expand their own professional competence and get appreciation objectives were that family caregiverpatient dyads were given longer consultation times as well as individualized and improved support within the hospital at last guided by triggering questions from the ar the main research question was formulated by the team how does the multidisciplinary research team of the rhinemaas clinic currently supports family caregivers and what is needed for offering comprehensive support planning in the third phase the coresearchers first decided that a qualitative data collection method is appropriate to answer the research question next they decided based on the organizational structure within the department on the groups of participants for the study six participant groups were indicated medical doctors nurses physiooccupational therapists speech therapists case management and social services the coresearchers chose data collection methods after an impulse lecture from the ar who preselected and presented five possible methods interviews focus groups storytelling structured interview matrix and community mapping for each method advantages and disadvantages were discussed first taking the existing experience within the geriatric setting into account interviews and focus groups seemed to be the best option next coresearchers were equipped to conduct the data collection within their own peer groups with an instruction memo and a question catalogue prepared beforehand to guide and harmonize data collection within the different professions 27 the ar monitored the data collection process data collection study participants for the interviews and focus groups were recruited by coresearch team members among their peers in total 31 individuals took part in the participatory data collection phase structured focus group discussions were organized by the medical doctors among the medical doctors nurses discussed with nurses and physiooccupational therapists with their own peers semistructured interviews were held by the speech therapists case managers and social workers each group organized their own meetings field notes were produced per group and then distributed within the entire research team to be analyzed analyses a dataanalyzing team was formed consisting of two medical doctors two nurses one occupational therapist one physiotherapist and one social worker the analyzing process was facilitated by the ar and cf the dataanalyzingteam met three times for approximately 70 min per meeting and used a stepwise thematic analysis strategy 4950 to analyze both the three focus group datasets as well as the three interview datasets all members of the dataanalyzing team were familiarized with all six sets of field notes themes and subthemes were agreed upon per dataset first after which the outcomes from the six data sets were merged resulting in one final comprehensive multiperspective understanding of both the actual state and the needs for offering caregiver support within their setting part 2 outcomes outcome 1 the actual state of caregiver support from the thematic analysis three themes emerged professionals perception of the family caregivers actual state of professional caregiver support activities and weak spots or deficits in current caregiver support ad professionals perceive family caregivers as an important interlinking person between the patient and the multidisciplinary team but also as at risk of becoming overburdened by infrastructural issues eg by changes in contact persons or not being informed about rehabilitation and support offers the social services said that the role of caregivers is underestimated in our department the physioand occupational therapists observed that only demanding caregivers are supported and quiet relatives often fall through the grid during their daily work some professionals experience caregivers in general as undersupported andor insufficiently informed nurses physiooccupational therapy while others even experience them as an encumbrance or added task in their daily work case managers medical doctors ad the intensity of contact extent and moment of involvement varies greatly between the different professions the existing caregiver support system is perceived as deficient unstructured and uncoordinated currently caregiver support is very chaotic physiooccupational therapy caregiver counselling is rather inadequate especially on medical and nursing topics since there are no fixed office hours nor are individual appointments offered social services however all professionals provide some support on an individual basis one medical doctor offers caregiver consultation talks from 300 pm to 400 pm medical doctor interdisciplinary consultations can be scheduled on request by the caregiver the knowledge concerning caregiverspecific offers varies greatly among the professionals and there is hardly any knowledge regarding the quality or acceptance of these offers within the hospital two offers are known individual dementia caregiver counselling which is provided by the clinic pastor and a peer group for dementia patients caregivers some professionals recommend external support offers to caregivers eg health insurances case managers or practical nursing skill courses provided by the communal services ad for the hospital management the importance of family caregivers in the patient care trajectory is not recognizable caregiver support and counselling activities are not financed additionally the number of available staff is so low that comprehensive caregiver support is difficult to organize caregiver support is insufficiently outlined in hospital job descriptions professionals feel frustrated and undervalued there is little appreciation from the side of the management about our work with the relatives medical doctor no caregiver support concept or guideline is implemented in the department or elsewhere in the hospital professionals lack important resources such as time staff infrastructure and internal support services we have no reserved time slots for caregiver instruction physiooccupational therapy our office is occupied by three people plus serves as the meeting room for caregiver consultation social services demonstration or training materials on site are either outdated or nonexistent physiooccupational therapy professionals recognize caveats in their caregiverspecific knowledge skills and competences blaming their vocational or academic education we received no orientation on how to conduct a conversation with caregivers in our vocational education we had to learn this in the job medical doctor we possess some experiences however our knowledge is still expandable case management professionals felt that insufficient attention is given to capacity building of staff concerning caregiver issues within the hospital although they can participate in external trainings the conditions vary greatly you have to acquire the knowledge yourself physiooccupational therapy outcome 2 needs of the geriatric team after careful discussion four themes emerged from the analyses the need for an inclusive caregiver support concept conceptual building blocks required resources and enabling conditions ad a holistic needsoriented personal and professional caregiver support concept is required we must find a system that involves relatives in a more structured way social services the values of caregiver counselling must be taught to the entire multidisciplinary team counselling should involve an orientation on caregiver support offers within the department and beyond eg communal support personalized information transfer eg financial medical and rehabilitative issues and practical support eg instructions for care and mobilization a mixture of good information about processes illnesses and supply options via internet flyers group offers and individual advice is needed social services relatives should know the duties of each professional group physiooccupational therapy moreover psychosocial support should be familycentered and better counselling facilities are needed maybe a selfhelp peer group caregiver information evenings and group counselling sessions would be supportive some caregivers may be willing to meet other caregivers nurses group counselling is in some occasions helpful social services ad to offer to caregivers relevant and valuable information a number of options were mentioned a caregiver welcome folder containing general information professionspecific flyers presenting the different professions processes and contact persons information boards within the department advertising caregiver support and a caregiver link on the hospitals homepage leading to general and specific information and to support offers within the region caregiver support needs to be tailored and longterm they need most support in the first days during the acute phase and a sound orientation on what to do when the patient will be discharged nurses creating a new job in the geriatric department providing professional caregiver counselling might be a solution a permanent contact person for caregivers is needed medical doctors this position requires professional experience strong communication skills system knowledge as well as special personality traits eg empathy openness the ability to communicate and resolve conflicts a degree of diplomacy the ability to keep calm and pay attention to facts as well as active listening is crucial social services furthermore outreach counselling is needed social services a family caregiver assessment tool selfadministered by the caregivers before the first counselling was proposed a separate sheet to be completed by caregivers would be useful in many cases social services the creation of an interprofessional network which connects all stakeholders providing internal and external support was suggested networking and participation in external events and organizations eg dementia network aachen alzheimers society other geriatric institutions is needed social services we must think and act as a team physiooccupational therapy we need to create access to supportive and furtherserving institutions social services ad the need for resources were expressed time infrastructure equipment for family education and more staff the social services should be on the spot all day every day as it has a large role in attending caregivers medical doctor fixed counselling hours should be offered eg caregiver friendly time slots and the contact persons name and accessibly should be provided social services adequate demonstration and training tools are required for caregiver and patient training physiooccupational therapy supervision and case review sessions should be organized social services needsoriented internal or external capacity building activities were advised caregiver support social services communication strategies case management deescalation training or how to best deal with overburdened relatives physiooccupational therapy the nursing school curriculum should extend to cover caregiver issues medical doctors capacity building should be financially compensated ad the need for enabling conditions within the hospital was expressed due to the new discharge management law we have a take care now also for the patient beyond the inpatient stay here more activities are needed across all professional groups within the department eg social services psychologists medical doctors to do this an increased appreciation and attention for caregiver support in the geriatric department by the hospital management is required we need increased attention to the special concerns of the geriatric department social services the management must encourage a caregiverfriendly climate within the hospital and should trigger the development of a comprehensive caregiver concept there is a gap in the system that needs to be fixed as soon as possible medical doctors part 3 critical reflection in a separate part of the final meeting the entire research team reflected on their experiences with the phr approach the phr approach overall the coresearchers cf and ar experienced this phr approach as inspiring and motivating the ar experienced the sharing of power as mutual learning process that enabled a true engagement of the coresearchers however compared to classic topdown research conducting phr for the first time in a hierarchic setting requires a great deal of time and investment in communication and project management the cf recognized the changing team dynamics and was positively surprised how her comments were stimulating and motivating the team during the different phases beside the positive effects she noticed that it was quite time consuming for the entire team initially coresearchers perceived this project as black box especially regarding its outcome and practicability within this hospital however the preconditions for the project were set as the head of the department was in favor of the phr approach finally coresearchers concluded that participatory research works it magnifies the knowledge and has changed us medical doctors participation grades as can be seen in figure 1 the participation grades of the coresearchers increased during the study from cooption in the orientation phase to collective action in the data collection phase and onwards colearning was already achieved during the kickoff workshop additionally it was possible to achieve a higher grade of participation in the course of one activity for instance during workshop 1 the grade increased from compliance during the impulse lecture to colearning when discussing suitable data collection methods however to enable coresearchers to participate actively in the next step it appeared to be obligatory that the ar took the lead by providing scientific knowledge to participate actively in the next step it appeared to be obligatory that the ar took the lead by providing scientific knowledge figure 1 coresearchers participation during phr project presented per phase in the project and per level of participation 43 legend 1literature review 2field visit 3impulse presentation 4impulse lecture phr 5exploring expectations and goals 6identifying the problem and formulating research question 7forming the research team 8impulse lecture methodology 9exploring methodological advantages and disadvantages 10determining suitable data collection methods 11impulse lecture data collection 12determining plan of action and question catalogue 13collecting data 14impulse session data analyses and decision on analyzing team 15interactive data analyses 16interactive data analyses 17critical reflection of experiences with phr 18dissemination activities although the ar was responsible for the impulse lectures the content of the presentations was to an extent influenced by the coresearchers these lectures were necessary as this was the first phr project in this department based on coresearchers´ needs the ar decided what to include in the impulse lectures for example in the second lecture various qualitative data collection methods were presented together with their benefits and limitations based on their input coresearchers cf and ar explored the advantages and disadvantages within their setting and decided on a suitable data collection method benefits and limitations the productive and constructive atmosphere the transparency of the research process the connectedness between the different professions as well as the reflective nature and being appreciated by other coresearchers were perceived as positive on the other hand phr was experienced as very time consuming the constant communication was demanding the process was sometimes unpredictable which provoked uncertainty the blackbox nature was challenging with respect to the subject of the statusquo and needs assessment the coresearchers appreciated the nearness of the research to the reality of their practical work and the new perspectives they gained through the process the structured way the ar organized the process was characterized as valuable the ar experienced the process as motivating and empowering eg understanding the problem from the inside giving up control and sharing the responsibility in the various study parts meant that the process required patience and tolerance from all team members especially in the data collection phase additionally flexibility of the entire team was essential coresearchers participation during phr project presented per phase in the project and per level of participation 43 legend 1literature review 2field visit 3impulse presentation 4impulse lecture phr 5exploring expectations and goals 6identifying the problem and formulating research question 7forming the research team 8impulse lecture methodology 9exploring methodological advantages and disadvantages 10determining suitable data collection methods 11impulse lecture data collection 12determining plan of action and question catalogue 13collecting data 14impulse session data analyses and decision on analyzing team 15interactive data analyses 16interactive data analyses 17critical reflection of experiences with phr 18dissemination activities although the ar was responsible for the impulse lectures the content of the presentations was to an extent influenced by the coresearchers these lectures were necessary as this was the first phr project in this department based on coresearchers needs the ar decided what to include in the impulse lectures for example in the second lecture various qualitative data collection methods were presented together with their benefits and limitations based on their input coresearchers cf and ar explored the advantages and disadvantages within their setting and decided on a suitable data collection method benefits and limitations the productive and constructive atmosphere the transparency of the research process the connectedness between the different professions as well as the reflective nature and being appreciated by other coresearchers were perceived as positive on the other hand phr was experienced as very time consuming the constant communication was demanding the process was sometimes unpredictable which provoked uncertainty the blackbox nature was challenging with respect to the subject of the statusquo and needs assessment the coresearchers appreciated the nearness of the research to the reality of their practical work and the new perspectives they gained through the process the structured way the ar organized the process was characterized as valuable the ar experienced the process as motivating and empowering eg understanding the problem from the inside giving up control and sharing the responsibility in the various study parts meant that the process required patience and tolerance from all team members especially in the data collection phase additionally flexibility of the entire team was essential figure 2 perceived benefits and limitations of the phr approach within the geriatric hospital setting outcomes of the brainstorm session in the final meeting reporting the project was concluded with reporting as a last and ongoing phase all findings regarding the status quo and needs of the mdt with respect to holistic family caregiver support were included in a final document which was presented in the hospital by the coresearchers together with the cf and the ar based on the outcomes a caregiver orientation folder was designed for the geriatric department to better inform caregivers regarding the different roles of the team and the caregiver offers within the department several coresearchers already presented outcomes and lessons learnt from their phr experiences in practice on various occasions whereas cf and ar presented the outcomes and methodological considerations in scientific conferences discussion our phr study resulted in two outcomes namely a comprehensive understanding of the actual state of the caregiver support within the geriatric acute and rehabilitation care and the needs for offering comprehensive caregiver support within the department the geriatric department needs a comprehensive needsoriented personal and professional caregiver support concept which includes activities on both individual and system level personalized caregiver counselling is required to prepare caregivers for their new role and guarantee the quality of care in the home environment practical accessible and timely information provision for family caregivers must be developed our professionals proposed to assess caregivers needs before the first counselling with a still to be developed assessment tool network building communication and information materials are needed to enable organizational change the hospital management should invest in a comprehensive caregiver support that goes beyond the usual economically focused case management routine resources and infrastructure are required investing in health system development on a system level eg offering capacity building activities and investing in intra interas well as extraorganizational networks may be necessary on an organizational level caregivers must be acknowledged as part of the support team of geriatric patients our outcomes are in line with conclusions from a qualitative literature review on hospital discharge planning practices for frail older people stating that there is room for organizational reporting the project was concluded with reporting as a last and ongoing phase all findings regarding the status quo and needs of the mdt with respect to holistic family caregiver support were included in a final document which was presented in the hospital by the coresearchers together with the cf and the ar based on the outcomes a caregiver orientation folder was designed for the geriatric department to better inform caregivers regarding the different roles of the team and the caregiver offers within the department several coresearchers already presented outcomes and lessons learnt from their phr experiences in practice on various occasions whereas cf and ar presented the outcomes and methodological considerations in scientific conferences discussion our phr study resulted in two outcomes namely a comprehensive understanding of the actual state of the caregiver support within the geriatric acute and rehabilitation care and the needs for offering comprehensive caregiver support within the department the geriatric department needs a comprehensive needsoriented personal and professional caregiver support concept which includes activities on both individual and system level personalized caregiver counselling is required to prepare caregivers for their new role and guarantee the quality of care in the home environment practical accessible and timely information provision for family caregivers must be developed our professionals proposed to assess caregivers needs before the first counselling with a still to be developed assessment tool network building communication and information materials are needed to enable organizational change the hospital management should invest in a comprehensive caregiver support that goes beyond the usual economically focused case management routine resources and infrastructure are required investing in health system development on a system level eg offering capacity building activities and investing in intra interas well as extraorganizational networks may be necessary on an organizational level caregivers must be acknowledged as part of the support team of geriatric patients our outcomes are in line with conclusions from a qualitative literature review on hospital discharge planning practices for frail older people stating that there is room for organizational improvement by including the family improving communication between professional health care employees and the family better interdisciplinary communication and ongoing support after discharge specific contextual needs of family caregivers should be assessed identification of resources that family caregivers need and active and early involvement in the discharge process 51 our study also fitted recommendations to achieve a whole system change with respect to comprehensive personcentered assessment and support for family caregivers towards the end of life both on what needs to be in place within an organization to provide this support eg a protocol for assessing caregivers and responding to the assessment as well as on what is required to implement and sustain this approach in practice eg a process for training practitioners and available timeworkload capacity 52 in a recent qualitative study from a norwegian oncology setting it was shown that health care workers in regional cancer care were also in need of organizational improvement including systematic involvement of family caregivers in care pathways and education of professional care workers in caregiver support 53 the multidisciplinary team at the rheinmaasclinicum intends to use the findings of their study in the next step building the new job of geriatric family companion 27 however to embed the new professional in the support system inside as well as outside the hospital input of experienced family caregivers is needed and cooperation of professional support providers working in the area methodological considerations a major strength of our phr study lies in the uniqueness of the applied strategy as a truly partnered project participatory research provides a specific form of understanding that emerges from the synthesis of expertise brought to the partnership and the necessary negotiation of powers within that partnership 54 this guarantees that the outcomes from the study are relevant acceptable and feasible apart from the background research that was done by the ar our coresearch team was enabled to complete the whole research project all function groups of employees within the german hospital setting that were in contact with family caregivers were represented and contributed to the outcomes throughout the entire project coresearchers were given the power to influence and shape the study itself through the active participation of professionals with different backgrounds and professional roles the research question was explored and answered from different perspectives and its objectives were developed from the reallife experiences 56 participation cannot be imposed on research but should rather be seen as an emergent process developing from the interaction between the problem the environment and the aims capacities and skills of those involved 35 participation depends upon the establishment of an environment of trust within the group 57 unfortunately we did not formally study our group dynamics eg with an instrument 58 so we cannot be sure that everybodys viewpoints and expertise were valued in the process one of the other limitations of the phr approach is that is has a gradualist tendency potentially leading to tunnel vision caused by selection mechanisms 28 the researchers have no way of knowing if what they discovered is actually true however since phr is practice research misinterpretations or gaps can still be uncovered and mended afterwards in the phase of the programmes implementation 28 nevertheless based on the success of our project and the positive reflections by the coresearch team we feel confident that the outcome of the study reflects the actual statusquo and needs of a family caregiver support initiative the coresearchers felt empowered to continue with their newly acquired skills and knowledge our phr project was terminated in january 2018 but some effects are still noticeable since the final meeting coresearchers continue to participate in dissemination activities eg authoring articles or presenting outcomes on conferences in addition a professional caregiverworking group was founded and a caregiver orientation folder for the geriatric department was designed our phr study was the first one applied in this hospital setting as the german health system has been functioning historically through hierarchical decisionmaking 59 some challenges were expected interestingly looking back on the phr approach our coresearchers and participants in the interviews and focus groups described phr to be transparent expedient interconnecting eyeopening appreciative and perspectiveproviding however the phr process was resource demanding it took a vast amount of time and required extensive communication on different levels in addition due to the high workloads and understaffing within the department the composition of the coresearchers in the research team varied over the project life cycle the different professions in the mdt were represented in each meeting but not always by the same persons this situation led to time constraints communication gaps and perceived chaos in the settingup planning and data collection phases with respect to the higher management level a lack of interest and willpower to be involved was perceived despite several attempts coresearchers were unable to schedule a meeting to present their outcomes to the management team even with the frustration caused by this the higher hospital management was kept informed about the progress and invited to the meetings phr seemed to be an effective strategy within this hierarchically organized hospital however conducting phr requires methodological experience elaborated communication skills a flexible time investment and an openminded atmosphere within the setting conclusions through a participatory research methodology a comprehensive understanding of the actual state of family caregiver support within the geriatric acute and rehabilitation care was gained the geriatric department requires a comprehensive needsoriented personal and professional caregiver support concept which includes activities on both individual and system level to prepare family caregivers for their new role and guarantee the quality of care in the home environment personalized caregiver counselling is necessary practical accessible and timely information provision for family caregivers must be established to enable organizational change network building communication and information materials are needed but above all caregivers must be acknowledged as part of the support team of geriatric patients on a system level investing in health system development may be necessary participatory health research appears to be a feasible and effective strategy within a hierarchically organized hospital however conducting a participatory methodology requires methodological experience elaborated communication skills a flexible time investment and an openminded atmosphere within the setting

because of societal changes family caregivers are becoming vital in longterm care provision for geriatric patients after discharge from hospital hospitalbased geriatric care teams need tools to prepare and support family caregivers for their future caregiving role in the home environment to explore the actual state and needs for implementing a suitable family caregiver support concept in a large geriatric hospital in germany a participatory health research methodology was chosen an academic investigator assisted by a critical friend facilitated all research steps geriatric care professionals joined as coresearchers and performed qualitative data collection using semistructured interviews and focus group discussions the entire coresearch team took part in the thematic analyses the existing family caregiver support was perceived as uncoordinated and incomplete and a lack of knowledge about support programmes in the community was apparent the needs regarding a comprehensive family caregiver support concept that acts on both individual caregiver as well as on system level but also connects the two levels were formulated high grades of participation of hospitalbased coresearchers could be achieved a critical reflection on the research strategy revealed that the participatory methodology although timeconsuming was perceived as a useful strategy within the hierarchically organized hospital

h uimin jin to begin with i should say thanks for your accepting my interview professor david morley as one of the leading figures of british cultural studies represented perhaps we could say chiefly by the socalled birmingham school you should be i believe in a good position to clarify some issues about which i am quite curious concerning the historical development of this school more importantly i am rather keen to know from your own perspective your special contribution to british cultural studies either in a hallcentred mode or in a broader sense well my first question is about popular culture recently scholars with manchester metropolitan university have shown a tendency to narrow cultural studies down to popular culture studies by doing so they foreground and intensify popular culture as a primary arena of cultural studies this is related to the british tradition of cultural studies from williamss definition of culture as a way of life via the centre for contemporary cultural studies subculture researches to the course on popular culture run by the open university from 1982 to 1987 you were invited to contribute a course unit on interpreting television for this historically significant programme as to the everexpanding field of popular culture studies as an academic enterprise my concern is given to such questions as why academics should take it seriously in the british context and if it has something specific to do with a politics of culture say to the turn to gramsci or to anthropologically our everyday life in which it has an enabling transformative force david morley i see no reason at all why cultural studies should now concentrate exclusively on popular culture indeed in my view it is crucial that cultural studies also attend to middlebrow and highbrow culture as these forms and their changing characteristics can only be understood in relation to each other at the point of cultural studies inception however the position was very different at that moment it was widely assumed that popular culture was not worthy of theorists attentions so the initial focus on popular culture was a polemical move in a particular context designed to show that popular culture was a field that was indeed well worth studying however nowadays that point is generally accepted so it doesnt need to be stressed so much so to narrow cultural studies focus down to only popular culture would be a very regressive move in the contemporary situation youre right to point to the important shift towards perspectives derived from anthropology as a way of understanding culture as a way of life but that argument doesnt have any specific or particular relation to the british case it would apply i think to the study of culture in all societies what is most specific to the development to cultural studies in britain in particular relates to the moment of the late 1970s and early 1980s the moment of the popular culture course which ran at the open university from 1982 to 1987 that was a moment when several key factors combined which led to the stress on the politics of popular culture let me explain at that point in the early 1980s mrs thatcher had just been elected and stuart hall and others argued that her victory was founded on a form of populism hall rightly argued that mrs thatchers victory could only be understood and effectively opposed on the ground of culture his point was that she had successfully articulated forms of authoritarian populism which genuinely resonated with the feelings and aspirations of the dissatisfied white working class of britain the argument was that the core explanation for the overwhelming workingclass electoral vote for her was their support for her vision of the return to what she called traditional victorian values they supported her rejection of the postwar liberal progressivism of the 1960s and 1970s halls argument was that if that was so then the understanding of the cultural dimension of politics especially in the form of popular culture becomes critical at the same time a variety of dissident groups in britain women gays black people disabled people etc were also insisting there were cultural dimensions to politics they insisted that their oppression often took cultural forms for instance negative stereotypes of them in jokes or in popular entertainment and thus they argued the transformation of these forms of popular culture was an important dimension of political struggle that was all part of the turn to gramsci and that was the reason for the corresponding stress on the cultural dimension of politics in which context the analysis of the dynamics of popular culture was then seen as the key task the further point here is that you have to understand that this was an argument which was made in the face of a rather hardline leftist marxism which said that culture was not really important at all and attributed everything to economic factors however that analysis completely misses out the extent to which mrs thatchers political success worked precisely by transforming british culture and by transforming what were understood to be british values she had to transform those things in order to gain the popular support to go on and win the later political and economic fights that she got into eg with the miners when they went on strike for a whole year so her first political victory was at the level of culture in shifting values and reasserting the sense of individualism individual achievement individual ambition and individual responsibility in all spheres of life having won that cultural battle she was then in a position to win the political and economic battles that was in a sense a cultural revolution in britain she achieved a revolution in the culture of everyday life and shifted everybodys assumptions a long way to the right the longrun significance of this can perhaps be seen now after the end of the period of the new labour government despite the claim that new labour had a different approach to politics in a very significant sense what the new labour government did was simply to live out its life under the hegemony of the terms of reference established by mrs thatcher i think you could very reasonably say as many people have done that tony blair represented mrs thatchers true heir because the cultural battles that she won about individualized responsibility and about the free market established the hegemony of a set of ideas which shifted the whole political terrain and which new labour did little to question for fear of losing middle ground electoral support politics in the uk today is still being fought out inside the terms of reference established by the cultural victories which mrs thatcher achieved now the new coalition government is pursuing that thatcherite agenda even more radically than new labour ever did in its plans to totally dismantle the remnants of the welfare state set up as part of the postsecond world war settlement in the late 1940s and thus establish a new common sense in which the market is taken as the hegemonic form for the modelling of all areas of social life hj there is a popular view that your reputation in the area of cultural studies was established by your television audience researches which are mainly shown in your two books the nationwide audience andfamily television from your empirical work what theoretically in brief have you developed or reinforced i should say sorry if you would think i am overconcerned with the theory per se which may be contradictory to the tradition of british cultural studies dm its quite true that my own reputation within cultural studies was largely founded on the audience studies that i did in the 1970s and 1980s published as the nationwideaudience and family television however i was never in fact particularly interested in either television or audiences themselves as objects of study what i was interested in was the question of cultural power the choice to make an empirical study of television audiences was simply a way to operationalize a study of the extent of ideological or cultural hegemony as manifested in the forms of media consumption as for your further question concerning what theoretically my empirical work has achieved my answer would be that it has produced a far better model of the operation of media power than would have been made possible by continuing to make abstract speculations about media effects of the sort offered by such scholars as adorno and horkheimer in the early period by mcluhan in the 1960s or by baudrillard in the postmodern version in my view despite the evident theoretical sophistication of much of this work it nonetheless still operates with what is in the end a very simplistic motion of media effects even the latest version of new media theory is still flawed by the simplistic assumption carried over from adorno and horkheimer that the media have automatic and unavoidable effectson people apart from anything else that is inadequate because it is ultimately a technologically determinist argument i have developed this line of critique of the severe limitations of socalled new media theory most fully in the section of my last book titled rhetorics of the technological sublime in relation to the problems posed by the foreshortened ahistorical perspective of these theories and their oversimpli¢cation of the crude binary divide which they draw between the old world of the analogue media with their audiences of supposedly passive couch potatoes and the marvels of the new digital era in which it is assumed that we are all more signi¢cantly active clearly my own inclination here would be to go back again to williams argument in television technology andcultural form which very carefully shows that technologies do not have effects built into them because its always a question of how particular technologies come to be institutionalized in particular ways there are many social and cultural forces which act to determine that as my own work has shown along with that of people such as the late roger silverstone new technologies dont simply have effects on people just as media dont have direct effects on their audiences the question is how particular people in particular contexts perceive the relevance of specific media technologies for their lives and how they then choose to use those technologies or ignore them or indeed bend them in some way to a purpose for which they were not intended in either case the effects are not directly produced if my work has been about one thing it has been about how to develop a more satisfactory model of the power of the media im not in the business of denying the power of the media or denying that particular technologies allow new things to happen my point is to better understand how that power operates in conjunction with the fact that people do make choices and do make their own interpretations of material provided to them by the media whether we are talking about the mass media of broadcasting or the micromobile media of todays world one of the interesting points you raise in your questions is the status of theory and its position within the tradition of british cultural studies i think it is a very interesting question and it does concern me deeply its very common in contemporary debates especially among people whose background is in sociology or philosophy rather than in cultural studies for people to make a claim for high status by presenting themselves as theorists however that is an approach which in terms of the role of theory in the tradition of cultural studies defined by stuart hall can only appear as extremely na« ve halls version of cultural studies is not at all resistant to theory as such but that tradition within which im situated is one in which we use theory in order to theorize some particular empirically specific conjuncture or situation not for the purpose of generalized and abstracted speculation if you look at halls marxs notes on method a reading of the 1857 introduction the point is made very clearly there for hall theory is not valued in itself but in terms of its usefulness in theorizing particular conjunctures the problematic issue about philosophicalstyle theory in the abstract concerns the high intellectual price which must be paid for any moment of abstraction of course theoretical abstraction is a powerful and often necessary intellectual tool as it allows you to condense what would otherwise be a mountain of potentially confusing data in order to see the underlying patterns but just like a powersaw it is also a potentially dangerous tool which must be used very carefully if it is not to do more harm than good of course any abstraction or categorization is of its nature reductive the question is always whether this particular formal abstraction is worthwhile in a specific case each time you abstract you have to ask yourself whether the benefit you will get in so far as the abstraction contributes to your ability to make some ordered analysis of cultural patterns is sufficient to make up for the fact that in making that abstraction youll be losing track of some part of the particularity of the situation you are trying to analyse coming as i have said from a tradition which emphasizes specificity in empirical investigations i am unsympathetic to what the french philosopher michel serres calls lazy forms of one size fits all theory as serres says it is lamentably easy to use that kind of theory to reduce all phenomena to one ultimate set of truths however as he observes a single theoretical pass key will never suffice to open all doors rather as he insists each time you want to unlock a specific problem you must forge the specific theoretical key which will be adequate to the problem in hand im interested in grounded forms of theory so for example if we take the case of tv as a medium i would not want to say that television is a thing which has some particular set of facets or that it is in the essence of the medium philosophically understood that it should always have these effects rather than that very deterministic and mechanical mode of analysis im interested in understanding how things work in particular circumstances or contexts when media technologies are actually used by different people of course we must find a way to see the deepseated patterns in our data and it is no good disavowing all generalizations and ending up in a poststructuralist morass of just telling a million individual stories of infinite difference but we must nonetheless use those generalizations very cautiously and be attentive to the extent to which every time we make a generalization we pay a price in the loss of contextual specificity the question is one of always keeping ones eyes on the price ticket making sure that what you lose in the use of that theoretical abstraction is outweighed by the gains in analytical power that it enables hj when you were developing your theory of active audiences did you have in mind german receptiontheory such as the works of the konstanz school say hans herbert jauss and wolfgang iser or you might have had some other theoretical resources available it looks as if british cultural studies concurs basically with receptiontheory in assuming that audiences are never passive receivers of media messages or that furthermore the reception or consumption of television messages can be elevated as a part of the whole television production dm your question puts me in mind of the story that janice radway tells in the introduction to the british edition of her book reading the romance which was published here some years after its initial publication in america there radway explains that when she subsequently discovered british cultural studies work she was astounded to discover how closely it fitted with the perspective that she independently had been developing in her ethnographic work on women readers of romance fiction the situation was rather parallel i think in terms of my own relation to the german theories to which you refer in fact i only came across the work of jauss and iser at some point in the early 1980s well after my work on the nationwideaudience had been done what was interesting of course was that rather like radway i then had the experience of coming across a body of fascinating theoretical work which was very close to what i had been doing even though it wasnt directly influential in the construction of my own perspective this is perhaps a general point about the fact that if something is a good idea it is probably going to be worked out by more than one person in more than one place often simultaneously so jauss and iser and i end up not exactly in the same place but on relatively close theoretical paths although we got there from different routes and by means of different theoretical resources in terms of my own theoretical resources the key ones were sociolinguistics and cultural anthropology i believe i was the first person to use the now wellworn term ethnography in relation to media audiences in a paper that i wrote in 1972 reconceptualising the media audience towards an ethnography of audiences where did i get that from from the work of people like dell hymes and clifford geertz in cultural anthropology as for the resources used to analyse the interpretations which people made of television programmes the key elements came from debates in the sociology of education about the role of linguistic codes in determining childrens educational success or failure which was a theory which seemed to me to also be applicable to how the availability of different cultural resources might play some part in determining patterns of decoding tv at that time in britain in the early 1970s the key debate was between basil bernstein and his critic harold rosen the issue at stake was to do with the role of class structure in the determination of language abilities and language uses bernstein had a rather deterministic approach which was very important in identifying differences between workingclass language and middleclass language much of which has very close parallels with the work of pierre bourdieu in france about the social distribution of cultural capital and cultural competences conversely while rosen appreciated the power of those analyses he was very concerned that they were being conducted in too essentialist a way rosen was aware that while class is very likely to have some effect on the forms of cultural capital to which someone in a given social position has access this is not an automatic process he was also concerned with the way in which people inhabit their membership of any particular collectivity in a certain sense already in the 1970s rosen was making exactly the kind of argument which someone like judith butler makes now 30 years later just as butler says that we are not all living in what she calls the prison house of gender rosen is making the same point about class we are not just prisoners of class because there are different ways of inhabiting middleclass or workingclass identities the main problem with bernsteins model is that it just avoided this issue entirely in its sociological determinism assuming that the effects of class position were more or less automatic this is a criticism which some of us would say also applies to the work of bourdieu which has much in common with that of bernstein thus one could make an analogy and say that if bernstein was the english version of bourdieu his critic rosen was the equivalent of michel de certeau one of bourdieus most important critics in france so to go back to where i started in my answer to this question my main theoretical resources came from cultural anthropology in terms of providing a model for a close reading of particular actions as understood in context they also came from sociolinguistics and especially from volos› inovs insistence on the multiaccentuality of the sign his insistence that there is no totally shared language system in a given society and that one has to be sensitive to the conflicts that are fought out in and through language and culture hj if you hold that individual readings will be framed by shared cultural formations and practices preexistent to the individual though in a complex and subtle way how could you demarcate your theory of active therefore resistant audiences from the frankfurt schools nonresistant conception of the masses that are passively injected with a prevailing ideology when the masses begin to decode the televisional texts they might have been premassed by some other factors social or ideological which you admit as preexistent other than by the modern communications television included by ideology or precisely being part of ideological totality or ideological apparatus a role whatever it may be which you seem to hesitate to recognize to be clear my inference here is that so long as you assert that individual interpretations are socially at least partially determined you would have already accepted that the cultural industry as a social or ideological force or apparatus does play a role in making the masses this argument may be supported by the texts role to which you still attach importance interpretations are not arbitrary but subject to constraints contained within the text itself dm essentially in the nationwideaudience i was trying to offer what i think is a better way of understanding media power than is offered by the frankfurt schools simplistic approach to audiences as passive dupes ŵhich was predominant at that time im quite happy to accept that adorno and horkheimer make sophisticated general arguments about the way in which the culture industry shapes consciousness in criticizing their model of the automatic effects of the media on the masses im not trying to replace it by a theory which says that all audiences are completely active and are making just any interpretation they want out of the media materials they come across in that respect my perspective is quite different from that of scholars such as john fiske in what has come to be called the active audiences tradition contrary to them im not trying to deny issues of media power moreover despite my criticisms of bourdieu and bernsteins overly deterministic model of class im also very interested in the way in which the ability of a person to reinterpret or reuse the media to which they have access is in fact to some extent determined by their social position thats because their social position will limit their access to particular types of cultural codes and cultural capital however im not advocating some model of freefloating individuals who are just able to do whatever they like with what the media offers to them here i would also distinguish my own position from that of people like ulrich beck when beck says that in todays individualized world class is no more than a zombie category of little use in analysing social life i think he is quite wrong class continues to exercise profound effects on peoples lives especially in an era where in the uk at least rates of intergenerational mobility are declining so that class position at birth is now an even better predictor of an individuals probable life course than it was 30 years ago of course class or any other mode of social categorization can be used in an overly deterministic and thus zombielike way but that is a matter of how exactly you use the categories in your analysis not whether or not the categories are intrinsically useful or not im also quite prepared to accept that the sociocultural identities which i use in the nationwideaudience analysis as explanations of how this or that person interprets a particular programme are themselves socially and culturally constructed in english we have this expression which is a kind of rhetorical figure or joke in which one says which came first the chicken or the egg in one way it is just a silly joke but at another level it expresses a rather profound philosophical dilemma of course in a sense it doesnt matter which came first what you have to understand is what their relationship is the same goes for the question of the role of the culture industry in the construction of consciousness and in the provision of the materials out of which people construct their identities through the decoding of tv programmes among other things the subsequent issue is how you can then look at those identities themselves as partly explaining why this person in this particular position will tend to be affected by this particular media or how they will tend to interpret some particular media programme one has to understand that as a dialectical process between determination and activity to go back to the original as marx says men and women make their history but not in conditions of their own choice in the media field what we are looking at is the way in which social positions go some way to determining the cultural resources available to you the cultural choices you can make out of which you construct your identity now thats not to say that you construct your identity on a tabula rasa in a world of completely free choices that you could decide to just be anybody or do anything at random or interpret the media just any way you like you couldnt we all have only a certain limited repertoire of possibilities available to us and yet nonetheless within that circumscribed repertoire there are still choices to be made and those choices are significant one cant explain the determination as total or automatic to take that view is just to wipe out the complexity of the dialectic which is at the heart of the process hj adapting from frank parkin stuart hall argues that there may be three hypothetical positions from which a media message is decoded by audiences the dominanthegemonic the negotiated and the oppositional among which the latter two compared with the ¢rst that rarely happens in practice are stressed for their frequency it can be seen that there is a point at which your theory of the active audience encounters this argument the resistance implicit in all interpretations of media texts here my concern is with the questions of what makes a reading active or resistant and why the cultural industry is not able to knead all the receivers simply into the masses dm i agree with the proposition implicit in your question that in a sense all readings are active to make any sense at all of a tv message you first have to interpret the dots and noise on the screen as representing images of people or voices and so on and youve got to read the rules of perspective through which you can reconstruct the image of a threedimensional world from a twodimensional screen thus activity is always present in the interpretation of media messages as for when an interpretation is resistant that is quite a difficult question you could argue for instance that in the nationwideaudience the reaction of the young black students who dismiss nationwide as irrelevant to them and who refuse in a sense to make any decoding of it at all is far more radical a move than that of the leftwing trade unionists in the study who produce a classically oppositional reading of the nationwide text but who do so from within a framework in which they recognize the programme as relevant to them while accepting some of the political terms in play they make a critical counterargument to them and that is a form of opposition certainly but you could argue that the reaction of those who dismiss the whole genre of that kind of politics as irrelevant to them is in another sense a much more radical form of negativity and i dont think that parkins model is able to deal with that question that model rather assumes that consciously politicized opposition is the most active and most radical and in that sense the most important form of response to the media im not sure that it is the case and thats why as my work developed i begin to operationalize the model in a slightly different way so as to take account of the ways in which all readings are active but also to take account of the fact that the forms of activity are themselves various in ways which parkins model is not really capable of dealing with hj socialcontextually why did the frankfurt school choose a passive model of media consumers while british cultural studies chose an active one to put it differently what are the social conditions that underlie this shift of media studies if there are any that work in connection with this textually i doubt that mass culture and popular culture are referred by them to the same media texts andor in the same way even though they might overlap i wonder if categorically the masses is more closely associated with the producers of the cultural industry while the popular more with consumers of the products if it is true can we argue that this shift reflects a social transformation from production society to consumer society as jean baudrillard has distinguished them and that your audience theory is rooted in such a consumer society in which people have more choices in the face of a plethora of commodities dm i think id put it rather differently im not sure that you can understand the frankfurt schools model of media power without thinking quite specifically of the contexts of weimar and nazi germany in the 1930s when those theories were being developed there you have the context of the emergence of powerful new media in that case radio and cinema ând new forms of political rhetoric operating in a relation to a population which in its mobility from rural to urban areas was becoming anomic and thus more vulnerable to persuasion and propaganda those circumstances demand attention and sensitivity to questions of media power and manipulation that is why adorno and horkheimer were interested in the particular questions that they focus on british cultural studies certainly arises in very different circumstances but im not sure that i would interpret that in the way that you seem to imply in your question as i understand your argument you are suggesting that we face a move from a producer society to a consumer society that the concept of the masses is a characteristic of what you call a producer society and that popular culture is then conversely associated with the consumer society from that premise if i understand you rightly you see active audience theory as being to do with the extent to which in this thing called the consumer society people have more choices i think thats a problematic form of historical periodization and one which is characteristic of a certain type of sociological approach many social theorists love inventing new periodizations for example nowadays many are people talking about deleuze and something called the control society without a clear definition of what that is or when it started then people speak of the consumer society but that has various definitions you could talk about the consumer society of postwar europe in the 1950s or you could talk about todays emerging consumer society in china which seems to me to operate a in very different kind of way those would minimally have to be understood as rather different subtypes of the overall concept and once you recognize that it follows that you cannot just assume that the same tendencies will apply in the same ways in these different contexts rather than thinking in terms of a total shift in historical periods from producer to consumer society as you suggest my own perspective would be to say that in both situations there always have been and still are both aspects of that question that is to say in what you would refer to as the producer society of the era of mass culture there were still choices to be made people still did choose between this or that aspect of mass culture and indeed reacted to it or interpreted it in different ways so they were still active even then and conversely even now in this socalled consumer society where people do get to make more choices we mustnt confuse choice with empowerment in any simple sense nor with a loss of producer power i might have a larger number of channels from which to choose what to watch on my television set these days but its still a menu set by someone else within which i have to choose to put it another way im more interested in the continuities and crossovers between these socalled different periods or different types of society than i am in just accepting such clear binary divisions unproblematically in that respect im influenced by derridas insistence on deconstructing and destabilizing those kind of binaries and by his insistence on the need to pay attention to the ambivalences which cut across the kind of binary divisions of which sociologists in particular are rather too fond of for my liking hj did the postmodernism for instance of fredric jameson michel foucault roland barthes and jean baudrillard help to shape your television studies and in the first place of course your audience studies if so in what ways did it work you know postmodern declarations such as the death of the author or of subjectivity were quite provocative and they tend to emphasize the role of readers in the process of reception dm let me take those authors in stages barthes was certainly influential for me at an early stage in setting up the kind of semiological model with which i was working but i rapidly moved towards volos› inovs critique of that rather rigid form of semiology so barthes was influential but perhaps umberto eco more so especially in his essay does the audience have bad effects on television but volos› inov was the key resource in producing an analysis that was attentive to the mobility of signs to the conflict between signs to what he calls the multiaccentuality of signs and to the way in which different people will use the same sign or word or image for very different purposes as for postmodernism the story is rather different the simple fact is that postmodernism came much later baudrillard jameson and foucault only came to have influence in cultural studies circles in the uk long after i produced the nationwide and family television studies again as far as these periodizations go just as im not much enamoured of the notion of mass society or consumer society or production society or control society likewise postmodernity seems to me a rather weakly defined category the notion that ours simply is a postmodernism era seems problematic to me unless i know when it began which in turn all depends on which definition of modernity or modernism you are using if there is such a thing as a postmodern era its hard to imagine that it started on the same day and exists in the same form in tokyo los angeles or in some village in rural uganda overall im more interested in the notion of how differential temporalities often coexist in any one historical moment in this respect im influenced by historians of the annales school such as fernand braudel and his ideas of differential historical time or at a simpler level raymond williams notion of the coexistence of emergent and residual dimensions in a culture alongside whatever is dominant at that particular time in that context one interesting issue it seems to me is to do with the different sequences in which particular theorists are read in different cultural contexts what i have in mind here is how all of this might possibly seem to you and to a chinese audience reading about these things in the 21st century 25 years or so after i was principally involved in doing this kind of work on tv audiences in a quite different context let me put that point another way in a public debate at a conference i was once asked what the difference was between british cultural studies and american cultural studies and i had to come up with an instant answer in that setting my answer was that it was the difference between foucault read through gramsci and gramsci read through foucault the point is that in britain people had been reading gramsci in cultural studies and then discovered foucault and began to rethink gramsci a little bit in terms of what difference foucaults intervention made to that perspective conversely in america a lot of people in cultural studies came across foucault first and only came to gramsci subsequently at the moment when british cultural studies imported gramsci into the usa so what you get in much american cultural studies is a framework that is fundamentally foucauldian but which then works in a little bit of gramsci my point is that this difference of sequence in terms of theoretical influences has considerable significance one has to pay attention to the modes of cultural transmission and be sensitive to the complex routes through which particular theories come to dominance in different circumstances one mustnt presume that which is or was useful or significant at one moment in a particular place will work in the same way or have the same significance in a different set of circumstances let me give you another example i once did some work with the late italian semiologist mauro wolf who died a few years ago before his death he was working on a book in which he was going to translate george gerbners works on cultivation analysis into italian in order to develop a model of the longterm effects of the italian media what was interesting about this was the potential significance of gerbners work in italy at that particular moment in the very early 1990s as far as people in the british or american cultural studies tradition were concerned by then gerbners work seemed rather old fashioned and very much displaced by the work in italian semiotics of people like eco however wolf could see that if you started from semiological premises as italian media scholars naturally did given the strength of that traditions development in italy then importing gerbner into the debate at that point could prove very useful im making an elementary point about the way in which the significance of any particular theory or theorist may vary immensely according to its context in different times and different places and according to the very different sequences in which intellectual life develops in particular countries as for the question of the death of the author and the birth of the reader again rather like what i said in relation to your counterposition of producer society and consumer society i dont think that you have to kill the author in order to give birth to the reader i think we still have to think about both authors and readers i quite agree with the polemical thrust of barthes original proposition that we have to find a way to allow more space to the reader than was allowed by classical literary theory but i dont believe that in order to do that we need to get rid of the idea of authorship not least because texts do still have authors even if those authors are now sometimes collective agents rather than solitary individuals to give you a different example theres a wonderful moment where in his debate with john searle derrida claims his authority over his own texts very strongly thus theres a moment in which he criticizes john searle for having misread one of his texts and derrida says as the author i claim the authority to tell searle what i meant so there you have derrida the doyen of deconstructionism claiming authority by virtue of authorship that perhaps indicates that authors are not yet quite dead and indeed they dont need to be dead in order for readers to breathe hj dont you think the ways in which television programmes are structured or rather destructured are postmodernstyled you know in his article cleverness is all which you quoted to deal with the topic of postmodernism m ignatieff finds that in television programmes narrative is replaced by flow connection by disconnection and sequence by randomness besides as you noticed dick hebdige also points to the characteristics of such texts popular culture o¡ers a rich iconography a set of symbols objects and artifacts which can be assembled and reassembled by di¡erent groups in a literally limitless number of combinations my further question then is whether this new kind of text appearing ¢rst and foremost in television programmes was a driving force among others that helped to open your horizon of the active audience dm no my analysis was developed in the mid 1970s long before this notion of postmodern flow disconnection or randomization really had much significance in the world of the media the media i was analysing both in the nationwide project and in the family television project were fairly conventional forms of narrative and were characterized neither by disconnection or randomness but beyond that point i have some conceptual problems with the question first im not convinced by the generalization that television are nowadays more disconnected and random than they were at some earlier moment im not sure how powerful that proposition is it may be true at a high level of abstraction but there really isnt very much which is true about television in general so from my point of view as i explained earlier its difficult to contrast the television of today with the television of yesterday unless you fill in at least some of the gaps and say which television where otherwise the generalization is so large as to hide rather more than it reveals indeed one might well argue that there has always been much more variation within television at any given moment than there is between the television of one era and the television of another second i dont think that audience activity depends on disconnection people can be very active with very closed texts umberto eco is very interesting about the contradictions that one can see at play in that situation in relation to the manipulation of closed texts i also think there is an interesting question to do with historical development in the 1970s you get a very important moment when structuralist analysts criticize the traditional forms of content analysis insisting that you cannot understand a television programme by simply counting the disaggregated bits in the way that traditional content analysis does their argument is that a programme is a structured whole and so you can only understand the meaning of one bit of content in relation to the other bits with which they are combined that analysis first developed in film theory was then largely taken over from film to television studies so then many scholars stopped doing the traditional kinds of content analysis of television because they understood that they needed to look holistically at the whole structure of a programme but then a further difficulty came with the ethnographic evidence that gradually accumulated showing thats not how people watch television especially once you have conveniences such as the automatic control device ŵith which a person can change channels without moving by simply flicking a button what you begin to get then is a new mode of viewing in which people dont necessarily sit down and watch whole tv programmes in fact most people most of the time only consume bits of different television programmes they might go out to do something else in the middle they might change programmes and watch something else and then come back later to the one they started with at that point the structuralist critique of content analysis loses its force one has to recognize that in so far as viewing modes are increasingly fragmented it might be the case that the kind of cumulative effects of media patterns of images and statements of the type researched by gerbner might have more relevance than the structuralist critics of the 1970s have supposed precisely because that critique was premised on the audience displaying a mode of focused attention on the complete single text that premise may be feasible if your object of study is film shown in special places called cinemas but it is not feasible when applied to the study for instance of domestic television where the circumstances generally dictate a rather different more distracted mode of consumption however one still has to allow for certain exceptions there are moments even in contemporary conditions of domestic consumption in which someone might well sit down and watch a whole text eg of their favourite programme conversely there may be occasions in which someone goes to the cinema and for whatever reason doesnt concentrate on the film all the way through you cant presume a one to one relationship between a particular architecture of display and a particular mode of consumption nor can you presume that there is only one mode of consumption for one particular medium one can realistically and usefully only research the identifiable patterns of consumption of different media in different contexts and one must always be sensitive to variations of the sorts i have indicated hj in the field of popular culture studies how has british cultural studies responded to french poststructuralism or broadly to postmodernism would you please give me an overview of their interactions or contestations in interpreting popular culture it seems to me that british cultural studies has never given up its modernist perspective by which popular culture is not depthless superficial and then meaningless as fredric jameson claims but a site of ideological struggles negotiations concessions compromises or in short of exactly that meaningfulness dm my own position is that interesting and stimulating as both jameson and baudrillard can be there is something fundamentally elitist about the contempt in which they both hold popular culture and thus about the contempt in which they implicitly also hold the majority of the people who are engaged with popular culture to dismiss this whole field as depthless superficial and meaningless as they do seems to me an act of the most stunning arrogance and that is definitely not a direction which id want to follow i notice that in a previous question you referred approvingly to the work of hebdige i think that by contrast to people like jameson and baudrillard he is an elegant example of someone who would never make the mistake of dismissing popular culture as either depthless superficial or meaningless rather like hebdige my concern is to understand the forms and modalities of popular culture but in doing so i take very seriously the meanings at stake for its participants to go back to one of my answers to an earlier question i think it would be impossible to understand the rise of thatcherism in britain without understanding how that battle was fought out on the field of popular culture i dont think that was in the slightest bit meaningless i do also think there was a difference between what one could see on the surface and the hidden significances that one could read at a deeper level from the visible symptomatic events some of the things that might have seemed rather superficial in fact turned out to be of huge cultural economic and political significance and it was only by studying these seemingly trivial shifts in popular culture very carefully that it was possible to establish what was happening in british culture and politics in that period the same would follow now one needs to analyse the contemporary developments of popular culture with the same degree of seriousness a theoretical point which goes back beyond stuart hall to richard hoggarts early work on popular culture in the uk in the 1950s hj there is a view which says that the good days of british cultural studies are now long past it might be true to the extent that stuart hall has been retired for years and the cccs has been closed and that what is more critical there have been few new themes and core figures emerging that generate as much interest as broadly as before however from another point of view after these changes it is time for us to redefine with some critical reflections british cultural studies or cultural studies there are many other centres for cultural studies both in and outside britain that is cultural studies becomes increasingly international concerning the new context i am quite interested in questions such as how british cultural studies is going on in britain in what way you and your colleagues continue british cultural studies how we can promote cultural studies in a global sense and last back to our main topic in this interview how you think about popular culture that crosses boundaries popular culture is always not only domestically but also globally popular dm clearly this is a very difficult and important issue the story of the influence internationally of british cultural studies is perhaps best understood as a kind of export industry through which a particular set of perspectives initially developed in britain in the 1960s and 1970s addressing the specific problems of british society were gradually exported to the englishspeaking territories of the previous british empire most notably australia canada and then at a later point to america manifestly british cultural studies was designed to analyse the situation of a particular country at a particular time of course there are certain theoretical and analytical positions built into it which can be abstracted and transported to different circumstances allowing for the relevant variations and distinctions that need to be made however the idea that british cultural studies can usefully be exported as a kind of readymade template according to which the whole world can be understood is clearly nonsensical that would just be another form of cultural imperialism this time in the intellectual sphere cultural studies wherever it is conducted has to construct modes of analysis which are relevant to its own conditions of production in a particular place at a particular time for instance it may well be that someone trying to develop a cultural studies perspective in china now as i understand you are doing can hope to learn certain things from the history of the development of cultural studies in britain or elsewhere but you have to approach those previous intellectual traditions located elsewhere with a strong element of critical intelligence and you have to think carefully about in what ways given the many differences between british and chinese society you would need to transpose the modes of analysis developed in britain in order for them to be of any use at all in china so again that takes us back to the contextual specificity of cultural studies one also has to be attentive to the way in which the world around us has changed significantly since the 1970s when my own audience work was actually conducted the model of cultural studies that we developed in britain then was one which was premised on the notion of a national society we were primarily concerned with class race and gender differences within britain and with the british media certainly those still remain very important problems but nowadays communications is simply not national in the way that it was in the 1970s we now have transnational broadcast systems and satellite systems of communication which mean that messages are mobile all over the place cultures are no longer simply national that is the force of appadurais argument about difference and disjuncture in the global economy when he talks about how the mediascapes of the contemporary world now exceed national boundaries he also talks there about how the ethnoscapes of our contemporary situation also now transcend national boundaries in so far as we live in a situation in which not only are messages mobile across boundaries but so too are audiences in a world of increased migrancy we are now in a situation as he says where moving messages meet deterritorialized viewers now clearly that is a very different situation from the one that we faced in birmingham in 1972 when i began my studies of audiences and we have to allow for those differences in any contemporary analysis that we want to make at the same time to go back to what i said before about my anxiety about clearly binarized divisions and periodizations i dont want to suggest that the age of the nationstate or the national era is completely over or that we now all live in some transnational period in which we are all equally mobile and all attending to messages which come to us from far away thats simply not the case some people in some places are much more transnational than others and many still effectively live out their lives within national and even more local boundaries that was the problem that i explored in my book home territories which was focused on questions of mobility and the media but was also insistent on continuing to pay attention to the ways in which boundaries of a local regional or national kind are still in many ways enforced today indeed it would seem to me that in china in particular the nationstate is not only still alive but is both thriving and powerful if in different ways than within the nations of europe in ending let me say again that we clearly cannot take any mode of analysis be it british cultural studies or anything else and imagine that it will automatically help us understand the situation in another culture at a different time without making all manner of cultural translations and transpositions however on the other hand we have no need to imagine that we live in some totally new world where all previous theories are now redundant as people like carolyn marvin have shown us all technologies all media were new in their own time the telegraph the cinema the radio the television the video game the computer there is always a moral panic about the latest new medium and its supposed e¡ects and many of the problems we face today have clear historical precedents which we need to consider i think that we have to develop a much more serious historical and comparative set of perspectives within cultural studies and i hope that you and your colleagues in china will ¢nd some parts of what i have to say in this interview of use to you in your project of trying to do that thank you heartfelt thanks are due to the british academy which approved my research proposal on british cultural studies and generously awarded me a fellowship which among others made this interview possible

british cultural studies represented perhaps chiefly by the socalled birmingham school is much marked by its strong orientation towards the application of grounded theory in the analysis of concrete cases rather than the development of abstract theory with a capital t in stuart halls words as a leading figure of the birmingham school and a key representative of the active audience model in television studies or broadly media studies david morley stands at a point where this trend was set as is evidenced in this interview questioned by huimin jin morley puts his audience studies into the contexts of british cultural studies postmodernism marxism social movements and so on and in doing so he shows the ambiguity and subtlety of his concepts of how to best theorize the active audience only by this method jin believes could morley launch his version of audience studies which aims not to invent a general theory of media effects but to use an interdisciplinary range of theories to explore how people actually respond to a tv programme and only by this approach to audience studies furthermore could morley develop a theory of the audiences activity which is embedded in the course of their everyday life and that cannot be thoroughly colonized by discourses cultural studies wherever it is conducted therefore morley suggests has to construct modes of analysis that are relevant to its own conditions of production in a particular place at a particular time this is the tradition as we know it but also the future as morley envisages of cultural studies

introduction while schoolbased violence can take many forms bullying is particularly prevalent despite definitions varying bullying is generally considered to be intentional repeated overt or covert inappropriate behavior from another that is intended to intimidate and harm the target 1 in school settings a student is bullied when he or she is exposed repeatedly and over time to negative actions on the part of one or more other students 2 for example negative actions or bullying can be direct or indirect and include physical verbal or psychological and relational acts that cause children to be systematically excluded from social activities by their peers 34 in many countries rates of bullying are high according to a crossnational study of adolescents aged 115 to 155 years the prevalence of bullying victimization ranges from 6 in sweden to 40 in lithuania with an average rate of 17 across 25 countries in europe and north america 5 another crossnational study the global schoolbased student health survey carried out among middle school students in 19 lowor middleincome countries showed that the prevalence of bullying ranged from 8 in tajikistan to 61 in zambia 6 in the 2011 progress in reading and literacy study which draws on a sample of fourth grade students spanning 52 countries and regions about 53 of students reported that they had been bullied at school and 20 said that they were bullied almost weekly 7 bullying has been shown to have significant consequences on a students educational experience and longterm outcomes 89 studies have found that being bullied at school causes school avoidance and poor attendance 10 inability to concentrate 1112 lack of academic engagement 13 14 15 early school dropout 16 and a weaker sense of belonging or connection with school 17 in addition to academic measures school environments may have an influence on student creativity 18 and bullying has been found to detrimentally affect school environments 1920 as such in addition to the immediate psychological and social consequences the negative impact of bullying on educational performance can inhibit human capital accumulation labor market opportunities and economic productivity in the longterm 21 22 23 in china little is known about schoolbased bullying the available research which draws upon samples that are almost exclusively urban finds that the prevalence of selfreported bullying victimization varies from 2 to 26 24 25 26 27 28 29 similarly studies of the correlates of bullying in urban china have varied widely while some studies show that bullying victims in china tend to be male students 252728 a study in tianjin finds no indicative gender pattern in bullying victimization 30 other evidence suggests that the gender of teachers was associated with their responses to student bullying behaviors in school 31 32 33 in addition some research reports that students from singleparent families had significantly higher rates of bullying victimization than children from twoparent families 3435 however another study shows that students who were dissatisfied with their parental caring not students who experienced parental absence were at a higher risk of being bullied 27 although existing studies have facilitated an understanding of bullying victimization in urban china the existing research provides little insight into the extent of the bullying problem in chinas vast rural school system where most of the countrys children attend school this area of inquiry is particularly important given that rural students lag far behind their urban counterparts in academic achievement and attainment 36 37 38 to the extent that bullying negatively impacts the social emotional wellbeing of students as well as their educational performance and creativity an understanding of bullying in rural schools is an important step in narrowing the ruralurban gap in chinas education system china is currently attempting to grow from an upper middleincome economy to a highincome economy but insufficient human capital in rural areas threatens this transition 36 as the government is exerting considerable efforts to improve human capital in both urban and rural areas 39 understanding the various causes of rural academic underachievement is crucial to effectively narrowing the ruralurban gap a more thorough understanding of the prevalence correlates and consequences of bullying victimization in rural china will not only inform efforts to reduce bullying and improve student wellbeing it will also offer insights into how to improve human capital accumulation in rural china and other developing contexts the overall goal of this study is to examine the prevalence correlates and consequences of bullying victimization in chinas rural schools focusing on its relationship to educational performance and creative attitudes more specifically the hypothesis we would like to test in this paper is the following bullying victimization is correlated with lower levels of academic performance and lower levels of creative attitudes among rural students in china to achieve this goal we pursue three objectives first we document the prevalence of bullying among primary school students in rural china and compare this to other countries using an international comparative metric from the trends in international mathematics and science study and progress in reading and literacy study survey 40 41 42 43 44 second we identify the student family and school characteristics that are correlated with bullying victimization third we examine whether bullying victimization is correlated with student academic performance and student creative attitudes both before and after controlling for school student and family characteristics the rest of the paper is organized as follows section 2 introduces sampling methods data collection and methods for measuring bullying victimization academic performance and creative attitudes section 3 reports the prevalence and correlates of bullying victimization and the relationship between bullying victimization academic performance and creative attitudes section 4 discusses the results section 5 concludes materials and methods sampling the data presented in this study were collected from three rural counties in the southern part of jiangxi province in china although our sample is from one province of china it is fairly representative of poor rural counties across china in terms of key economic and social indicators first all three sample counties are nationally designated poor counties that were identified by the chinese government in 2012 as areas with extreme poverty 45 as such the economic development in these three counties lags behind the national average in china as well as other areas of jiangxi province per capita disposable income in each of the three counties was less than rmb 8200 in 2015 which is similar to the average per capita disposable income of rmb 9264 in the 832 nationally designated poor rural counties across china 46 additionally more than 80 of the population in the three counties are rural residents 46 in these respects the three sample counties are typical of poor rural areas across china which are home to nearly one fifth of chinas total population to select our sample we followed a twostep sample selection protocol the first step involved selecting a representative sample of schools from the three counties to do so we used official records from county education bureaus to create a population frame of all rural public primary schools in the three counties totaling 458 schools we then randomly selected schools using a sampling fraction that ensured the total number of schools in each township was proportionally represented in our sample this led us to randomly select 120 schools of which 37 were in county a 25 were in county b and 58 were in county c in this way our sample is representative of the three counties being studied after selecting schools we next sampled classes and students in grades four and five due to financial constraints we randomly selected at most two classes in each grade in each school specifically if there were one or two classes in a grade all classes in this grade were selected if there were more than two classes in a grade we randomly selected two classes we then surveyed all students in the sampled classes we also surveyed the math teacher and chinese teacher for each sample class our final sample included 10528 students from 286 classes in our 120 sample schools this sample is far larger than previous samples that have been used to examine bullying in chinese schools 262729 data collection all data collections were conducted at the end of the school year in may 2015 we collected four blocks of data the first block collected information on bullying victimization in school the second block collected socioeconomic information about students households and schoolsteachers the third and fourth blocks collected data on student academic performance and student creative attitudes respectively bullying victimization to collect information on student bullying victimization among our sample we used the students bullied at school scale the sbs scale was developed for the trends in international mathematics and science study and progress in reading and literacy study 40 41 42 43 44 both the timss and pirls are international comparative assessments of academic achievement among fourth grade students across 52 countries and regions representing a variety of development and income levels 7 the sbs survey was translated into mandarin chinese and the translation was verified according to the pirls translation guidelines 47 the sbs scale also has good reliability among teachers in rural china with a cronbachs alpha reliability coefficient of 093 the sbs scale asks students to rate how often they experienced each of six bullying victimization behaviors the six behaviors are i was made fun of or called names i was left out of games or activities by other students someone spread lies about me something was stolen from me i was hit or hurt by other student and i was made to do things i didnt want to do by other students to create a raw score for the sbs scale each response was assigned a numerical value the raw scores range from 0 to 18 a lower sbs score therefore corresponds to a higher level of bullying victimization in school following the pirls protocol raw scores were transformed into sbs scaled scores which were then used to sort students into three categories by frequency of bullying victimization almost never about monthly and about weekly transformed sbs scale scores range from 3 to 13 points pirls guidelines categorize students with transformed scores higher than 101 as almost never bullied students with transformed scores between 83 to 101 as bullied about monthly and students with transformed scores below 83 as bullied about weekly students experience bullying victimization behaviors about weekly and about monthly are considered to be frequently bullied socioeconomic information the survey team collected data on the basic socioeconomic information of each student as well as information about each students family teacher and school student socioeconomic information included gender grade and a sevenitem checklist of household assets the checklist asked students to indicate whether the family owned a car a microwave a refrigerator a camera a computer an electric fan andor a flush toilet a value was attached to each asset to produce a single metric of household asset holdings summing the value of all household consumption assets then produced our proxy variable for family asset value enumerators also asked students about where they lived during most of the school yearat home or in the schools boarding dormitories in addition a survey form was sent to each students caregivers to collect data on parental education levels and on whether the students parents were often away from home finally we surveyed teachers and principals to collect data on the gender of chinese and math teachers in each class the studentteacher ratio of each school and the schools distance from the local government seat academic performance tests we conducted a set of academic performance tests including a 30min standardized reading test a 30min standardized chinese language test and a 30min standardized mathematics test all sample students were administered the reading test which was carefully designed to measure student reading skills the test questions were adapted from those found in the pirls test the test questions were carefully translated according to the pirls translation guidelines and reviewed by a panel of experts and local teachers who are wellversed in chinas education system the translated reading tests then went through several rounds of pilot tests in chinese schools the results were independently reviewed by a group of test assessment experts and were revised to make sure they were of the highest quality and appropriate for the designated student levels in addition to the reading test students were administered mathematics and chinese language tests the tests evaluating math and chinese language were carefully designed with assistance from educators in the local education bureaus to ensure coherence with the national curriculum and both exams were pretested multiple times to confirm their academic relevance and appropriate time limits within each selected school we randomly assigned half of the sample students in each classroom to take the math test the other half of sample students in each classroom took the chinese test in total 5237 students took the reading and chinese language tests while 5291 students took the reading and math tests trained enumerators proctored all exams to prevent cheating and enforce the 30min time limit for ease of interpretation we converted all test scores into zscores using the mean and standard deviation of scores in each grade creative attitudes in the final survey block students were asked to complete the schaefers creativity attitude survey 50 this instrument includes 32 questions designed to assess childrens attitudes associated with creativity such as confidence in ones ideas appreciation of fantasy openness to impulse expression and use of novelty 50 students were given unlimited time to complete the survey the total score ranges from 0 to 20 with higher scores indicating greater creativity analytical approach our analysis is comprised of three parts first in our initial analysis we looked at the prevalence of bullying at school second to understand what kinds of students are more likely to be bullied we compared the rate of bullying victimization with different individual family teacher and school characteristics we conducted ttests to measure for significant differences between groups and to analyze which characteristics correlate with bullying victim status finally we estimated the correlation between bullying victim status and academic performance as well as the correlation between bullying victim status and creative attitudes to do so we used an ordinary least squares regression model including a set of covariates in a regression on student dropout we first ran an unadjusted regression y ij α βbullied i ϕ j ε i where the dependent variable y ij denotes the academic performance and creative attitudes of student j in school k bullied i is a dichotomous variable that equals 1 if the student is being bullied at school about weekly or about monthly and equals 0 if the student is almost never bullied at school ϕ j represents countylevel fixed effects and ε i is an error term capturing shocks and characteristics that are specific to the student or are unobserved β is the withinschool mean gap in academic performance and creative attitudes between bullying victims and nonbullied students to control for the potential confounding effects of student family teacher and school characteristics we ran a multivariate analysis building on equation above with the addition of a vector of control variables y ij α βbullied i γx i ϕ j ε i where the vector x i includes student family and teacher and school characteristics student individual characteristics include binary variables representing student gender grade and boarding status family characteristics include household wealth type of family whether parents graduated from junior high school and whether parents are often away from home we control for chinese teacher gender when the outcome variable is chinese or reading performance for the mathematics teacher gender when the outcome variable is mathematics performance and for the gender of both teachers when the outcome variable is creative attitudes school characteristics include the studentteacher ratio and distance between the school and government seat we chose to include the aforementioned variables in our equation based on previous studies that identified them as important factors correlated with student academic achievement past research has indicated that individual 51 family 4851 teacher and school characteristics 52 are all closely related to the academic performance of students therefore controlling for these variables allows us to better isolate the effects of bullying on student achievement and compare the magnitude with other factors in both equations and we computed clusterrobust standard errors results prevalence of bullying among primary school students in rural china figure 1 presents the rates of bullying victimization among students in our sample our results show that the prevalence of bullying victimization among primary school students in rural china is alarmingly high seventy three percent of sample students were bullied frequently this is a significantly higher rate of bullying than the average rate across 52 countries reported by the timss and pirls survey in which 53 of students experienced bullying weekly or monthly 3 the prevalence of bullying in our sample is also substantially higher than previous estimates of bullying in china previous studies have found that the prevalence of bullying is around 20 in hong kong 5354 and 2 to 26 in urban areas of mainland china 24 25 26 27 28 29 meaning that the prevalence of bullying in our sample is nearly three times higher than the highest prevalence reported in studies of urban china in addition among our sample 41 of student reported being bullied almost monthly and 32 reported being bullied almost weekly this is also much higher than the rates reported in the 2011 timss and pirls survey which found that only 33 of students experienced bullying monthly and only 20 were bullied weekly 7 in comparison to the bullying victimization scale score of other countries and regions our results show that students in rural china experience bullying more frequently than students in most other places in the world the average sbs scale score for our sample of rural students is 92 meaning rural chinese students are categorized as being bullied monthly according to the timss and pirls survey cutoff this puts our sample region at a rank of 5th out of 52 countries or regions with only slightly lower rates of bullying than south africa botswana qatar and trinidad and tobago when we examine each of the six bullying behaviors assessed in the sbs scale we find that certain types of bullying were reported more frequently than others among our sample students the most common types of bullying that students experienced were being made fun of or called names being stolen from and exclusion from games or activities by other students of our sample students 73 had been made fun of or called names at least a few times in the past year 73 had had personal items stolen from them at least a few times in the past year and 58 had been excluded by other students at least a few times in the past year the three other bullying behaviors included in the sbs scale were also fairly commonplace among sample students in the past year 50 of students had experienced lies being spread about them at least a few times 50 had been hit or hurt by other students at least a few times and 41 had been forced to do things they did not want to do at least a few times when we examine each of the six bullying behaviors assessed in the sbs scale we find that certain types of bullying were reported more frequently than others among our sample students the most common types of bullying that students experienced were being made fun of or called names being stolen from and exclusion from games or activities by other students of our sample students 73 had been made fun of or called names at least a few times in the past year 73 had had personal items stolen from them at least a few times in the past year and 58 had been excluded by other students at least a few times in the past year the three other bullying behaviors included in the sbs scale were also fairly commonplace among sample students in the past year 50 of students had experienced lies being spread about them at least a few times 50 had been hit or hurt by other students at least a few times and 41 had been forced to do things they did not want to do at least a few times figure 2 comparison of average students being bullied at school scale scores between rural china and other countriesregions note a lower sbs score corresponds with a higher level of bullying victimization in school to enable comparison across countries and regions sbs raw scores have been converted to scales scores according to the pirls conversion chart factors correlated with bullying victimization table 3 presents the results of our analysis of the characteristics associated with bullying victimization we found that several student characteristics were associated with higher rates of bullying victimization namely gender age and boarding status boys were slightly more likely to be bullied than girls in addition grade five students reported being bullied at a slightly higher rate than grade four students students who board at school also experienced significantly more bullying factors correlated with bullying victimization table 3 presents the results of our analysis of the characteristics associated with bullying victimization we found that several student characteristics were associated with higher rates of bullying victimization namely gender age and boarding status boys were slightly more likely to be bullied than girls in addition grade five students reported being bullied at a slightly higher rate than grade four students students who board at school also experienced significantly more bullying in comparison to students who live at home however it is important to note that although these differences are statistically significant the rates of bullying victimization for all groups are far higher than the international average regarding household and school characteristics several variables associated with socioeconomic disadvantage were significantly correlated with more frequent experiences of being bullied students in the lowest quartile of family asset value students from single parent families and students whose fathers or mothers did not finish junior high school were more likely to experience bullying victimization interestingly there was no significant difference in bullying victimization between the left behind children and students whose parents lived at home we also found that remote schools were associated with higher bullying rates and students at schools with higher studentteacher ratios experienced more bullying than students at schools with lower studentteacher ratios however in contrast with previous studies 31 33 our results find no association between the gender of teachers and students bullying victimization to further investigate the correlates of bullying victimization we ran a multivariate regression that includes all student family teacher and school characteristics the results are overall consistent with that of table 3 of the individual student characteristics boys and boarding students tended to be bullied more frequently our finding that boarding students experienced more frequent bullying is consistent with past findings in urban china and in other countries that boarding students show higher levels of bullying victimization and perpetration in comparison to nonboarders 55 56 57 as pfeiffer and pinquart discuss this may be because students who board at school spend more time with peers for example in dormitories 55 similarly chui and chan suggest that more peer contact especially with deviant peers in dormitories contributes to bullying victimization 57 this is certainly the case in rural chinese boarding schools where students may share a dormitory room with more than ten peers 58 moreover separation from parental influence may reduce the impact of parenting practices meant to reduce problem behavior leading students to engage in more bullying behaviors 55 additionally the results of our multivariate regression show that students whose families have the lowest family asset values students in singleparent households and student whose mothers or fathers have not completed junior high school were more likely to experience frequent bullying these findings are consistent with previous studies that have found children and adolescents from families of lower socioeconomic status are more likely to be involved in bullying victimization 59 60 61 62 low family wealth itself may be one cause of victimization as students have less access to financial resources and inability to afford material goods 3562 additionally as jansen et al 63 suggest students from singleparent households are more likely to experience an increased level of stress due to broken families and fewer parentchild interactions the latter explanation is further supported by the evidence presented in spriggs et al that found a reduction in parental involvement and communication to be associated with increased bullying victimization 64 among our sample the higher magnitude and significance of singleparenthood than family asset value implies that parenting characteristics associated with single parent households are contributing factors to the risks of bullying victimization the literature also supports our finding that students whose parents have lower education levels are at greater risk of being frequently bullied research has shown that there is an inverse relationship between parental education levels and child bullying victimization especially maternal education levels 60 65 66 67 together with family asset value and singleparenthood parental education levels serve as a socioeconomic status indicator 63 in addition to financial resources parents of higher socioeconomic status can provide more time knowledge and aid to help their children cope with social conflicts both aspects reduce the chances that children will be bullied this point is further supported by the statistically insignificant relationship between whether the father or mother lives at home and bullying victimization the mere presence of parents at home when other family factors are controlled for does not have a significant impact on whether a child is bullied instead it is the underlying socioeconomic status of the family determined in large part by parental education which matters finally we found that students at schools with higher studentteacher ratios tended to be bullied more frequently frequent bullying victimization has been found in the literature to be associated with a large school size 6869 and a high studentteacher ratio 70 this may be because high studentteacher ratios limit teachers from effectively managing student behavior and preventing bullying victimization 70 variables being bullied correlations between bullying victimization academic performance and creative attitudes table 5 presents the results of our ols regression analysis examining the correlation between bullying victimization and academic performance our unadjusted ols regression results show that experiencing frequent bullying is significantly correlated with lower academic performance being bullied monthly or weekly is associated with a decrease of about 026 standardized deviations in chinese language performance 025 standardized deviations in reading performance and 022 standardized deviations in mathematics performance our adjusted ols regression results tell a similar story frequent bullying victimization is associated with a decrease of about 021 standardized deviations in chinese language performance 022 standardized deviations in reading performance and 021 standardized deviations in mathematics performance the magnitude of the effect of bullying victim on student academic performance is equivalent to almost half a year of learning 71 additionally we find a significant negative correlation between bullying victimization and student creative attitudes students who were bullied weekly or monthly scored lower in creative attitudes than their peers in both the unadjusted and adjusted models with coefficients of 060 and 057 respectively this corresponds to a difference in creative attitudes of about 024 standard deviations the findings in both tables 5 and6 are all significant at the 1 level in other words the magnitude of these associations and their statistical significance are similar in the nonadjusted and adjusted regressions for both academic performance and creative attitudes to better understand the relative importance of bullying for academic performance and creativity we compare the magnitude of bullying victimization to other significant factors in our multivariate analysis of note the magnitude of the correlation between bullying victimization and student academic performance is as large as the gender gap and singleparenthood and it is greater than that of boarding status low parental education and absent fathers moreover the magnitude of bullying victimization on student creativity ability is greater than all other factors measured in this study including gender boarding status low family asset value singleparenthood low parental education levels remote school locations and high studentteacher ratios these results confirm our initial hypothesis that bullying victimization has a negative impact on academic performance consistent with the findings of previous studies 8 more specifically the literature has found that when a student experiences bullying the stress incurred from victimization can lead to school avoidance poor class attendance and the inability to concentrate in class all of which directly impede learning and academic achievement 10 11 12 similarly the creative attitudes of students are hampered when they experience bullying as previous research suggests positive and encouraging environments are more likely to foster creativity 7273 the stress and reduced selfesteem incurred from bullying victimization might create a hostile environment that inhibits student creativity moreover when we compare the magnitudes of correlation we find that bullying victimization is negatively correlated with academic performance and creative attitudes at a larger magnitude than many other factors this suggests that reducing bullying in rural schools may have a larger positive effect on student academic performance and creative attitudes than targeting other factors that have been traditionally considered discussion to the best of our knowledge ours is the first largescale study to document the prevalence of bullying victimization among students in rural china this study also identifies the student individual family and school characteristics correlated with bullying victimization additionally this is the first study to examine the correlation between bullying victimization and student educational performance in rural china before and after controlling for student and family characteristics our study finds that students are bullied in rural chinese elementary schools at rates far higher than both the international average and the rates found in urban areas of china about 73 of sample students in rural china were bullied almost monthly or weekly which is much higher than the international average of only 53 the prevalence of bullying in rural china is also much higher than that of hong kong and urban areas of mainland china where rates of bullying vary from 2 to 26 24 25 26 27 28 29 5354 the most frequently experienced type of bullying in rural china is being made fun of or called names by other students we also found several characteristics predictive of frequent bullying victimization including being male boarding at school having less educated parents having a family with a lower family asset value having a singleparent family and attending a school with a higher studentteacher ratio perhaps most importantly even after controlling for student family teacher and school characteristics student academic performance and creative attitudes are both strongly negatively correlated with frequent experiences of bullying a student being bullied monthly or weekly is correlated with a decrease of about 021 standardized deviations in chinese performance 022 standardized deviations in reading performance 021 standardized deviations in mathematics performance and 057 points in creative attitudes in other words bullying significantly impedes the ability of students to perform academically and think creatively why do we see such high rates of bullying victimization in rural china one factor may be that rural teachers lack the time and resources to intervene and prevent bullying with chinas rapid economic progress and intensified urbanization more financial and educational resources have been poured into cities rural areas though on the radar of policymakers still face a scarcity of educational resources 7475 additionally fiscal decentralization has aggravated the unequal distribution of resources in rural areas leading to low perpupil basic education expenditures in rural schools 76 77 78 this means that rural teachers face lower salaries worse working conditions heavier workloads and limited school budgets for professional development compared to their urban colleagues all of which lead teachers to move within the public education system to betterpaying urban schools creating a shortage of rural teachers 7980 as a result rural schools tend to have larger class sizes and higher studentteacher ratios leading to less individualized attention for each student this can explain in part the observed high prevalence of bullying victimization especially in an examcentric education system such as in china where the exam scores are the primary metrics for academic performance teachers tend to focus their limited time and effort on teaching and student academic achievement rather than behavior management another key factor may be parenting quality and socioeconomic challenges in rural china low socioeconomic power in rural families creates adversities for rural children for example many rural parents leave rural areas for jobs in chinas cities and leave their children behind in the countryside in the care of grandparents the absence of parents and reduced parental involvement deprives children of opportunities to learn conflict management skills and other related social skills 61 moreover grandparents often have even lower levels of education which means that can only provide limited guidance to address the troubles in their childrens social lives 81 82 83 bearing the disadvantages of both educational resources and parental attention rural students face a higher level of bullying victimization the negative consequences such as stress hinder not only their academic performance but also limit their creative abilities this in turn perpetuates the preexisting urbanrural educational divide conclusions the findings in this paper offer insights into factors that may contribute to student academic performance and creative attitudes in rural china beyond those that have been traditionally considered such as teacher quality school funding and student physical health while our data do not support a causal analysis of the relationships among bullying academic performance and creative attitudes in rural china studies conducted in other countries can provide guidance for future causal research in china specifically many studies find that bullying has negative consequences for a students educational experience and longterm outcomes 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 disrupting their ability to learn think and thrive in the school environment future research into the effects of bullying in rural china should therefore focus on the causal links between bullying and physicalmental health the results of this study also have implications for china outside of its academic system if bullying victimization does in fact has a significant negative impact on student academic performance and creative attitudes then widespread bullying may not only be hurting individual students it may also harm chinas longterm economic development by slowing human capital growth supposing that the proportion of students found to be frequently bullied holds true across rural china then based on the ministry of educations statistic that there are about 30 million primary school students in rural china 22 million primary school students are bullied frequently in china at the expense of their academic achievement given the important link between education and human capital the correlation between bullying and academic performance offers a direction for improving human capital in rural areas where widespread low academic performance and high rates of dropout negatively affect educational attainment and labor market performance among large parts of the population given these findings we recommend that chinas education policymakers consider incorporating bullying research and prevention initiatives into their agenda bullying is a complex and pervasive phenomenon and it is necessary to understand the problem in full especially in poor rural areas where academic performance lags in comparison to urban areas therefore causal studies of bullying and its effects on students are vitally important in addition although selfreported data on bullying victimization may reveal the true prevalence and magnitude of bullying behavior future research should explore the characteristics of rural bullies using direct observation methods as understanding the profile of bullies is critical in addressing bullying more broadly antibullying programs should also be piloted throughout rural schools furthermore funding for controlled trials of such programs should be prioritized so that there is a solid evidence base for developing antibullying policies in the future data availability statement data are available upon request acknowledgments we would like to acknowledge our collaborators in china author contributions conceptualization hw and jt methodology hw jt software hw jt validation hw jt formal analysis hw jt investigation hw jt resources hw sr data curation hw jt jx writingoriginal draft preparation hw jt sed jx mb writingreview and editing hw sed mb cc visualization hw jt supervision sr project administration cc hw all authors have read and agreed to the published version of the manuscript funding this research was supported by enlight foundation the funding source did not have a role in in the design or conduct of the study the collection analysis or interpretation of data the preparation review or approval of the manuscript or the decision to submit the manuscript for publication institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by the institutional review board of stanford university informed consent statement informed consent was obtained from all subjects involved in the study

school bullying is a widely recognized problem in developed countries but remains underinvestigated in developing countries especially in remote rural areas in this paper we examine the prevalence correlates and consequences of bullying victimization and its relation to educational performance and creative attitudes using data from 10528 students across 120 primary schools in rural china we find an alarmingly high prevalence of bullying victimization and that several individual family and school characteristics are correlated with bullying victimization analyses indicate students who are bullied frequently score lower in chinese reading and math tests and creative attitudes taken together the results demonstrate a need for further research and policy interventions to reduce bullying in schools

introduction since the dawn of humanity communication has been a regular activity for passing information triggering a continuous evolution from the drawings on the walls to the zettabytes of today that circulate around the world this huge amount of data and the ability to transmit it in real time is due to information and communication technologies the world bank has recognized the importance of ict for promoting economic human and social progress sustaining that technological advance is the second force after economic progress given that since 1990 it has lifted more than 10 percent of the world population out of poverty likewise the united nations highlighted that ict are the right podiums for knowledge sharing skills improvement and some electronic services such as egovernment that can bring welfare in areas like employability health and education the european commission wants to ensure until 2020 the growth of an information society across the members of the european union by sponsoring innovation and knowledge sharing among member states making the most of ict encouraging innovation and smart solutions and creating the right structure to deal with the social challenges of the european and global society the ec recognized that europe is behind her economic partners in matters of growth rate due in part to the lack of use of ict although the ict sector in 2010 was responsible for more than 5 percent of european gdp and even more of the productivity growth the novelty of ict at the beginning along with the fast evolution of ict in recent years has led to discrepancies between and within countries resulting in a technological divide research has been conducted to analyze the european digital divide among or inside countries but rarely both at the same time though the digital divide within countries can be as high as that between countries the goals of this study are to appraise the european domestic digital divide for its 28 members and to analyze europeans demographic characteristics scrutinizing the main dimensions of digital divide of the 28 members of eu the main sociodemographic characteristics that most impact the digital divide in the eu the main sociodemographic characteristics that potentially contribute most to the digital divide and those that lead to greater asymmetries in the use of ict for each country of eu in addressing these issues this paper is structured in seven sections the next one section twopresents a literature review about digitalization from the digital revolution to the current digital society with reference to the challenging digital divide the third section is dedicated to the domestic digital divide and describes four sociodemographic drivers that influence ict adoption the fourth one defines the methodology describing the data and the applied multivariate data technique as well the outcomes of the data analysis section five presents the discussion of findings as well as the limitations of the study section six presents the theoretical and managerial implications in the last section a synopsis of findings is presented literature review digital revolution with the emergence of the information society a turning point came in the living standards of individuals with groundbreaking technologies restructuring the traditional society the first computers and later the internet enabled boundless information besides data giving a new meaning to manipulation and exchange of these resources creating a service society and increasing productivity and standards the personal computer and the presence of the internet are recognized in the literature as the key ingredients of the digital revolution since they not only brought material condition and services that otherwise would be unreachable but also redesigned both cultural and human nature directly or indirectly this technological revolution influenced societys fundamental elements such as world population life expectancy governance entertainment human relationships and others the ability to use ict and surf the internet became requirements to live in contemporaneous society also known as the information age there are no doubts that in the past it were already considered the lynchpin of our modern society being this revolution acknowledged as one of the most remarkable accomplishments of humanity ict is one of the most important generalpurpose technologies on a par with electrification for instance when comparing the us labor productivity in the electrification era and the ict era remarkably similar patterns of productivity growth are visible even though in different time periods still in the year 2000 the it revolution was just emerging with mobile phones and internet usage growing by more than sevenfold between 2000 and 2015 globally digital divide as ict became better known within societies and the internet technologies became popular given the placeless connectivity with the anywhere anytime approach intensifing their adoption notwithstanding the high level of adoption internet access still evaded some individuals retaining some doubts about how this access gap will affect them in the coming years over the years these gaps widened and led to the isolation and marginalization of individuals and communities given the uneven access to ict the most common term to describe these ict disparities is digital divide and although fairly old the following definition provided by the organization for economic cooperation and development is still one of the most suitable to clarify this phenommena defining it as the gap between individuals households businesses and geographic areas at different socioeconomic levels with regard both to their opportunities to access information and communication technologies and to their use of the internet for a wide variety of activities ict handling has evolved at an unprecedented speed generating uneven spread of these technologies depending on whether countries are industrialized or developing widening digital disparities and attracting the stakeholders attention the united nations states that individuals were falling behind due to the lack of access to technologies missing opportunities and personal added value that the online world entails so it has raised the bar for digitalization trying to make ict universal and affordable united nations 2016 p 78 the definition and classification of the digital divide is volatile although this is not related to capriciousness or an inability to be precise it is not a unique concept and it has varied because technology itself has changed considerably the continuous evolution of ict has given rise to different digital divides digital inequalities are gaining new forms shifting from a matter of access to a matter of intensity frequency and aim of internet use the firstorder digital divide which represents the lack of adoption the binary divide of have or have not access to ict has become outdated patronized and imprecise the secondorder digital divide representing the ict usage and the proficiency of ict usage has become relevant as a measure of digitalization allowing the intercountry assessment van dijk analyzed the technological differences and affirmed that in most developed countries the physical access divide is narrowing leaving behind the digital divide confined to access metrics alleging also that digital skills vary according to innovation speed of new technologies in 2012 the same author remarked that there is a shift from the firstorder digital divide that represents unequal access to ict to a secondorder digital divide embracing inequalities of skills and usage it is known that ict access is on track but not all of the problems are yet solved on the contrary the problems grow deeper the secondorder digital divide reveals itself to be one that is even more important and more difficult to bridge than the firstorder digital divide separating those who are able to make good use of all of these technologies entailing opportunities and improving their standards of living from those who are not the emergent secondorder digital divide is about capabilities and abilities recognized as a knowledge divide linked to fundamental skills that allow exploring all the benefits of the access this raises a new challenge a second form of inequality that should be fully appreciated people and organizations that use computers and internet have a relative advantage compared with others that do not this digital competence of handling ict is relevant inasmuch as it gives responses to other citizens satisfying their societal needs strengthening socially economically culturally and politically and opening space for innovative content digital inequalities of first and secondorder can be used as a measure for digitalization these digital gaps can be analyzed whether between nations or within nations according to çilan and sadowski the level of ict access and usagefirstorder and secondorder digital dividesvary among individuals within countries and digital discrepancies inside nations can justify the differences among them ritzhaupt considers the digital divide as a manysided phenomenon crossing different digital extents such as access usage and skills as does lindblom and räsänen stating that the digital divide at the individual level springs from many different sources which emphasizes that individuals act differently in terms of digitalization for instance the most disadvantage individuals such as the elderly less educated women and individuals with lower income widen the domestic digital disparities given their disadvantage in society fig i the scope of the study crossing different technological divides digital divides drivers technology on its own without any other catalyst may drive deep divides within societies rather than narrow socioeconomic problems it negatively impacts the sustainability of a society hindering the competitiveness and the economic growth in the long term and is vital to comprehend vulnerable groups behavior guiding them to the best opportunities toward digitalization fostering economic and social progress van deursen et al mention that sociodemographic characteristics affect online behaviors as does yu who explains the variability of ict access through socioeconomic conditions to understand domestic susceptibilities and their implications in the contemporaneous society four demographic segments were chosen age education gender and income age age is one of the most popular drivers when it comes to ict adoption with the united nations stating that the digital divide is also an age matter the generational rift is particularly important to understand the daytoday appropriation of ict by the younger and by the elders the first group labeled as digital natives that were born and grew up already surrounded by ict and the second group as digital immigrants that were not and therefore had to adapt themselves to ict there are some previous evidences that this second group can present computer anxiety and technophobia given their agespecific characteristics and their nonintuitive ict skills and usage exhibiting social conditions such as disabilitieschronic health problems living alone single or widowed presenting lower level of education than ict users there are evidences that the online communication among the older group people over 65 years is significantly lower when comparing to the youngsters it is also evident that for seniors older than 70 years the relation between age and internet use seems not to be linear but rather exponential likewise with every additional year of age the likelihood of internet usage decreases by 8 in fiveyear differences when considering a range of 6590 years or more senior citizens are usually stereotyped as unable or reluctant however they simultaneously perceive that technology could enhance their selfsufficiency by increasing ict adoption and usage by this group there would be less isolation via the social networks strengthening relationships and more medical assistance via telemedicine increasing social and health care education educational digital divides persist in contemporaneous society affecting digital development justified by the complexity of ict which is considered as a major obstacle for adoption van deursen et al agree that education is an important predictor for the types of activities that people engage in online activities which is in tune with nishijima et al who consider that the educational attainment affects access to ict as it is positively related to ict usage in both developed and developing countries explaining most of the disparities in personal skills for ict utilization for kathuria and oh is necessary a threshold level for education and skills to diffuse faster the ict for instance the united nations mentions that most websites are in english for people with low education level who are uncomfortable with the english language it is a hindrance for einclusion rogers assumes that the complexity of an innovation is negatively related to its rate of adoption hence education can be the turning point for the digital divide overcoming the ict complexity making the difference when individuals are faced with ict providing the opportunities to achieve digital dividends prospects for future employment making it a competition between traditional qualifications and technologies gender the genderrelated digital divide reflects gender related inequalities in which digital inequalities mirror structural social inequalities the main digital disparities are more visible in developing nations where the gender gap in accessibility and use of icts increases the existing gender inequalities this driver plays a role in drawing ict asymmetries as some authors argue the phenomenon of technology itself cannot be fully understood without reference to gender families institutions and religions shape gender roles and stereotypes giving the idea that computers are toys for boys not for girls determining and framing conducts income the income level is considered by international organizations as a key component of digital methodology data to measure the digital divide between and within the 28 members of the eu 14 variables were chosen from eurostats digital agenda scoreboard key indicators for the year of 2016 having into account their relevance in the digital divide matter the support and rationale behind each one is provided in table 2 each variable is disaggregated per each of the four drivers mentioned in the previous section resulting in 11 sublevels these sublevels are three for age generation y generation x and baby boomers three for education lowno formal degree secondary degree tertiary degree two for gender female and male as for income three subsegments were defined 1 st quartile 50 around the median and 4 th quartile for ireland italy malta and united kingdom data compiled at income classes is not available the three levels of education were defined using eight basic isced levels as they allow the control of differences in education levels across countries and are consistent with eurostat which states that at this level of aggregation data are considered as comparable over time for all available countries as for income using intranational quartiles allows for the control of specific national differences like exchange rates purchase power ict and other products and services costs etc moreover we have one group representing the ict disadvantaged one of the advantaged groups and another which is hypothesized to be in the middle this is consistent with age and education also in which generation baby boomers and the lowno formal degree represent the ict disadvantaged whereas generation y and tertiary degree represent the ict advantaged in this way we can assess which sociodemographic characteristic is more relevant in drawing digital inequalities to effectively measure the digital divide variables such as the usage of ict and the channel to access it must be acknowledged considerable lack of ict usage continues to exist given that the lives of the majority of the worlds people remain largely untouched by the digital revolution in developing countries mobile phones are the main form to access the internet and according to kathuria and oh mobiles have diffused the fastest among all ict hence the percentage of individuals that never used the internet and the percentage using mobile phones to access the internet were included the frequency of usage is also appropriate for the study affecting the ict knowledge zillien and hargittai the united nations mentions that efforts are being made to ensure privacy and security of personal data pointing out that privacy is a contemporaneous and growing concern thus a measure of privacy awareness was also included finally despite all these technological progresses one of oecds first concerns related to ict was how to foster the access and adoption of ecommerce among citizens the single digital market taunted a shift from the traditional decentralized consumerism to a flexible universal market in which tradinggoods services or online contentis one click away prevailing popular in the current society converging to the single global market for these reasons two measures of electronic commerce were included one regarding individuals who buy online and another for individuals who sell digital divide dimensions given the multidimensionality of the subject that mirrors the eu countries disaggregated by 11 subsegments for 14 variables a multivariate approach factor analysis is appropriate to find the underlying patterns and to deal with the complexity of this matter as the successful use of this technique is grounded on the correlation between the variables these were the first to be analyzed concluding that a strong correlation structure appears to exist this finding is supported by the kaisermayerolkin measure of sample adequacy 09 which is according to sharma marvellous the next step is to decide the best number of factors taking into consideration the kaisers pearsons and scree plot criteria this choice resulted in a twofactor solution as is recommended to increase the interpretability of the factors different rotations were used starting with the two most popular and widely used in this context varimax and quartimax however although most studies in this and other contexts use these orthogonal rotations implying that factors will be completely uncorrelated from a theoretical standpoint it does seem plausible to hypothesize that the different dimensions of the digital divide may be at least to some extent correlated from the authors understanding countries performing very well on a specific dimension should a priori also perform well in others and viceversa orthogonal rotations do not allow this to happen affecting artificially countries performance especially those that score very well in one dimension and to keep the zero correlations between the factors are prevented from performing well also in the other this was by the way noticeable in the results using orthogonal rotations especially in the northern countries which scored very well in one dimension and belowaverage in the other without a valid reason meaning that they were poorly represented in the new axes hence an oblique rotation promax was employed if the hypothesis of the analysis is true the results should lead to factors that have a significantly different from zero correlation and since oblique rotation allows for correlated factors whereas orthogonal rotation does not it would appear that oblique rotation would be preferred to orthogonal rotation on this basis notwithstanding orthogonal rotation is a subset of oblique rotations factors represent the extent to which variables are correlated and an oblique rotation could allow seeing the extent to which the factors themselves are intercorrelated according with iacobucci the correlation between the two factors was calculated yielding a value of 063 meaning that the data are adequate for this rotation as it is neither below an absolute value of 03 which could mean that orthogonal rotation could be enough nor above 07 which could indicate that many factors had been retained the two dimensions are interpreted one related to ict applications and services labeled as eservices and the other representing the social networks and the communication channels labeled as social networks thereby responding to the first research question of this study in the solution provided by varimax the two dimensions found explain 80 of the variance contained in the original 14 variables the factor structure is similar between the orthogonal and oblique rotations note that the reference structure ie the correlations between each factor and variable after the common variance with the other factor has been isolated provided a clear differentiation between the variables highly correlated with the eservices from those with social networks it is noticeable that given the correlation of 063 and looking at the overall correlations although the structure is still clear some indicators are relatively well correlated with both dimensions the factor scores of this analysis ie the values that each countrysegment has on each dimension are examined below from different perspectives to answer the second and third research questions of this study assessing the impact of sociodemographic characteristics multivariate analysis of variance was chosen to assess the existence of different digital adoption levels among the 28 eu member states when looking at different sociodemographic subsegments this analysis aims to compute the distances between the centroids of the subgroups detecting if the distance between them is statistically significant in manova the null hypothesis assumes that all means are the same testing the differences in two or more vectors of means manova tests for each sociodemographic segment if the subsegments share the same mean toward eservices and social networks also a posthoc test was conducted to find which groups specifically have significant differences fig ii multiple comparisons of the means of the sociodemographic subgroups notes the mean difference is statistically significant the mean difference is statistically significant the mean difference is statistically significant according to figure ii within the age segment there is statistical evidence that the baby boomers present different levels of adoption for both eservices and social networks when compared to the two younger generations as for education all three subsegments present different levels of adoption for both dimensions as well as for income except for the first quartile of income group and the 50 percent around the median group who do not present statistically significant differences in the level of adoption of eservices among the 28 eu countries in a developed society such as europe gender does not present statistical evidence of different levels of adoption between men and women manova tests the differences of the meanslevels of digital development without testing if the digital disparities across the subsegments of the same driver are similar in other words manova cannot test which driver if any present higher digital divide which is clearly of interest to know given the statement of conover that the variance of the population may be the quantity of interest as for this study the asymmetries of the four sociodemographic indicators will be assessed identifying which of them engender biggersmaller digital disparities in the eu by using the abovementioned subsegments so given the assumptions of the data not following a normal distribution according to the kolmogorovsmirnov test a nonparametric significance test was computed conovers squared rank test for variances was applied to evaluate if the digital asymmetries ie the variance within the sociodemographic segments is different and if so identify in which of these segments there are significantly different disparities regarding social networks age is unanimously the sociodemographic indicator that generates the biggest disparities among the subgroups when compared to the dispersion of other subgroups such as for education gender and income fig iv the main sociodemographic indicators affecting domestic digital divide per eu countrymeasured by the standard deviation discussion discussion of findings the eu member states have different backgrounds with diverse levels of expansion and standards of living influencing unequally the sociodemographic groups and thereby disrupting the equal usage and adoption of ict when analyzing the four sociodemographic segments starting by the age groups the baby boomers are far below the arithmetic average adoption point for eservices and social networks presenting statistically significant differences against the youngest two generations at a confidence level of 99 this matches with quanhaases statement affirming that baby boomers are still behind in terms of internet access digital knowhow and enthusiasm regarding education the differences between the subgroups average for both dimensions are statistically significant among themselves gender in eu28 in opposition to developing countries does not present significant differences in terms of digital adoption toward the two dimensions of the study for income on the other hand individuals with higher income present significant differences against the other two groups of income on eservices as for social networks there is statistical evidence at a confidence level of 99 that all income categories have different levels of adoption these differences in developing countries would be even more noticeable as most european individuals regardless their income subsegment have sufficiently high yields that allow ict acquisition which is in line with earlier research is noticeable that for the most proficient groupsgeneration y those with tertiary degrees or in the 4 th quartile of incomethe mean differences toward the less proficient groups are statistically significant on both dimensions high education and income levels are recognized as an entrance ticket to access and ict usage enabling individuals with solid knowhow in technology to identify which of the segmentsage education gender or incomepresent significant asymmetriesaccording to the conovers variance test there is at least one sociodemographic segment with asymmetries significantly different from the other three segments for instance on the eservices dimension among the four sociodemographic segment there is at least one pair of them that present unequal asymmetries statistically significant with a probability of 90 to be true on social networks the corroboration of significant asymmetries achieves 99 of probability revealing stronger evidence of disparities regarding social networks for both dimensions there are no statistically significant differences in digital asymmetries between each pair of segments except for education and gender and income and gender for social networks age presents statistically significant differences toward all of the other three segments displaying the largest disparities looking at the two dimensions found education levels draw the most noticeable asymmetries for eservices adoption given that the most educated individuals deal better with ict complexity taking advantage of online services in their regular day to day activities compared to less educated individuals for countries such as denmark estonia finland germany and latvia eservices adoption is more unequal among generations spain and lithuania present more inequalities on both income and education for social networks it is unanimous among the 28 eu countries that age is the indicator that generates the greatest inequalities when compared to education gender and income largely justified by the detachment between the youngest and the oldest coelho et al enumerate several reasons that can lead to this gap between the elders and the social network services such as the apathy to ict prejudgment of sharing online their privacy in opposition to the young adults that esteem the online network and the communication associated with it limitations the study analyzes the domestic digital divide for a specific point of time considering data from 2016 some changes might therefore have occurred and findings must be considered as a proxy to the present reality another limitation of this study is that are there are only 14 variables which can be considered as too few given the multidimensionality of the digital divide and the constant innovations in ict the income segment had missing data relative to income for four countries italy ireland malta and united kingdom and for that reason this segment must be seen with caution nevertheless the main goal of the study is to identify the main sociodemographic characteristics that cause greater disparities despite the implicit level of adoption there might exist low levels of dispersion between the subgroups of a sociodemographic indicator which is positive however their digital level of adoption could be very low or very high which is not considered implications theoretical implications oecd mentioned that the digital divide among households appears to depend primarily on two variables income and education and was a matter of access that only the wealthier therefore also more educated could afford scrutinizing the divides of the 28 eu countries in 2016 namely age education gender and income there are still some digital disparities that need to be closed this study specifies the neediest groups with lack of adoption for instance eservices adoption is more related to the education level of individuals while social networks adoption is more determined by age income is no longer the main trigger for digital divide for the 28 eu countries when analyzing developed societies such as those that belong to the eu digital divide results should be analyzed with caution since it is a multidimensional phenomenon and different backgrounds ask for different measures if the goal is to narrow digital discrepancies in an effective way regarding the multivariate technique that was applied findings show that an oblique rotation when analyzing the digital divide through factor analysis better represents the reality eservices dimension is correlated with social networks sharing 36 of variance within each factor managerial implications europe is suffering from a growing professional ict skills shortage and a digital literacy deficit these failings are excluding many citizens from the digital society and economy and are holding back the large multiplier effect of ict takeup to productivity growth this requires a coordinated reaction with member states and other stakeholders at its center it is necessary to flip the spotlights eu strategies and efforts according to the two dimensions eservice and social networks ensuring different focuses consonant with the sociodemographic subsegments as ict became a commodity the effort to narrow within and between digital divides was through the implementation of initiatives that could bridge the generational gap in case of social networks and that could harmonize the educational level within countries raising awareness of the benefits of the electronic services public authorities private organizations and individuals should make a personalized effort to narrow digital differences if each eu country would analyze the within country digital divide by sociodemographic segments and act according to its necessities the eu would benefit more as a whole narrowing at the same time the international and domestic digital divide improving digital literacy of europe conclusions the european strategies and recommendations intend to narrow digital disparities achieving similar conduct between and within countries but there is still work to be done this study analyzes the domestic digital divide for a specific point of time considering data from 2016 relative to age education gender and income disaggregated by 11 subsegments three for age education and income and two for gender on the 14 variables of the study two dimensions were identified to represent the digital divide eservices and social networks there is statistical evidence that the level of adoption of the two ict dimensions varies according to the sociodemographic subsegments within each sociodemographic segment presenting a confidence level of 99 when computing multiple comparison for eservices education presents the biggest disparities and for social networks age classes are clearly the most unequal nevertheless there is statistical evidence that the segments present disparities between them with a confidence level of 90 for eservices and 99 for social networks revealing greater evidence of inequalities in this dimension when analyzing the countries asymmetries the main drivers for digital divide in eservices are mainly education and age as for social networks age is unanimous as being the driver that affects this digital divide for all countries

this paper assesses the digital divide between and within the 28 memberstates of the european union the analysis comprised four sociodemographic contexts age education gender and income because of the digital divides complexity a multivariate approach was applied factor analysis with oblique rotation which resulted in two distinct dimensions eservices and social networks to test the significant differences of european union positioning and european union disparities multivariate analysis of variance and squared rank test were computed findings show that eservices adoption is influenced primarily by the education level of individuals while social networks adoption is more affected by individuals age

introduction although religious beliefs are typically considered at the individual level religion is fundamentally a social phenomenon sociologists long ago recognized not only that religion is social in function but also that it is socially produced and reinforced for instance simmel argued that the faith which has come to be regarded as the essential the substance of religion is first a relation between individuals similarly durkheim emphasized that interaction in groups creates and reifies religion by fostering solidarity through the genesis of shared symbols historically religion has been viewed as a creation of groups as well as a source of group and thus interpersonal connection in contemporary terminology this suggests that religion is a source of friendship selection leading to network homophily that is a means by which people come to know affiliate and become close to each other of course the processes producing religion socially can also change participants religion whether renewing it or inspiring new faith ernst troeltsch for example considered religious faith to be socially and contextually rather than individually produced this theme is evident in much of durkheims work too for instance in his emphasis on how religious interactions generate symbols that preserve feelings of group solidarity thereby transforming individuals by shaping cognitions and emotions and stimulating the desire for more religious experiences in other words the religious content of peoples social worlds can be a source of personal and possibly religious change to the extent that religion is socially derived and embedded in social networks the religious content of those networks may feedback to influence the affiliations beliefs and involvement of individuals in this way the religion of friends can influence that of individuals through socialization processes in contrast to the focus on the social origins and influences of religion by early sociologists however most quantitative research on american religion is now based on surveys of unconnected individuals with the result that the social context of religion is obscured more than four decades ago white criticized the implicit assumptions of the psychological consonance model that had become and remains so dominant in the sociology of religion as white argued the prevailing sociological approach to religion is peculiarly individualistic we do not argue that all scholars of religion endorse this view so much as they have their hands tied by design and method so that even as data collections and analytic tools have become more sophisticated individualistic approaches to studying religion still dominate in contrast to this individualistic emphasis we concentrate on the friendship dynamics of adolescent religion in doing so we find that religious beliefs activities and affiliations are both a cause and consequence of friendships for adolescents who attend small schools the findings are consistent with collins interaction ritual chain theory which builds off of durkheim and goffman to argue that social interactions create powerful symbols such as religion that influence and organize subsequent interactions the analytic approach we adopt uses innovative new social network analysis models that decompose social selection and socialization processes directly social selection reflects changes in social networks that result from the religious similarity among actual and potential friends and socialization reflects religious changes in persons as a function of friends religion we use data from 7 to 12th grade adolescents from seven small k to 12th grade schools where friendship networks were collected over time to assess whether religion is uniquely friendshipinducing a friendbased socializing factor or if both processes are jointly operative we build upon this analysis by quantifying the relative contributions of each to the networkreligion autocorrelation while also assessing whether the selectionsocialization results derive from additional structural network and background factors religious individualism in adolescence individualistic narratives are quite common in contemporary society as bellah and his coauthors outlined in their influential book habits of the heart the account they present describes the contemporary american preoccupation with individual agency even among regular churchgoers in particular american youth are thought to be highly individualistic in their religious beliefs and activities smith and denton summarize the contemporary adolescent preoccupation with individualism nearly all american teenagers believe that they are not influenced by anything at all religious or otherwise like most of the adults who have socialized them teenagers take for granted an image of themselves as autonomous and selfdefining individuals fully responsible for and capable of the formation of their own lives many teenagers actually bristle at the suggestion that they are directly influenced by people and institutions outside of themselves it is during adolescence when americans are apparently most resistant to the idea that they are social beings even while paradoxically entering what is generally the most intensely social phase of their lives that we examine the social nature of religion during adolescence youth expand the time they spend socializing with peers as they seek to forge their own futures they interact together in various settings in and out of school at church youth groups during sporting events parties etc and so come to develop histories with each other that form and reform friendship networks socializing each other in the process though research on adolescent social networks tends to focus on risky behaviors and delinquency late adolescence is a time of substantial religious and friendship change making this period particularly when combined with the strong social and interactional foci provided jointly by school and church a key time to study the individual and social natures of religion friends and religion homophilous social selection vs socialization network autocorrelations reflecting the tendency for friends to be similar to each other in various ways is a normative feature of social relations expressing the fact that interpersonal associations are socially arranged for the most part americans interact with people similar to themselves in terms of age class race gender and religion in fact americans social networks are predominantly composed of people with similar religious perspectives affiliations and levels of religious participation this is especially true for women conservative protestants jews and the religiously unaffiliated yet the question remains how does networkreligion autocorrelation arise there are two primary global mechanisms leading to crosssectional network autocorrelation the first mechanism social selection involves friendships forming among those who are similar to each other friendship selection processes have become a widespread concern in adolescent research albeit one that is rarely but increasingly being studied directly for our purposes religionbased selection reflects changes in the ties between individuals comprising the network based on religion the emphasis on homophilous social selection is evident in research in the sociology of religion for instance the church growth literature asserts that people prefer friends with religious beliefs and affiliations similar to their own similarly the religious economies perspective argues that sociodemographic characteristics play a smaller role than homophily of preference in structuring religiously homophilous social networks more recently vaisey and lizardo suggest that worldviews are related to selection but not influence sherkat perhaps most clearly exemplifies the emphasis on homophily people choose friends and spouses in accordance with religious preferences hence valued others are likely to reinforce existing desires rather than arouse new ones thus our first research question is do adolescent friendships disproportionately form amongst those who are religiously similar to each other and is this the primary mechanism of networkreligion autocorrelation the second mechanism socialization posits that friends socialize each other and so become similar over time this mechanism postulates changes in religion as friends adapt to and influence each other possibly in order to find balance with the perspectives and beliefs of their friends to impress them or to gain social acceptance and status furthermore as we elaborate below socialization may also reflect the internalization of shared religious symbols that increase in emotional salience as a result of socializing together the influential lofland and stark theory of religious conversion emphasizes the role friends play in bringing new members into the fold and is based on a version of a socialization hypothesis other research in the sociology of religion supports this perspective suggesting that social networks are instrumental in introducing people to new religious groups and viewpoints this view is also a reflection of the general concern in the risk behavior literature that peers negatively influence each other our second research question is thus do friends socialize each others religion over time and is this the primary mechanism leading to networkreligion autocorrelation friends and religion homophilous social selection and socialization in contrast to the emphasis on either selection or socialization it is possible and perhaps likely that both selection and socialization operate to produce religiousbased network autocorrelation leading to the question of the relative contribution of each collins interaction ritual chain theory provides a framework for conceptualizing and expecting such joint social dynamics in irc theory the ritual often an everyday interaction between friends or acquaintances is a mechanism of mutually focused emotion and attention producing a momentarily shared reality which thereby generates solidarity and symbols of group membership irc theory posits a joint process of interpersonal engagement leading to observable patterns of social selection in friendship networks and peer socialization in religious participation and belief key to irc theory is the idea that interactions are ritualized in the sense of goffman so that actors have behavioral and emotional expectancies for their socializing these interactions both create and sustain symbols that have meaning to the participants indeed religious symbols and ritual styles organize interactions and thereby form a basis for new and renewed interaction the result is that even changes in friendship networks outside of religious institutions will reflect religionbased social selection at the same time the very experiences promoting group solidarity and vitalizing religion changes participants when participants become caught up in a mutual focus of attention they become emotionally entrained with one another which heightens the salience of the social experience creating emotionally charged intersubjectivity is what religious services are designed to do and the emotions evoked by religious symbols are qualitatively different from those evoked by other symbols similar processes can unfold between peers in friendly interactions so individual religious views or engagement can change as friends socialize each other such interpersonal influences capitalize on communal symbols during interpersonal interactions and through the creation of shared emotionally charged interpersonal symbols created during socializing irc theory thus provides the foundation for understanding the microdynamic processes aggregating across individuals to produce homophilous selection in networks and socializationinduced patterns of individual religious change which can also produce homophily when viewed crosssectionally moreover the theory is clear on a number of points first both processes should unfold concurrently since the two are inextricably interlinked social selection mechanisms lead people to form relationships with those to whom they have more emotionally entraining interactions of which shared religious symbols are likely to be important collins also argues that we are emotional energy seekers and so intersubjective shared realities experienced during interactions change people second these processes should be evident outside of religious congregations to the degree that participating in religion creates powerful socially shared symbols that can be reinforced and changed through interactions with others therefore our third research question is do both friend selection and socialization work jointly to produce networkreligion autocorrelation and are the magnitudes of both processes comparable network and background factors both network processes and background factors could result in spurious estimates for selection and socialization if not accounted for network mechanisms reflecting the fact that these processes are sources of change and stability may be particularly influential for selection processes accounting for triadic closure may be especially important consequently we control for network closure as a source of friendship change network closure in particular appears to vary across religious traditions and is correlated with religious participation in addition we also explore the roles of popularity and activity on selection since religious youth may have more exclusive friendship groups and as alternative mechanisms of individual religious change finally because individuals have a profile of background characteristics that may jointly influence the role of religion in selection and socialization processes we also account for several background factors capturing alternative selection and socialization mechanisms for instance previous research suggests that religiousbased network homophily varies across religious traditions of course the behavioral outcomes measures of adolescents religious participation and belief should also vary across religious traditions we include controls for parents religiosity and education too since parents religious beliefs and activities and social class are strongly associated with adolescents religious perspectives and behaviors previous research also suggests that social networks and religious participation and belief are correlated with friends having the same religious affiliation these factors and other sociodemographic background factors implicated in adolescent network processes must be included in the models to ensure reasonable effect estimates assessing the central research questions around which the analysis is organized data and methods data come from waves 1 and 2 of the inhome components of the national longitudinal study of adolescent health add health is a stratified longitudinal study of 712th grade youth begun in 1994 with inschool questionnaires administered to approximately 90000 students in 140 schools a nationally representative sample of over 20000 students was drawn from the inschool study and data were collected inhome in 1995 from both adolescents and parents another survey was administered again to the adolescents approximately one year later at wave 2 this longitudinal sample consists of a core probability sample and special oversamples including 16 saturated schoolsettings where efforts were made to collect data on all attending 712th grade students so that a network sample could be maintained over time of these 16 schools two were large and 14 were small we used seven of the saturated settings all k12th grade schools that are relatively racially and ethnically homogeneous to construct our sample our decision to use these schools was based on several criteria first because our analysis requires longitudinal measures of friendship networks we were limited to the saturated schools second one of the schools was a special education school and another six were 68th grade we chose not to use these latter schools because the 8th graders moved into high schools for which full network data is not available third larger schools capture different macrosettings than the small schools as indicated by the enormous size differences the grade cohorts of the two big schools are larger than the entire 712th cohorts of the smaller schools the result is that we focus on the social dynamics in a collection of smaller more homogeneous settings the joint sample size of the small schools comprising this study is 798 mostly white 712th grade students the largest school contributed 163 students to the analysis and the smallest contributed 61 three were public rural schools the remaining four were private three of which were urban network data was present for 7089 of the students on the schoolprovided roster rates that are acceptable for social network analysis measures dependent and focal independent variables we employ six dependent variables that measure religious activity belief and affiliationidentification 1 religious service attendance is coded from the question in the past 12 months how often did you attend religious services youth service attendance is similar in that it asked about attendance at special activities for teenagers at churches synagogues and other places of worship these two variables take on values 1 never 2 less than once a month 3 once a month or more but less than once a week and 4 once a week or more importance of religion is assessed with responses to the question how important is religion to you the importance of religion measure takes values from 1 not important at all to 4 very important frequency of prayer ranges from 1 never to 5 at least once a day religious identification is captured with two dichotomous variables whether the respondent selfidentifies as a born again christian or reports no religious affiliation 2 1 although some researchers combine measures of religion into scales such as public and private religiosity we examine singleitem indicators for three reasons first since this is the first analysis to simultaneously model selection and influence in the religious homogeneity of adolescents social networks we did not want to assume that selection and influence operate the same across different aspects of religion second as recent research shows individual attributes can impact different indicators of religion in unique ways which can lead to misleading results if measures of religion are combined into scales third the models we employ are designed to work with ordinal dependent variables making scales more complicated to use 2 due to an unfortunate skip pattern in add health adolescents with no religious affiliation were not asked about their religious beliefs and activities these unaffiliated respondents must be kept in the sample for all analyses to ensure proper specification of the network portion of the model consequently we code unaffiliated respondents as never attending services or youth services as not being born again as placing no importance in religion and as never praying this coding most closely reflects what we know about unaffiliated adolescents for instance according to wave 1 of the national study of youth and religion a nationally representative survey of adolescents ages 1317 94 of unaffiliated adolescents never attend religious services only 13 of unaffiliated adolescents say religion is very or extremely important in daily life and more than half of all unaffiliated adolescents never pray the last dependent variable the friendship network matrix is used to map whom each adolescent views to be a friend over time the network thus reflects the peers each adolescent views to be a close friend at each wave this includes best friends but is not limited to them since our definition of friendship captures individual views onto their network and not dyadic consensus reflecting reciprocal ties the adolescent friendship network at each wave is constructed from two sets of variables requesting nominations of up to five male and five female friends from the school roster the total sample makes use of all available nominations control variables for controls we include whether the respondent is female grade whether the youth is white and whether the parent is single religion is also included in two ways first religious tradition is included with the following categories evangelical protestant mainline protestant catholic other religious affiliation and no religious affiliation this scheme follows the denominational coding outlined by steensland and colleagues though we combine the jewish and other religion categories due to small number of respondents in these groups 3 second the wave 1 parent interview is used to construct a standardized scale for parent religiosity for the responding caretaker coded from the following four items religious service attendance over the prior year importance of religion frequency of prayer and agreement with sacred scriptures of their religion 4 the parent education of the responding parent is included as a fivevalue variable with categories ranging from 1 did not graduate from high school to 5 received postgraduate training finally we include the number of off list nominations provided by the adolescent during the network portion of the survey although the majority of nominations in add health are to friends at school close to 30 are not in addition we also include an indicator for whether the respondent was in the restricted nomination sample because some adolescents were allowed to nominate only one male and female friend due to a survey implementation error the result of this error is that the full friendship network was not captured at the wave 1 inhome survey for 40 of the youth in the sample we carried the wave 1 inschool nominations forward for these youth5 to preserve the full network so that we could conduct the longitudinal social network analysis there will thus be greater change in the networks for the restricted nomination than regular sample so we have constructed this indicator to reflect the fact that overall change in friendships will be greater for these adolescents the model studying religionbased network selection processes is complicated by the fact that the model must account for tie changes between individuals consequently the model must consider both who is a friend with whom and who is not socialization processes reflect how individuals change in response to characteristics of their friends as well as the changing composition of friends over time as interpersonal interconnections change changes in behaviors can also feedback to influence the friendship network to the extent that selection is a salient interpersonal process in order to address this complicated set of interlocking processes with friendships predicting changes in religion and religion predicting changes in the friendship network the analyses presented in this paper utilize the new class of simulation investigation for empirical network analysis models developed by snijders and colleagues the model has a number of advantages over traditional analytic approaches for instance the model incorporates friendship preferences as well as structural network mechanisms and direct information on friends in the network allows estimation of how friends influence each other these models are unique because they are designed specifically to model tie changes and simultaneously link these alterations to changes in behavioral variables so that socialization effects control for selection and vice versa the parameters are estimated by constructing models decomposing the total amount of change in the networks and religion between observation moments into a series of smaller changes called microsteps in the siena procedure these microsteps reflect one change in either the interconnections or the religious behavior of a focal adolescent that together across many microsteps aggregate up to produce the total amount of observed change in application this means that the estimated coefficients capture changes in the logit of creatingkeeping or terminating one tie in the network selection portion of the model or the logit of a oneunit change in a religion measure the sequence of these microsteps is designed to be a markov process where changes in friendship and religion are linked together and modeled jointly for more detailed and technical discussions see snijders et al and steglich et al friendship selection processes are studied in the network portion of the model since selection reflects changes in friendships over time that result from prior religious belief activity or affiliation and from structural as well as other factors this model component specifies the effects of network structure and adolescents attributes on change probabilities in friendship status religious selection is operationalized with three parameters including the influence of religion on the number of friends chosen the effect of religion on being chosen as a friend and a dyadic religion similarity effect religion similarity ranges between 0 and 1 and expresses how similar the adolescent and their friend potential friend are to each other and is the key homophilous selection parameter under scrutiny friendship choices can depend on the configuration of the network more broadly so a number of network structure effects capturing triadic network closure processes are also included along with parameters for the control variables the adolescent potential friend and potential friend and focal adolescent operationalizations these effects are described in table 1 the friend socialization process is captured in the religion dimension of the model since individual changes are motivated by friends religion and other factors this component models individual religion with functions of network statistics and the main effects of control variables in a way analogous to logit coefficients from ordinal logit models the key socialization parameter a network statistic is the average religion similarity between the focal adolescent and their friends as we indicate below it is possible to include other network effects however those we explored using score tests were unrelated to changes in religion and so have been omitted control effects include main effects of the background variables indicating increases decreases in religion as well as the shape parameters both linear and quadratic describing the distribution of religion over time these parameters are described in table 1 analysis the analysis uses the siena software to model friendship and religion changes in the joint combined social network of the schools because youth in different schools are unable to select each other as friends outofschool elements in the sociomatrices are fixed all respondents were included in the analysis and were allowed to enter the study later or leave early using the composition change method of huisman and 6 first there is a full metaanalysis approach requiring estimation on each network separately this approach is generally considered preferable because it allows parameters to differ across networks there were estimation problems due to the small network sizes model complexity and limited observations over time however so we opted to use this simpler method in other work with these schools results have tended to be nearly identical whether network models are grouped as we have done here or the metaanalysis approach is used the second approach treats schools as different time periods and so allows rate parameters to differ across schools while fixing the coefficients inferences were virtually identical to those reported here so we have used the joint network approach since doing so simplified other aspects of the project management a positive effect implies generalized reciprocity while a negative effect with a positive transitive triplet effect suggests local hierarchies b this effect is an inverse effect of network closure so effects tend to be negative suggesting that indirect connections tend to close through eg the formation of transitive triplets or else the indirect connections are lost snijders missing attribute and religion data were treated as noninformative following the method described by huisman and steglich parameters were tested using tratios of the coefficient estimate divided by standard error based on findings indicating that the distribution follows an approximately standard normal distribution additional parameters that were tested but not included in the analysis are also presented at the bottom of table 1 score tests were used to determine if these parameters improved the model performance against a baseline model including the network structure effects and religion influence and selection parameters because these parameters did not improve the model performance they are not included in the model series we present score tests were also used to simplify the model structure with respect to the control variables ego alter and similarity parameters were omitted from the model specification when they were not statistically associated with half of the outcomes to maintain a consistent model structure across behavioral and network processes finally the contribution of the different processes to the autocorrelation between the friendship network and the religion outcomes is decomposed by the method described in steglich et al the spatial networkreligion autocorrelation is calculated using morans i across a special model series disaggregating the contributions of different mechanisms in this way religion similarity is decomposed into the proportionate contributions of selection socialization alternative selection and influence from the other control variables and structural network effects and general trend effects in friendships and individual religion results descriptive statistics descriptive statistics for the religion outcomes at both waves are presented in table 2 average service attendance is 3 on a scale of 14 with approximately equal proportions increasing or decreasing their scores over time in addition the average similarity between friends is over 7 indicating that friends are on average about 70 similar to each other in general average similarity at wave 1 is high for all of the outcomes youth service attendance is the lowest at 69 and no religious affiliation is highest at 84 these results indicate that friends religious homophily is already substantial by the later grades for youth who attend small schools in addition 3045 of youth increasedecrease their participation or religiosity over the study period while much smaller proportions change their affiliation andor born again status although there is substantial preexisting similarity the considerable change in participation importance of religion and prayer indicates that adolescent religion is not fixed over this time period the amount of change in the identification variables is much smaller and the total proportion of nones is also low which suggests that there is less information for identifying social dynamics of religious identification than for participation importance of religion and prayer descriptive network and covariate statistics are shown in table 3 on average youth nominated 24 offlist friends while sending and receiving approximately 33 friend nominations about 12 of which were reciprocated moreover adolescents were in nearly 34 transitive triplets two 3cycles and were connected to seven other students through one intermediary the sample is almost entirely white and only 22 reside with a single or divorced parent half of a these columns present the proportion increasing or decreasing their religion between waves b this column presents the combined proportion increasingdecreasing their religion between waves the sample is affiliated with an evangelical denomination 23 are affiliated with a mainline denomination and 11 are catholic finally the average responding parent in the sample had between a high school degree and some college attendance model results we present coefficients and standard errors for the service attendance model series in table 4 in the logit metric the first service attendance model denoted s1 includes the religion and structural parameters in addition to the off list and restricted nomination sample controls because these models are complicated and not familiar to most researchers we begin our interpretation of the model with a discussion of the structural rate and shape parameters the outdegree parameter is negative because the network density is low given that the average adolescent nominated fewer than four friends who were also present in the network at the same time the reciprocity parameter expresses the tendency for friendships to be reciprocated the transitive triplets 3cycles and number distance 2 are three ways to express network closure in this case friendships tend to form among the friends of friends to the effect that the odds of a friendship that closes a transitive triplet are larger by a factor of 155 while friendships producing the other two structural patterns are less likely as indicated by the negative coefficients this suggests that there are local hierarchies so that some youth are more popular in their local network neighborhood than others as implied by the combination of the positive transitive triplet and negative 3cycles effect moreover distance 2 connections tend to close over time or to be removed these factors thus drive friendship change and consistency through structural closure processes before interpreting the focal parameters we turn briefly to the rate parameters to clarify them although we do not view them as substantively meaningful rate parameters capture the change opportunities in either the selection and socialization models at each microstep of the routine thus there were an average of 127 friendship change opportunities which were 44 higher for the restricted nomination sample reflecting the longer timelag between networks for this group and three opportunities to change service attendance we do not view these as substantive parameters since they reflect the number of microsteps needed for the dataconstrained simulation portion of the estimation algorithm to reproduce the total amount of change in the network and religions variable the shape parameters capture the distribution of service attendance so the other parameters in this part of the model reflect movement along this distribution the fact that the linear and quadratic parameters are both positive indicates a shape function with small frequencies at low values and high frequencies at high values in other words the frequencies increase at an increasing rate which is consistent with the descriptive statistics showing high levels of service attendance among these adolescents finally the service attendance parameters in the network selection model indicate a tendency for more religious youth to be more popular that there is no difference in the tendency to nominate others and most importantly that there is homophilous social selection the odds of having a friendship relative to not having one are approximately 138 38 larger among perfectly similar compared to maximally dissimilar youth all else equal moreover average friend similarity is large and positive in the service attendance model which shows that individual service attendance changes to become similar to that of friends a form of social influence we have referred to as socialization the odds of increasing service attendance is 65 times larger for an adolescent maximally similar to their friends than for one maximally dissimilar but it is important to note that full coverage over that range is not realistic particularly when considered in light of the fact that selection is operative and that preexisting similarities are large more realistically each average similarity difference of 1 relative to friends raises the odds that attendance increases by 121 21 these results are thus consistent with the idea that both selection and socialization processes take place simultaneously so that changes in religious attendance is responsive to that of friends even while it forms a basis for friendship the remaining models s2s5 build the full model by including the background factors in groups although the magnitude of the homophilous selection parameter shrinks by model s5 when parent religiosity is included service attendance selection remains an important process in the model the same holds true for socialization which also remains large and significant across models the other parameters in the model indicate that friendships tend to form among those of the same gender same grade similar parent educational backgrounds the same family structure and the same religious tradition moreover whites reported more friends than minorities in these schools and were more likely to be friends notably youth whose parents were religiously similar were more likely to be friends as well results for the service attendance portion of the model further indicate higher levels of attendance among those with more educated and religious parents notably the no affiliation effect is significant this captures a regression to the mean since the nones had very low involvement at wave 1 a few increased their involvement leading to the counterintuitive estimate this finding shows a few times over the course of the analysis overall comparing effect magnitudes for the service attendance selection and influence processes is complicated by the meaning of the similarity measures used and the fact that the coefficients are derived from two different probability models in order to facilitate comparisons we have decomposed the networkbehavior autocorrelations into key model components in table 5 7 results are presented for each of the outcomes so we will refer back to this table to supplement the additional outcomespecific results the networkservice attendance autocorrelation is observed at 41 and the estimate at 39 is very close to this value in model s5 over 64 of this reflects the trend of existing homophilous friendships and the consistent pattern of attendance observed among these youth approximately 92 results from selection similar to the amount due to the other background factors including the influence of parent religiosity and nearly 20 from socialization these findings suggest that the influence of friends plays a larger role than friendship preferences a subset of results for the remaining outcomes is presented in table 6 two models for each outcome are reported the first corresponds to model s1 in table 4 and the second corresponds to s5 only focal parameters in the network portion of the model are included because the other coefficients are generally similar to those reported in table 4 youth service attendance shows stronger signs of both selection and socialization than service attendance does as indicated by the larger coefficients indeed both key parameters are significant in y1 and y2 once again suggesting the presence of irc processes the autocorrelation results in table 5 corroborate and elaborate this approximately 35 and 27 of the 38 autocorrelation results from socialization and selection respectively moreover the proportion due to trend effects is much smaller because youth service attendance is more socially responsive than regular service attendance in y2 the alter effect is also marginally significant suggesting that more involved youth are also 7 these are estimates of the decomposition and there is uncertainty in these estimates that is not quantified this uncertainty reflects other factors such as the uncertainty in the parameter estimates themselves moreover as one anonymous reviewer pointed out it remains possible that the proportionate contributions do not fully capture the endogenous process resulting in some misattribution of the contributions made by both selection and socialization because of the narrow time frame that the study covers more popular all else considered with respect to youth service attendance females decreased their involvement relative to males over time surprisingly and in contrast to regular service attendance parent religiosity was unrelated to youth service participation note too that the negative linear and positive quadratic slope for the shape parameters indicates a bimodal distribution with groups of youth at opposite ends of the distribution importance of religion is also a dual process combining elements of social selection and socialization in both the simpler and more complicated model interestingly youth for whom religion has greater importance both receive fewer friendship nominations and report fewer which when considered in conjunction with the selectivity parameter suggests that they are more exclusive in who they consider friends as shown in table 5 although trend effects indicating some state dependencies are important nearly 25 and 17 of the 42 autocorrelation reflect socialization and selection respectively importance increased for those with single parents and no affiliation over time and among those with more religious parents results are somewhat similar for frequency of prayer at least in terms of support for the idea that prayer is both a source of friendship selection while also being responsive to friends prayer with both contributing about 15 to the estimated autocorrelation as with importance youth who pray more are also more socially exclusive both in nomination receipt and in who they view as friends surprisingly parent religiosity is unrelated to changes in prayer at the same time females youth with more educated parents those with single parents and the unaffiliated all increased their frequency of prayer the final set of outcomes captures religious identification despite the low numbers of religious nones and the small amount of total change in this variable between waves model n2 reports selection and socialization effects with each accounting for over 20 of the 25 autocorrelation whereas those who pray frequently and place a great importance in religion were less popular model n2 shows that those with no religious affiliation are more popular of the background factors only parent religion predicted no religion youth with more religious parents were less likely to be a none identifying as a born again christian is also related to friendship selection while also being responsive to whether or not friends identify as born again although born again youth are more popular they report fewer friends when combined with the selectivity parameter this suggests once more that more religious youth are more cliquish mainline and catholic youth were substantially less likely than evangelical protestant youth to report being born again as were those with no and other religions though these latter two effects were not statistically significant discussion and conclusions sociologists have long been interested in the social nature of religion but directly incorporating different social and contextual processes into the study of religion has proven challenging we sought to remedy this situation by examining the social nature of religion with the adoption of a dynamic longitudinal social network analysis framework in so doing this study offers a number of innovations and unique insights into the sociological study of religion while also extending the adolescent research literature and providing a broad empirical assessment of a key expectation derived from interaction ritual chain theory when viewed crosssectionally the youth in this study prefer friendships to those who are religiously similar even so religious participation devotion and identification changed for many and these changes were systematically related to changes in the friendship network we have shown that religion whether measured as participation devotion or identification is pervasively social among adolescents who attend small schools that is religion is a source of social attraction influencing who spends time with whom and is thus a source of the religious homophily that has been noted by others at the same time however individuals religious participation devotion and identification also respond to that of friends which shows that how people engage with religion is subject to the same social forces as other behaviors and preferences such as alcohol use and music tastes in fact the results show that socialization plays a somewhat larger role than friend selection in explaining network autocorrelation for four of the six measures of religiosity overall then these results suggest that both processes captured in our first two research questions play an important role among adolescents who attend small schools but that of the two socialization appears to be a slightly stronger force than selection since we estimate that it accounted for 25 vs 17 of the autocorrelation on average given the salience of these two processes and the fact that neither is predominantly important these results are consistent with the idea that religion and networks mutually influence one another overall we interpret this to be more consistent with irc theory expectations than the traditional frameworks motivating the first two mechanismspecific research questions although scholars have recently begun incorporating social contexts into the study of religion using multilevel approaches to operationalize grouplevel effects these studies have a number of limitations that we have begun to address here first they tend to focus on congregations as the relevant religious contexts we have shown that religion can be important and pervasive in other social contexts too religious contexts are not selfcontained and they clearly spillout to influence social processes in other settings collins framework suggested that this would be the case because the powerful symbols religious participation generates create a foundation for interpersonal interaction which renew old and generate new symbols and thus lay the foundation for interpersonal influence and changes in religion second grouplevel effects as typically operationalized and modeled take the whole group to be a monolithic entity in which the interpersonal processes unfolding within them are invisible to the analyst these processes are undoubtedly important as adolescents compete for standing and acceptance in peer crowds that extend beyond the local friendship groups studied here and even into the broader adolescent marketplace for relationships while group effects matter for religion there is also a great deal of social activity within larger groups religion among the adolescents comprising this study was an important part of those dynamics religion is both consequential for structuring the group itself and is differentially distributed based upon the subgroup friendship structure through interpersonal friend socialization processes this demonstrates that the difficulties of incorporating social contexts into studies of religion are exacerbated by the fact that individuals influence their environments so that the flow of influence between group and individual levels is nonrecursive third some years ago white critically noted that a psychological consonance model had become dominant in studies of religion and we believe it still remains commonplace albeit often implicitly according to white this model assumes that theology is the primary source of religious behavior even so motivations for studying aspects of the interpersonal dynamics of religion have long been evident in the sociology of religion though the theoretical focus tends to be on only one of our equations namely the role of selection or socialization in contrast our results suggest that a broader conception of interpersonal social process and religion may be warranted that is there is jointness in the friendship selection and socialization processes leading to social congruence the role of theology in predicting religious behavior may in fact be less central than has been assumed thus a broader integration of collins irc theory into the study of religion and more broadly in adolescence since the social forces at play in religion may be similar to those for risky behaviors should prove fruitful the approach we adopted is inferentially stronger than others since we measured the network directly and thus the behaviors of friends were measured directly moreover the siena models we employed allowed for both selection and socialization processes to be assessed longitudinally and concurrently most research on religion and social networks is handicapped by reliance on the information that respondents provide about their friends religion but not their friends actual religion or the religion of their potential friends in their personal networks this information on potential friends was an integral portion of the analysis allowing us to clearly identify how religion is incorporated into selection processes consequently change in our models was not biased by either inaccurate cognitions that arise when individuals impute the behaviors of others or the reflection problem that is inherent in multilevel analyses because reference groups cannot be identified just as there are strengths to this analysis there are also a number of important limitations that circumscribe the generality of our findings first this study covers only a 1year period over adolescence while studies among adults suggest similar social dynamics of mood across the lifecourse more studies over longer periods and age ranges are needed the result of this limitation however is that some youth may already be going through transitions in both friendships and religion and it is not entirely clear if two waves are sufficient to completely disentangle this process second the schools in our sample do not comprise a random sample and so generalizability as with most social network analysis studies is suspect third while we have limited our analysis to friends that adolescents feel closest to social influences and possibly even selectivity may extend out further into the network this could reflect the desire to participate in crowds like jocks or geeks indirect connections to other youth whom adolescents share friends with or romantic partners and their friends that is we have only captured a narrow albeit important slice of adolescent social life fourth our analysis is limited to adolescents in small schools leading to concerns that social processes may differ substantially across settings indeed there are several reasons to believe that the social dynamics of religion may differ by school size for instance youth in small schools have more knowledge of each other and they are more connected to each other and to their schools just as attendees of smaller congregations are more likely to know one another in addition there is evidence that network processes vary across schools school size has a large impact on administrative factors and the structure of the curriculum which via course selection can constrain friendship opportunities in larger schools and thus the knowledge that students have about each other such as their religious affiliation and involvement there will also be more opportunities for shared religious experience among adolescents in smaller settings to the extent youth may be more likely to attend the same religious congregations as a result of these factors we have focused on this set of smaller schools as the first step in a larger research agenda studying broader sets of schools across a deeper set of more heterogeneous settings is an important goal to be addressed in future research even with these restrictions however the findings we present here are highly relevant and show that at least in some places in contemporary america about 770 k students attended small k12th schools over the 2009 2010 school year religion among adolescents is very socially dynamic future research will shed further light on the extensiveness of these processes across settings but as we have shown models of individual religious change should strive to incorporate a richer interpersonal backdrop this is of course not a new proposition sociologists since durkheim weber simmel and troeltsch have argued that religion is social in nature in this article we offer new model and empirical evidence to support this proposition that religion is a social phenomenon both in the sense that religious similarity promotes social connections and in the way friends influence each others religious participation devotion and identification

longitudinal social network data on adolescents in seven schools are analyzed to reach a new understanding about how the personal and interpersonal social dimensions of adolescent religion intertwine together in small school settings we primarily address two issues relevant to the sociology of religion and sociology in general 1 social selection as a source of religious homophily and 2 friend socialization of religion analysis results are consistent with collins interaction ritual chain theory which stresses the social dimensions of religion since networkreligion autocorrelations are relatively substantial in magnitude and both selection and socialization mechanisms play key roles in generating them results suggest that socialization plays a stronger role than social selection in four of six religious outcomes and that more religious youth are more cliquish implications for our understanding of the social context of religion religious homophily and the ways we model religious influence as well as limitations and considerations for future research are discussed

introduction the past 20 years have seen dramatic rises in suicide rates in the united states and other countries around the world these trends have been identified as a public health crisis in urgent need of new solutions and have spurred significant research efforts to improve our understanding of suicide and strategies to prevent it unfortunately despite making significant contributions to the founding of suicidology through emile durkheims classic suicide sociologys role has been less prominent in contemporary efforts to address these tragic trends though as we will show sociological theories offer great promise for advancing our understanding of suicide and improving the efficacy of suicide prevention here we review sociological theories of suicide with the explicit goal of building bridges we begin where all sociologists must with durkheim however we offer a more comprehensive understanding of durkheims insights into suicide than prior reviews provided by nonsociologists this is critical much of the nuance and richness of durkheims insights have been lost in modern suicidology and yet durkheim is foundational to understanding sociological theories of suicide as well as understanding the potential of sociology for suicidology we also discuss limitations in the durkheimian approach and how more recent efforts have not only addressed those concerns but have done so by bringing sociologys broader theoretical and empirical toolkit to bare on suicide these insights draw largely from social network theories cultural sociology sociology of emotions and sociological social psychology we conclude by making explicit bridges between sociological and psychological theories of suicide and by noting important limitations in knowledge about suicideparticularly regarding the roles of organizations inequality and intersectionality that sociological scholarship is uniquely prepared to address durkheim explained the sociological study of suicide remains rooted in founder émile durkheims empirical study of suicide still the disciplines greatest contribution to suicidology durkheims theory posits two core principles that the structure of suicide rates is a positive function of the structure of a group or class of peoples social relationships and those that social relationships vary according to their level of integration and regulation though durkheim never clearly defined his dimensions sociologists have generally treated integration as the structural elements of social relationships like the number and density of ties and regulation as the degree to which a collectives moral order controls and coordinates its members attitudes and behaviors additionally durkheim articulated two continua and four types of suicide related to integration and regulation egoisticaltruistic suicides and anomicfatalistic suicides importantly durkheim was not interested in the subjective appraisals suicide decedents provided for why they chose suicide but rather saw suicide like alcohol abuse or homicide as a symptom of collective breakdown of society in turn rather than focus interventions to reduce suicide on individuals he argued like many population health scientists today that a more efficacious avenue to protect individual wellbeing lies in collective public projects to produce protective structural changes these changes can restore the integrative and regulative functions of the social groups to which individuals belong or lessen the intense pressure on individuals in social groups where integration and regulation have exceeded healthy levels durkheim was writing at a time of immense political economic and cultural change which in turn motivated his emphasis on the types of suicide predicated on too little integration or regulation over the dangers of too much consequently empirical research examining when and why connectedness or moral clarity might prove fatal to a groups members was sidelined until rather recently a point we will return to below integration and suicide of the two social factors durkheims integration has had the most profound impact on both sociology and suicidology in explaining the power of integration durkheim argued that the more extensive and denser a collectives social relationshipsie the more integrated the collective the more enmeshed individual group members become and therefore the more meaning and purpose individuals feel about their lives he remarked the bond that unites individuals with the group attaches them to life and prevents their feeling personal troubles so deeply he continues that suffering physically psychologically or spiritually does not exist for the believer firm in his faith or the man strongly bound by ties of domestic or political society this collective belonging protects individuals from what durkheim termed egoistic suicide or suicides resulting from isolation and a lack of collective belonging integration then is borne of the recurring social relationships that require tending and care and which are embedded in larger networks that form groups communities or perhaps even nationstates this includes being tied to families and neighborhoods as well as communities these relationships provide members with what sociologists call social capital or tangible and intangible benefits built on membership in recent theories of suicidology integration has been operationalized through perceptions about belongingness and connectedness however durkheim was not interested in perceptions or appraisals which he argued were subjective instead integration is meant to be a characteristic of the group not of individuals regardless durkheims basic premise that being highly integrated is protective against suicide has received consistent strong empirical support across time and space and disciplinary boundaries conversely the flipside of egoistic suicide suicides caused by too much integration or altruistic suicide has received scant theoretical and empirical attention in durkheims estimation tightknit societies could rob individuals of their ability to make decisions under certain conditions leading to suicides for the good of the group he pointed for instance to hindu sati a rare form of suicide in which hindu widows are compelled to throw themselves on their husbands funeral pyre though durkheim thought overintegrated suicides relics of earlier forms of society abrutyn and mueller have argued they are more common than we think pointing to the literature on social capital and on suicide clusters they argue that in the mesolevel of society we can find numerous examples of communities where social structure can be exceedingly dense like some religious communities high schools and neighborhoods army bases and institutions like prisons or psych wards indeed many of these places are disproportionately vulnerable to the emergence of suicide clusters this highlights potential downsides to connectedness such as groupthink or high costs for nonconformity and cautions scholars from positing connectedness as a purely protective phenomena regulation and suicide durkheim also argued that suicide rates were related to the degree to which a given groups rules and social norms were consensually clear coherent and shared living in a poorly regulated society or social group resulted in what durkheim termed anomic suicides in essence durkheim posited that humans as animals were not inherently moral creatures but had to acquire morality from without notably moral was synonymous with social in durkheims day and thus he saw social bonds as having integrative features like intimacy and regulative features like moral obligations and expectations thus durkheim set up several routes to deregulation causing suicide first societies where norms were constantly changing and or where there was a general breakdown in moral clarity peoples ability to easily identify their purpose would be constantly under attack second regulation could suddenly be weakened either by a change of status in the individual or by a collective crisis that challenged societys ability to provide clear moral or social guidance in short durkheim saw a sense of shared moral clarity as an independent force providing protection to members of a group while durkheim emphasized the societal level it is important to note that we can also develop moral relationships with a group and an abstract system of norms which expands the web in which a given person may find themselves protected like integration too much regulation may also cause what durkheim termed fatalistic suicide for durkheim fatalistic suicides occurred when members of a group or social category were subjected to intense psychic and physical coercion such that there was no hope for a future without suffering though baumeister has argued suicide is very often about escape from pain like other durkheimian types fatalistic suicides refer to a class of suicides that are not limited by specific individual motives to date few studies have explicitly explored durkheims fatalistic suicide though we can provide some examples of its possible research potential first structural inequality or violent oppression within families or communities may render groups of oppressed individuals disproportionately vulnerable to suicides for example we know that women in violent relationships often feel trapped and overregulated and are more susceptible to suicidality women in rural china or iran for instance may also fit this pattern as may women of color who emigrate to another country and find themselves in precarious employment situations second suicide bombers are often overregulated which may produce the type of structure that delimits options for resisting and expressing ones obligations to their community durkheims limitations despite the importance of durkheims theory to suicidology generally and sociology of suicide more specifically durkheims theory is not without limitations which have in turn shaped more contemporary sociological theories of suicide one of the oldest and most notable limitations of durkheim is methodological durkheim fails to adequately address the ecological fallacy of studying suicide rates to understand individual behavior durkheim forcefully argued that societalor macrolevel forces caused individuallevel behavior and yet the link between societallevel social forces and individual behavior is challenging yet crucial to document compounding durkheims methodological limitations was the intellectual climate of his day as a nascent discipline durkheim worked hard to distinguish and legitimize sociology apart from psychology and anthropology hence using social psychological or cultural ideas two sets of phenomena associated respectively with the other disciplines was impossible he could not for instance think about identity or emotions in sociological terms and therefore could not bring sociology into the microlevel of social reality as we shall see this limitation as well as durkheims explicit rejection of gabriel tardes imitation theory has also constrained contemporary sociologists until rather recently from thinking about how suicide may spread from one person to another finally durkheims own lack of attention to power and inequality and the legacy it has generated represents a major limitation though durkheim sees regulation as comforting and supportive there is a line between moral authority being an anchor in a chaotic storm and it being a source of domination and oppression this line as we shall see has obscured the role inequality stratification and oppression play in suicidality in short regardless of the importance of durkheims basic insights they fall short of helping us understand why a particular person dies by suicide and the mechanisms through which external social forces get inside someones psyche generating pain and rendering them vulnerable to suicide in this next section we map sociological advances in understanding suicide by focusing on the new structural and then culturalsocial psychological approaches that have emerged over the last two or three decades to be sure durkheims approach continues to loom large over sociology with a recent review lamenting the sheer lack of new approaches to the sociology of suicide and thus while we highlight all major scholarship and theoretical contributions as possible the basic dearth in research programs or teams is a more general limitation of the sociology of suicide like durkheim these theoretical and methodological projects build on the idea that there are emergent distinct properties that are not reducible to the individual and her perceptions or decisionmaking yet they do not deny the importance of intrapersonal factors instead they seek to supplement them collectively these advances have great significance for general theories of suicide and for suicide prevention structural insights one of the first big innovations to durkheims macro theory was to incorporate advances from structural sociology and namely insights from social network theories to elaborate how social integration and regulation matter to suicide social structure is a notably elusive concept but it usually refers to sets of stable social arrangements that evince certain properties regardless of the specific incumbents social structures deeply shape individual life chances by sorting us into particular opportunities experiences subcultures social roles and obligations they can be both easy to measure as in the neighborhoods we live in or the schools we attend or complex and intangible network theories facilitate the identification of local social structures that are salient to the individual and more closely capture the reality of the social world that surrounds them in their daily lives one of the greatest advances in sociology of suicide is the social network elaboration of durkheims theory this approach allows for greater specificity of social structures and crossfertilization with contemporary social theory with durkheims societies translated into the operation of different networks solidarity comes from the presence of strong interlocking social relationships the power of the external social world is preserved while situating the individual more realistically in it another advantage of a network approach is that it avoids the overly optimistic view of personal ties as always protective indeed a plethora of work within the social network perspective has long demonstrated that the presence of negative ties is potentially more powerful in affecting individual wellbeing than positiveties perhaps most importantly a network approach highlights how integration and regulation coexist and in fact likely codetermine placebased vulnerability to suicide an idea that is contrary to durkheims four distinct idealtypes of suicide instead scholars advanced a curvilinear theoretical predictive plane with four dangerous poles matching durkheims types one dimension running from left to right represents integration another dimension running from back to front represents regulation both dimensions run from high to low and their interaction generates the four types of suicide when individuals live in social structures characterized by too little integration or regulation the threads of the social safety net are too far apart to catch them when crises destabilize their equilibrium egoistic and anomic suicides are then theorized as diseases of the infinite because of the extreme gaps in the societal safety net that normally support individuals during times of individual or community crisis conversely the social safety net closes up when social structures are overregulated or overintegrated with no flexibility or give in the safety net individuals who experience crises hit a wall that shatters rather than supports it is in the center of the net where ties are moderately integrated and regulated that individuals can be safely caught and restrained from their suicidal impulses a recent study illustrates the power of this structural approach using novel us data connecting the social profile of individuals to the social profile of the communities where they live the study draws from social network theorys principles of selective attachment or homophily and differential association specifically researchers examined whether the presence of more like or similarothers would affect individual suicide risk and found that community sameness generally reduces individual risk of suicide this multilevel examination of individuals embedded lives provides a glimpse into how sameness taps into structural ties normative climates and social diffusion processes in fact some of the most robust suicide research findings at the individual level are dramatically moderated by a consideration of their social environmental counterpart recent research further reaffirms the notion that current gaps in societal safety nets contribute to emotional distress and suicidality during the covid19 pandemic collectively these findings suggested a critical and fundamental sociological insight into suicide connectedness is protective to a point where there are too few others at risk socially supportive ties may be unavailable but when others share the same fate the sense of individual failure transforms into structural failure potentially reducing the psychological harm of the experience but when that sense of despair or fatalism engulfs the community as a whole the ability to see any future can be restricted in isolated and historically stigmatized communities these studies illustrate how essential it is to consider the roles of social structure and culture in social interaction as a core feature of theories of suicide to not do so contradicts basic contributions to contemporary population health research it also illustrates that while durkheim offered foundational insights into suicide focusing overly on his specific hypotheses rather than the general theoretical propositions or attempting an artificially general theory of suicide only weakens our capacity to understand how the external social world shapes suicide and while structural insights into suicide represent major advances contemporary sociological research raises two theoretical issues that cannot be ignored and must be synthesized into the understanding of suicide as a complex phenomenon culture and contagion exposure to suicide while durkheim presented himself as a general theory of suicide there are intricate aspects of social interaction that fall outside his purview but are related to how social structures and connectedness impact suicide a second major line of sociological scholarship examines exposure to suicide through ones social networks and communities and in so doing offers perhaps the clearest example of how social ties can produce harm decades of research from a variety of methodological approaches and causal modeling strategies has confirmed that exposure to media reports of suicides especially celebrity suicides or personal role models like parents or friends is associated with increased risk of suicidality this line of research emerged from a series of studies by sociologist david phillips that found that suicide rates among audiences exposed to media reports of suicides would spike temporarily at the time this was radical in that durkheim famously denied the roles of microsociological processes related to social interaction as well as diffusion or contagion in suicide phillips turned to a forgotten sociologist gabriel tarde to think theoretically through what he came to call suicide suggestion a term derived from tarde who wrote about the diffusion of ideas and behaviors through social relationships tarde was what would be called a social psychologist but in the late 19thearly 20th century his epistemology was too close to psychology and thus durkheim rejected it out of hand durkheim firmly committed to the idea that larger structural forces were causal and thus he is usually understood as rejecting the idea that suicide could spread or be socially contagious and while research has repeatedly found using more conservative methods than phillips an association between media exposure and increases in suicide rates like durkheim these studies fall short in their ability to identify the primary mechanism or mechanisms that link the media exposure to the individuallevel actions nevertheless a series of promising studies emerged following phillips work which focused on the consequences of being exposed to a personal role models suicidality with the growth of network analysis in the 21st century suicide scholars in this burgeoning tradition began taking cues from network studies that found many social behaviors like obesity and smoking were socially contagious net of individual factors it became apparent that the structure of a persons social network mattered as longitudinal research found that adolescent exposure to friends of friends was associated with greater risks of suicidality likewise networks appear to have gendered effects with girls being most at risk of suicidality when they have exceedingly small social networks or are immersed in exceedingly large ones additionally in a groundbreaking study baller and richardson used spatial analysis to determine how crucial characteristics of place like the degree of infrastructure are to the clustering of suicides in places they concluded that the structure of place and diffusion processes cannot be divorced from each other once again illustrating the importance of theorizing and modeling the multiple levels of society within which human behavior is situated despite these advances the question remained why and how suicide contagion worked while this is still an area in need of further exposition in one unique study researchers leveraged network data with pairs of adolescent friends to determine whether knowledge of a suicide attempt was necessary for suicide contagion to occur the study found that youth who did not know their friend had attempted suicide were not at higher risk of suicidality over time though if they did know they were additionally exposure to a friends suicidal thoughts was not sufficient to increase risk of suicidal thoughts or behaviors 1 year later these findings suggest the power of behavioral role modeling how why and when social behaviors diffuse through social networks or contexts is an important and ongoing area of inquiry within sociology of suicide specifically and social network science more generally regulation culture and behavior while these structural sociological theories described above offer multiple important advances for the sociology of suicide they leave several unexplored social scientific questions specifically what mechanisms translate structure into meaningful social beliefs and practices that shape our attitudes and behaviors related to mental health and ultimately suicidality arguably these gaps in the sociology of suicide can be addressed by drawing on insights from the broader theories in the sociology of culture and sociological social psychology the incorporation of culture and sociological social psychology matters for several reasons eschewing explanations that motivate behavior by intrapersonal perceptions sociologists have generated substantial evidence that individual behavior is motivated and justified in reference to the web of social relationships and the broader structures and cultures in which these are embedded we begin by reviewing theoretical advances that reconceptualize durkheims regulation as a cultural force to better elaborate how culture shapes behavior and suicide durkheims choice of regulation as a key causal force was rooted in the idea that collective ways of acting and thinking not only reinforced integration that is everyone is or is believed to be doing the same things and thus share more than they differ but that they were psychologically emotionally and socially healthy although durkheim could not imagine using cultural analysis his conceptual ideas about regulation square quite neatly with contemporary cultural sociology groups of all sizes have cultures and these cultures are shared within reason providing individual members with a sense of who they are what they are supposed to feel think and do under various conditions and what it means to belong to that group culture is activated every time members interact in real life or when one member anticipates or imagines interacting with another member culture is also activated whenever we come into contact with externalized representations of it such as a catholic individual seeing a crucifix members watch each other and sanction each other to regulate each others behavior however culture also is internalized in our conceptions of the generalized other people do not just act because they do not want to be sanctioned by others but rather are motivated to act by the cultural schema scripts and frames they are exposed to and internalize and come to take for granted as normative this set of insights is fundamental to explaining social behavior of all kinds but has largely been neglected in suicidology even as structural and psychological accounts of suicide have been criticized since the 1960s for ignoring the role cultural meanings play in understanding and explaining variations in suicidality across time space and groupsclasses of people and though it may be tempting to dismiss cultural regulation as a causal mechanism research on other types of behavior shows culture not only shapes us it regulates us morally that is it may proscribe or prescribe a behavior as a normative option under a shared set of conditions this is imperative for suicidology for two reasons first the last two decades have seen theories attempting to explain how suicide ideation is transformed into action expand dramatically second these theories largely neglect the simple fact that suicide is a social act and therefore is replete with cultural meanings that attempters symbolically externalize to their intended and unintended audiences who make sense of the suicide via meanings they too have internalized put in the language of many current psychological theories cultural sociology argues that suicide is not just about acquiring the proper cognitive and practical capacities to attempt but also the normative capacity or the belief that suicide is a viable and socially acceptable option for expressing outwardly something felt internally recent decades have seen a growing body of historical anthropological and sociological evidence supporting the argument that culture matters to suicide research clearly demonstrates that societies andor subgroups within those societies carry different beliefs about suicide across time and space and death more generally these beliefs ultimately contribute to notions of when suicide is justified if ever and therefore erect prohibitions for entire classes of people or may make suicide a normative option this argument extends beyond whole cultures and applies to subpopulations and their subcultures for instance research has shown that how americans interpret the suicides of men and women is through very different cultural scripts which has consequences for how their performed suicidality may be expressed and received by both the attempter and her intended audience and for which type of person might be at risk of suicide under certain conditions other research has found distinctive beliefs and subsequently suicidal practices among young latinas in the united states in rapidly growing urban spaces in southern india and some indigenous communities in the united states and canada a second body of research underscoring the role of culture in suicide comes from a clinical psychology of bereavement in short robert neimeyer and his many collaborators have demonstrated that sudden deaths like suicides are shocking and compel individuals to make sense of them to sift through available meanings as part of the bereavement process though not a sociologist neimeyer and colleagues repeatedly find that meaningmaking and bereavement always occur within the confines of a collective as they build a coherent sense of why the death happened through each members individual meanings and more general societal ones in the event that collective meaningmaking fails or that unhealthy meanings are arrived at bereavement can become prolonged thereby placing the individual at a significantly higher risk of emotional distress and suicidality a similar set of studies examine how structure and culture interact together marrying durkheimian insights to some of the more innovative cultural studies for instance research in indigenous communities has made important connections between the social cultural and geographic circumscription that delimits social networks within some indigenous communities to the intergenerational negative affect experienced and passed on due to discrimination and prejudice in one community for instance youth associated suicide with belongingness that is to die by suicide was to express ones commitment to the groups expectations and its members in rural china fei also identified linkages between structure and culture where traditional patriarchal families tightly constrained womens ability to express grievances suicide had become means of expressing grievance justice and anger finally in a recent publication sociologists muller et al leveraged extremely unique longitudinal data linked to death records to examine how male adolescents desired occupations translated into risk of suicide by midlife when those occupations became unavailable due to economic declines in those occupations the structural changes in the labor market interacted with cultural ideals for work and success such that when worked declined men who expected a reliable workingclass job were more likely to die by suicide than their peers this study suggests that it is not simply occupational or education attainment that generates risk of suicide and not simply economic societal changes but rather the macrosocietal translates into distress through an individuals cultural values identities and expectations a third set of studies revolved around an indepth ethnographic case study of a community called poplar grove a white affluent homogeneous community with an intense highpressure culture revealed that youth and parents alike had developed suicide explanation that had expanded for whom suicide was an option youth believed other youth used suicide to escape the intense pressure and that the misery induced by the pressure caused suicide though more research is necessary on this this study suggests that identification with perceived and socially legitimated motives for suicide may increase youths vulnerability to suicide and may be one explanation for why suicide clusters form and persist further teasing out the mechanisms that translate external social environmental factors into internal psychological pain is a crucial project for the sociology of suicide one strategy is to integrate principles drawn from sociological social psychology a project the sociology of suicide has recently begun and which we turn to next the necessary role of social psychology although durkheim was not and could not be a social psychologist contemporary sociological social psychology offers key mechanisms for understanding and explaining suicide within the context of structural and cultural contexts durkheim recognized in suicide that individuals membership in a specific group or category of people made them more or less vulnerable based on that collectives integrative and regulative characteristics contemporary accounts have extended these insights linking them to individual feelings or beliefs about who we are and what we are supposed to be doing however it is the mechanism linking us to the group or what sociological social psychologists call identities and the emotional attachment we have to our identities and to the group that help us make sense of why structures and cultures may be harmful or protective the basic premise of a social psychological theory of suicide then rests on four key aspects of identity and emotion first persons whose identity is structurally and culturally embedded in a relationship group or broader social system will feel higher levels of commitment to the identity commitment depends on both intensive and extensive social ties that evoke the identity second where commitment to an identity is high the person will also be affectually attached to the bond itself third the more committed an individual is to an identity and attached to a bond the more influence other members have on the feelings thoughts and actions of the individual fourth where fewer alternative identities and bonds exist subjectively andor objectively cultural regulation will be at its most powerful as continued commitment and attachment are more desirable than exclusion and isolation below then we examine a little more closely what identities are and why emotions especially social emotions can help explain suicidality identity identities are internalized meanings that cluster around how an individual understands themselves as a social object in relationship to a real person a group a social class or an abstract collective which are embedded in social structure and culture in turn like the example of catholic objects imbued with collective emotions and public meaning our identities are objects inseparable from the collectives they are anchored which makes them as emotionally charged as the external objects themselves they matter to us because the relationships that allow them to exist matter and like any object that takes on meaning in interaction relationships are where people acquire these identities as they learn about who they are the expectations that others have of them and that they have others what rewards performances and influence they can expect to have and so forth identity matters then to suicide and mental health because it is one prominent pathway through which the external social world comes to matter to perceptions of self our identity renders painful the possibility of exclusion rejection and isolation from cherished social groups not simply because we feel lonely but because a part of our self can be damaged or lost through these social experiences and when we assign blame to our self for the rejection by a group emotions signaling we are bad or worthless may snowball into psychache and negative emotion feedback loops returning then to the study of poplar grove youth in this community did indeed internalized a very clear rigid coherent sense of what was expected of the typical poplar grove youth the small nature of the community delimited the variation in how this identity could be performed and thus made even the counterfactual cases we spoke with painfully aware of expectations and because the school took on an outsized role in community life this identity was transsituational defining nearly all of the relationships inside and outside of school this had three key consequences for the suicide problem in poplar grove first youth had also internalized the cultural script of pressure leads to emotional distress which can lead to suicide being a normative option for expressing ones identity and extinguishing the pain second the community had set most of the kids up to fail as only one kid could be captain of the football team lead actor in the big school play or most popular kid anything short of five ap classes per semester and straight as was viewed as a failure by youth making falling short of expectations the norm and not the exception third fear of failure imagining or anticipating failure and actual failure all lead to the same thing shame shame is a painful social emotion signaling that the person has not only not met expectations but are actually a bad person because of doing so it is social in that they believe whether true or not that others judge them as deficient identities are intimately implicated in this process as not meeting expectations generate negative affect that compels us to meet them but because of the second consequence described above failing was perceived as a chronic normal state of adolescence and thus we must consider in a bit more detail the role of emotions in suicidology emotions generally speaking suicidology has focused on cognitive appraisals of emotions as opposed to the affect themselves which is very often shaped by the cultural world around us emotions are both the glue of social relationships and can signal our successful integration or fulfillment of obligations or expectations or our failure to do so and as such are a fundamental element of how durkheims regulation becomes internalized into psychological wellbeing or pain thus emotions create and sustain attachments to others and our own commitment to the identity associated with the attachment in turn this level of integration engenders greater regulation as we are more likely to adopt the feelings thoughts and actions of those we are most affectually attached on the other hand emotions particularly negative social emotions like embarrassment guilt or shame are the signals that this connection is in danger dissolving or lost the link between identity and culture points then to two key insights drawn from scholarship on emotions and behavior first when we are not performing our identities as others expect or as we expect we feel negative social emotions like embarrassment guilt and shame what makes us feel bad about ourselves or creates the cognitive appraisals like worthlessness or hopelessness is very much a product of the cultural milieu that provides us with expectations about who we are and why we are supposed to do second depending on the structural and cultural context these social emotions may endure over time making it increasingly difficult to live up to expectations and overwhelming our ordinary cognitive and behavioral functions leading us to draw from existing cultural options for dealing with those emotions in particular shame or the social emotions that that the self is viewed as being corrupt polluted deficient and contemptuous by others objectively or not plays a key role research has demonstrated the role shame plays in a range of negative behaviors such as domestic violence eating disorders and criminality it also has some anecdotal links to suicide the shame pathway then can be tied directly to our discussion of social psychology identity and expectations failing to meet expectations can trigger shame in part this may be due to the publicly shared cultural meanings for instance research in cultures or subcultures with strong traditional male norms evince far more honor suicides as failure to meet masculine expectations are closely tied to suicide as a way of restoring honor sudden loss of status in most cases is followed by intense shame and the need to process the shame shame also plays a role for those in subordinate positions whose identities are wrapped up in being powerless in some traditionally patriarchal societies like rural china there may be no other culturally available recourse to processing their shame besides suicide indeed as zhangs use of strain theory and innovative methods reveal there are severe structural constraints on access to many legitimate means to reducing anxiety and stress youth too are in a relatively powerless position coupled with being at a disadvantaged cognitive and emotional developmental state that precludes being able to see far into the future shame can be experienced so acutely for these kids the availability accessibility and applicability of a suicide script may be the only ingredient missing for leading to suicide visàvis drug or alcohol abuse thus social emotions are a powerful vehicle particularly when rooted in salient social identities in valued social environments through which the external social world is translated to internal psychological pain discussion sociological theories of suicide inspired by durkheims original work help explain how the external social world matters to individual wellbeing and psychache thereby revealing the social roots of suicide the external social world is complex and multilayered and can be characterized by network structures and shared cultures which in turn impact individual group members through their social identities and social emotions that the external social environment matters to human development across the life course including to physical and mental health and even suicide is not necessarily new however as rates of suicide have climbed in the united states and around the world the importance of understanding the social environments roles in suicide and suicide prevention has become more prominent and even urgent sociology with our long tradition of specifying how society conditions human lives is well situated to answer this call while also building bridges into other disciplines implications for psychological theories of suicide many psychological theories of suicide acknowledge social and environmental factors facilitating the incorporation of sociological insights to suicide for example belongingness is critical to joiners interpersonal theory of suicide and connectedness is a key component of klonsky and mays threestep theory of suicide there are two primary ways that sociological insights should we argue be incorporated into major psychological theories of suicide first while psychological theories of suicide recognize that the external social world matters they generally distill the social world down to an individuals perception of it sociological research suggests this is insufficient and that using strategies to measure the external social world independent of a persons perception or experience is important this could be as simple as using egocentric network methodology to better measure the culture and structure of a persons proximate social environments this approach would involve having focal research respondents report their multiplex network ties using name generators and characterizing them through theoryinformed name interpreters an ideal research design then involves interviewing some of the nominated network ties so that data does not rely solely on the focal respondents perception second structuralcultural insights into suicide reveal that cultural scripts for suicide that prevail in peoples salient social groups may impact their capacity for suicide while the notion of individuals capacity for suicide already exists recognizing that normative capacity or how a groups beliefs about why people die by suicide who is expected to be vulnerable to suicide as well as when where and how people suicidecontributes to making suicide an accessible and applicable option for an individual recognizing and measuring this may be a useful pathway for future research to examine particularly given research linking explicit and implicit beliefs about suicide to suicide attempts and even death implications for suicide prevention recognizing the importance of the social environment is also critical to strategies for suicide prevention some current suicide prevention strategies recognize the potential of broader upstream environmental interventions such as the centers for disease control and preventions emphasis on social connectedness in communities the focus on building connectedness has also been leveraged to great effect in schools specifically building trust between youth and adults in schools is associated with lower rates of suicidality among students similarly there are suicide prevention interventions that address cultural biases like mental health stigma in communities or schools these interventions raise mental health awareness and normalize discussing mental health which may foster helpseeking and diminish suicidality in the entire community additionally suicide prevention strategies in healthcare specifically socalled zero suicide approaches promote changes in the social environment within healthcare organizations to improve medicines ability to prevent suicide specifically a major component in the zero suicide model is generating system wide cultural change that renders suicide prevention a core organizational goal of any medical setting finally recent research suggests that interventions into economic safety nets are associated with suicide rates specifically increases in the minimum wage are associated with meaningful decreases in suicide mortality perhaps especially when unemployment is high this suggests that macrolevel economic policies untheorized as suicide prevention may actually be powerful tools for just that while collectively these interventions show promise limitations remain for example in terms of culture much of these interventions focus narrowly on mental health stigma despite substantial research that demonstrates a plethora of cultural beliefs that can promote vulnerability to suicide and its precursors this may be particularly harmful when connectedness is leveraged in schools schools that house harmful youth cultures may find that intensifying connectedness even when combined with positive mental health messaging may at worst amplify their harmful culture or at best find that the unaddressed harmful culture undermines any positive cultural interventions similarly with regard to organizational interventions like zero suicide it is potentially not enough to encourage an organization to value suicide prevention and mental health it is likely necessary to broaden the scope of research and understand the external pressures obligations or cultural directives the organization faces and examine how mental health and suicide prevention complements or competes with those other organizational directives this critique is motivated by previous sociological research that shows that understanding how organizations balance competing goals is crucial to effective prevention unfortunately when organizations face external pressures public health safety is often deprioritized in favor of more dominant goals future directions this last point highlights a broader limitation in suicidology that in turn points to a crucial future direction for research zero suicide approaches are one of the only explicitly organizational approaches to understanding suicide or suicide prevention in general though we acknowledge the role of several key organizations schools and healthcare in suicidology we have largely neglected to theorize or examine empirically the role of organizations in suicide risk and prevention this is a major limitation since suicide prevention largely takes place within formal organizations and several formal organizations are implicated in suicide risk eg occupations military and schools it is also a missed opportunity to leverage organizational science to improve suicide prevention within organizational science there are substantial literatures that have identified how to build safety systems to prevent hard to predict tragedies like suicide an organizational approach to suicide prevention has other advantages as it can help identify existing unused safety systems in organizations that could be leveraged for suicide prevention for example schools generally have existing multitiered systems of support often for academic interventions or violence prevention that potentially could be leveraged efficiently and effectively for suicide prevention there is a second critical future direction and current substantial limitation that warrants discussion to date theories of suicide largely neglect how structural inequality colonization and intersecting systems of oppression privilege and power shape vulnerability to suicide though there have been some exiting new efforts to theorize how structural inequality and intersectionality matter to suicidology much more work is needed based on broader research within the sociology of mental healthwhich does take up this issue the patterns are likely to be complex and again not distillable to individual experiences with discrimination or prejudice prior research on mental health and inequality demonstrates that external social structures condition mental health above and beyond individual experiences while its beyond the scope of this review to propose a new theory of inequality power and suicide we can point scholars to useful theories of inequality in mental and physical health to aid them as we collectively take up this critical agenda additionally understanding inequality will likely have real consequences for suicide prevention for example though upstream suicide prevention strategies are showing great promise in schools many schools struggle to sustain even evidencebased strategies over the longrun this may be in part because many schools particularly those that serve disadvantaged youth experience intense resource scarcity thus considering the complex ways that inequality shapes suicide and suicide prevention is necessary to a robust comprehensive theory of suicide conclusion sociology is best known for our durkheimian insight into why people die by suicide namely that lacking meaningful social relationships that support us during difficult times and celebrate us when times are good is extremely harmful to individual wellbeing however a review of the full body of sociological scholarship and especially the empirical and theoretical advances of the past 10 years reveal the social roots of suicide incorporating sociological insights into how the external social environment can matter to suicide and suicide prevention may help us better understand the complexity of suicide and determine how to effectively intervene 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

the past 20 years have seen dramatic rises in suicide rates in the united states and other countries around the world these trends have been identified as a public health crisis in urgent need of new solutions and have spurred significant research efforts to improve our understanding of suicide and strategies to prevent it unfortunately despite making significant contributions to the founding of suicidology through emile durkheims classic suicide 18971951 sociologys role has been less prominent in contemporary efforts to address these tragic trends though as we will show sociological theories offer great promise for advancing our understanding of suicide and improving the efficacy of suicide prevention here we review sociological theory and empirical research on suicide we begin where all sociologists must with durkheim however we offer a more comprehensive understanding of durkheims insights into suicide than the prior reviews provided by those in other disciplines in so doing we reveal the nuance and richness of durkheims insights that have been largely lost in modern suicidology despite being foundational to all sociological theories of suicide even those that have moved beyond his model we proceed to discuss broadly acknowledged limitations to durkheims theory of suicide and review how more recent theoretical efforts have not only addressed those concerns but have done so by bringing a larger swatch of sociologys theoretical and empirical toolkit to bare on suicide specifically we review how recent sociological theories of suicide have incorporated insights from social network theories cultural sociology sociology of emotions and sociological social psychology to better theorize how the external social world matters to individual psychological pain and suffering we conclude by making explicit bridges between sociological and psychological theories of suicide by noting important limitations in knowledge about suicide particularly regarding the roles of organizations inequality and intersectionality in suicide that sociology is well situated to help address

introduction art museums1 are continually in flux over the past century art museums have slowly moved away from being spaces that contained private collections that could only be accessed by a select number of people to now playing a central role in making culture accessible to the mass audience this emphasis is demonstrated by related research and the suggestion that social interaction particularly for families is a significant motivating factor for visitors going to art museums alongside leisure recreation and the acquisition of knowledge the spatial and social character of art museums has also been affected by the gradual incorporation of new and emerging technologies such as virtual reality which is the focus of this article in 1995 for example benjamin britton developed the vr art installation lascaux which was a reimagining of the cave of lascaux in france between1995 and 1997 he toured this exhibit across the us france italy england and south korea the huge success of lascaux is not only testimony to the international power of vr but equally demonstrates that despite some initial hesitation museology and humanities disciplines in general are catching up with this major technological breakthrough today vr is going through a renaissance after many decades of incubation fully immersive virtual reality has finally become a customerready technology this is evidenced by the mounting popularity of modern systems like the oculus rift and the htc vive as well as oculuss most recent standalone system the oculus quest immersion and presence are two terms that are frequently used to describe the experience of vr while immersion is simply what the technology delivers from an objective point of view presence is contrastingly understood as being a human reaction to immersion in other words immersion implicates the technological while presence implicates the psychological symptomatic of this there is mounting evidence to suggest that the ability to create virtual worlds that users feel as if they are part of is predicated in part at least on the technology underpinning the experience notwithstanding the impact physical setting can of course have on any given experience virtual or otherwise vr today is significantly more advanced than it was in the 1980s and 1990s which was marked by low resolution and unacceptable latency and the consequent potential to create more convincing experiences of being there has not gone unnoticed by both scholars and industry practitioners alike a body of work now surrounds vr and its manifold uses studies have explored the role vr might play in the realm of healthcare serving as a tool to rehabilitate stroke victims tackle phobias and train surgeons research has also considered the implications of vr in education with some of the suggested effects of this technology being that it can increase the speed of learning and deepen the retention of information likewise scholarly enquiry has recently extended to the application of mobile virtual reality headsets in public environment and the suggestion this assemblage temporarily places users in a dislocated space where the the digital no longer augments the physical but rather the digital supersedes the physical while simultaneously being constrained by the norms and constraints of the surrounding shared space at the same time studies have also started to investigate the application and utility of vr in art museums as a nascent form of edutainment that could provide the digital space required for new forms of sociality to arise while these studies are undoubtedly helpful and do raise interesting questions for the most part such work has tended to focus on the technical character of vr and has not necessarily presented qualitative data on the lived experience of vrbased exhibitions given the forecasted growth in vr technology and its diffusion into other industries a better understanding of the impact of vr in art museums becomes more critical our article therefore reports on an original research project conducted at anise gallery in london uk between june and july 2018 focusing on the multisensory and vrbased exhibition scents of shad thames2 the research comprises 19 semistructured interviews with participants who had just experienced the scents of shad thames exhibition 11 interviews were conducted with individual participants and the remaining 4 interviews were conducted in pairs the study advances along three lines of enquiry first the research investigates whether the inclusion of vr might alter the endemic practice of peoplewatching second the research explores whether established ways of navigating the physical setting of art museums might influence how users approach the digital space of vr third the research examines whether the incorporation of vr might produce a qualitatively different experience of the art museum as a shared social space in the following section we outline the conceptual framework that underpins this research this begins by detailing an antiessentialist understanding of spatiality alongside a symbolic interactionist approach to the development of social rules we then summarise three recurring spatial and social behaviours that have emerged within the art museum peoplewatching the physical navigation of space and the experience of this environment as a shared and social space these behaviours inform our research questions that revolve around the possibility of vr reshaping the lived experience of art museums we briefly describe the anise gallery as well as provide a detailed description of scents of shad thames before outlining the methodological design of this research finally we present and discus our findings the spatial and social norms of art museum for falk and dierking the experience of an art museum is affected by the physical social and personal context not only does the architecture shape how visitors experience this or that exhibition so too does the surrounding sociality alongside the personal motivations for going space is not just an empty container that we simply inhabit but instead a social product rooted in shared values and socially produced meanings space is modified through continued use with ascribed meanings changing over time as a consequence of interrelations and interactions the art museum then is very much a lived space in which social actions often dependent on social norms can alter and modify the phenomenological experience this is not to suggest however that art museums are not governed by tacitly agreed rules of conduct established norms within these spaces make social behaviour predictable and understandable an individual may actively decide to visit an art museum but the behaviours enacted during this visit are strongly influenced by the social norms that predate this decision a symbolic interactionist approach to social rules suggests that society is constructed through the continued interaction and negotiation between social agents and that agreement upon the relevant norms will be entwined with the activity needed to make sense of the sort of social event to which one is party context is thus an important factor social agents apply specific contextbased behaviours so that a shared understanding of a situation can be developed and common norms adopted within the setting of the art museum the following behaviours have gradually emerged peoplewatching the physical navigation of space and the experience of this environment as a shared and social space peoplewatching is a recurring motif of art museums visitors attention is always partially devoted to observing others coinhabiting their space visitors watch either their own social group other social groups or art museum staff to learn how to behave appropriately and to become oriented to the implicit conventions of their environment this process is known as modelling casey argues that the viewer is acutely aware of his place in the museum and acts appropriately he positions himself in front of the painting in a certain way seeing himself see the object mindful of how he is viewed by others for falk and dierking a notable part of this selfawareness revolves around the fear many adults have about making mistakes in front of an audience navigation of the art museum is another important feature of these environments in many ways this is indicative of the necessary ordering of objects and artefacts exhibits and displays are usually grouped in a decisive manner and designed to be experienced in a particular sequence that visitors are expected to follow likewise adults have been socialized to not touch the items contained within these spaces duncan argues that art museums provide both stage set and script for visitors to performatively adhere to while the overall flow of bodies may seem chaotic most people consistently move from one object to the next and the majority of people are also conscious of not negatively affecting the experience of others as falk and dierking point out visitors often quietly wait their turn to look at exhibited objects and respect the rights of others to have a turn consequently people are more likely to participate in interactive exhibitions if they feel their experience is not prohibiting other people from similarly taking part art museums are of course very much shared social spaces predicated on a publicprivate duality whether they arrive accompanied or not all visitors have to negotiate an often delicate balance between two irreconcilable poles conviviality sharing exchanging ideas and introspectionestablishing a personal relationship with the art works being accompanied by someone else is frequently part of the experience of art museums and individuals tend to move through these spaces as a unit sharing their thoughts and exchanging ideas to help comprehend and validate each others reactions yet the introspective element of the art museum is just as important as the social experience the process of engaging with a work of art creates a conceptual space that can feel solitary the practice of visiting an art museum alone can therefore make the overall experience feel more private and provide an opportunity for selfreflection tranquillity and personal freedom that the elevated austere even magical atmosphere of a museum particularly lends itself to consequently many visitors establish verbal or physical barriers to social interaction in order to be able to seamlessly move between the public and private experience of the museum drawing on an understanding of spatiality as something that is socially constructed alongside a symbolic interactionist approach to social rules it is our contention that the addition of vr in art museums has the potential to present new ways of approaching and experiencing this setting while a body of research has gradually developed around the social norms between avatars within virtual environments little empirical research exists regarding social norms when vr is adopted in public spaces like art museums similarly there are limited studies that explicate the lived experience of vrbased exhibitions our research therefore addresses these gaps in the literature the questions guiding our study are as follows first does the inclusion of vr within art museums alter the practice of peoplewatching second do established ways of navigating the physical setting of art museums influence how users approach the digital space of vr third does the incorporation of vr produce a qualitatively different experience of the art museum as a shared social space method this article reports on an original research project that explores the spatial and social impact of vr in the context of art museums our research was conducted at anise gallery in london between june and july 2018 anise gallery presents a variety of exhibitions and events that relate back to architecture technology and the built environment founded in 2012 anise building is situated along historic shad thames occupying the ground floor of renovated spice warehouse the multisensory and vrbased exhibition scents of shad thames which is the focus of this article chiefly engaged with the regeneration of london and how the identity of the architecture is shaped by its inhabitants and vice versa after putting on the supplied vr headset which was tethered to a powerful pc visitors were presented with a detailed virtual depiction of the london se1 postcode area which effectively hovered in the middle of the room they were standing in six selected shad thames buildings including wheat wharf anchor brewhouse anise building cinnamon wharf tea trade wharf and 28 shad thames then slowly floated upwards from of the map before moving towards six evenly spaced positions within the gallery each designated position was accordingly marked by a red building shaped block and as each building reached its destination the red blocks became detailed versions of the buildings listed above significantly these virtual buildings corresponded to six physical tables within the gallery each with a doll house sized crate perched on top of it and each filled a different spice tea or fruit accordingly visitors engaged in a multisensory experience taking in the scents historically associated with this envirnoment it is also important to point out that this experience took place amongst various other exhibitions and was thus not cordoned off from the shared social space of anise gallery in total 19 semistructured interviews were conducted participants comprised 10 females and 9 males 11 interviews were conducted with individual participants and the remaining 4 interviews were conducted in pairs the mix of interviews was considered appropriate because couples often wanted to be interviewed together and their individual experience was influenced by the presence of a companion in the gallery purposive sampling was employed throughout this project participants were selected if they had experienced the vr portion of the scents of shad thames exhibit and were over 18 years old in all instances potential participants were approached within anise gallery given a participant information sheet and then asked if they would like to take part in the project participants then completed a consent form which detailed how their data would be used following the study all participants were given pseudonyms interviews consisted of 16 questions and 45 subquestions each interview was effectively broken down into three sections the first section focused on the art gallery with questions exploring why participants visited this gallery and how they usually felt and acted spatially and socially speaking when interacting in similar settings the second section focused on the scents of shad thames with questions exploring how users described this experience and how they approached and interacted with the exhibit itself the third section focused on both the spatial and social effect of using vr within this context with questions exploring how participants felt this experience differed from nonvr based exhibits and what effect the dislocated space of vr had on the social aspect of their visit interview data were thematically analysed using an established series of codes that related to the key themes underpinning this study peoplewatching the physical navigation of space and the experience of this environment as a shared and social space with each theme containing several subthemes or codes a question that focused on both the spatial and social effect of using vr within the context of the art gallery for example elicited responses that were commensurate with the following broad themes emerging forms of privacy the impact of the physical setting on the digital experience concern for how participants might appear to visitors outside of the headset and reconciling the sensorial configuration of vr with the desire to continue socialising this approach to data was both inductive and deductive all data were initially coded outside of our theoretical framework before being reinterpreted through the chief themes underpinning our study peoplewatching in line with established understandings of art museums peoplewatching remained an integral facet of our participants experience of anise gallery as nici explains i was thinking wheres the vr and then i could see it in the corner and then i saw people walking around very slowly so i thought okay there are things to take in here many participants observed other visitors to gain information or knowledge about appropriate ways to use museums or rather how to approach this vr exhibit this point is supported by the following extracts before i did it i saw this other woman doing it and she was very careful about what not to touch i think she felt that she was going to touch the wall or something or fall i saw some people walking into the crates so i was mindful of that when i was looking at the model i was aware that there was a wooden crate in front of me well once you see somebody bump into the box you think ill do better the spatial and social norms of the art museum were therefore a significant factor in the inclusion of vr at the same time we would also suggest there is something noteworthy about the incorporation of this technology that differs from the peoplewatching norms commonly associated with more conventional exhibitions effectively making the practice less casual and more active certainly the observation of others that typically occurs in relation to nondigital displays involves a visual connection of sorts between the actions of visitors and their physical environment in other words there is a tangible referent that corresponds to a certain sensibility vr however is different to account for the physical visual and audible schism that occurs within a vr experience saker and frith use the term dislocated space which they define as concrete space being temporally superseded by … digital space this digital space remains concealed from those outside of the headset just as the meanings communicated by the physical actions of users are necessarily partial for some participants the disruption of this practice meant that the process of people watching suddenly lacked meaning when youre looking at people who are experiencing it it doesnt mean that much to the bystander you do not know what they are doing and why they are doing it this doesnt have a meaning to you in the same way as you are looking at a picture interestingly thomas compares witnessing someone interacting with vr to looking at a picture which is of course an established behaviour that facilitates a shared understanding as well as implicates common norms for durkheim norms are the essence of social order norms effectively provide a sense of solidarity among individuals and this is no different in the setting of an art museum when thomas comments that the actions of the person he was watching lacked meaning he is equally suggesting the solidarity of the space has been altered symptomatic of this some participants found the attenuated nature of their experience evoked reflexive concerns about how they might appear to others were they to inhabit this digital space themselves as leahs pondering attests would i look silly would i trip up how to behave within an art museum is of course not something that is intuitive visitors with limited experience of these spaces might therefore feel more fearful of behaving in a manner that was unfitting in the context of vr our research found that the practice of peoplewatching not only took on a more active and contemplative hue it also prophetically provoked anxiety in some participants about the prospect of reckoning with this seemingly normless experience navigation the scents of shad thames was designed so that digital objects correlated with physical objects placed in the center of the gallery many participants approached this experience in a manner that closely resembled the norms ordinarily associated with the physical site of art museums as kat explains im in a gallery so i have to go carefully one two three then go to the other side one two three and i think thats a way that you should be in a gallery importantly this way of being is predicated on a particular sequencing of objects which is another rule generally associated with art museums the rules or norms for navigating art museums involves visitors sequentially moving from object to object in a methodical and purposeful fashion as falk and dierking explain many museums design exhibitions composed of groupings of cases or interactive displays that present a single large multifaceted story or concept this sentiment was echoed by peter when he explained why he chose to adopt a regimented approach to this virtual exhibit to get the most out of the place for peter the navigation of this space is intentionally structured to produce an optimum experience in the majority of instances participants described approaching the digital space of vr following a normative pattern and comprehended virtual items as being curated in a manner not dissimilar to their physical counterparts our research also found that many participants approached the virtual space of vr as if it were physical these participants consequently spoke of being wary of walking into digital objects even though they knew of course that this was not possible you know that the table is not really there youve seen the space you could walk straight through it but you just obey the rules of the virtual space and walk around it you know its not real but were walking around it as if in terms of perception for safety if we walk into it will cause us some sort of danger i found that the space was so small for me to walk because there was that map in the center and i was afraid to crash with it it was weird because i really know that it wasnt really there behaviours commonly associated with the concrete space of the art museum therefore carried over into the digital space of vr with each participant demonstrating a marked level of restraint here even the idea of transgressing the virtual map was discussed as being a rebellious act we can do whatever we want and i think thats the kind of rebellious renegade kind of idea like im just going to stand in there at the same time this is not to suggest these perceptions of restraint were necessarily experienced as being undesirable for many participants the sense of alignment between the physical and digital world did not restrict their experience but instead assisted their navigation of this space i felt comfortable in the space and one of the things that i liked the most is that it is the same area so you already saw the space you have already seen where you are going to walk around it is the same one so you dont feel that youre going to fall or drop for beth the relationship between the physical and the digital meant she was attuned to the experience because she already had an understanding of the concrete space of the museum as david amusingly describes this process its like seeing a friend in a funny hat significantly then the internalised parameters of this exhibition were not cast in a deleterious light virtual objects acted as boundaries performing a similar function to physical objects and the confines of the art museum itself for many participants going outside of these boundaries felt weird specifically because the norms associated with both physical and digital aspects of the museum appeared commensurate the practice of avoiding virtual objects adhered to the social norm of not touching or interacting with items in a museum which adults have been socialized to do as falk and dierking note people know how to act in certain spaces and they do not feel coerced into this behaviour they just do it similarly our participants reinstated established norms even though they were not compelled to perform in a certain way it is our assertion however that this process does not simply illuminate the collective desire to establish boundaries to help make sense of an exhibit per se but rather the power of the physical setting visàvis the vr experience as sherman et al concurringly suggests if the same vr system and application are placed in two different venues such as an entertainment arcade versus the guggenheim museum there will be a significant difference in the way the experience is perceived a shared social space the art museum has been recognized as providing both a public and a private experience for visitors our research found that the use of vr in this setting readily amplified both the public and private aspects of anise gallery what i was seeing was certainly private but how i was viewing it and how i was interacting with it the way i was putting my hand out was public it was public because there was somebody else in the room somebody else was watching you while you were seeing a private exhibition while both kat and katherine felt that they were inhabiting an environment that was qualitatively concealed they were equally aware that their physical movements within the digital space of the virtual corresponded with a physical space that they were equivalently cordoned off from for george it was the acoustics of the physical setting that made him more cognisant of the space outside i was aware of the presence of others because people are being loud for some participants it was precisely the ability of vr to place them in a space that felt distinctly removed from other people ocularly and audibly speaking that made their experience feel qualitatively different carol makes an equivalent point while discussing the difference between a gallery she had recently visited and the scents of shad thames when you had it all by yourself and you were the only person there that was really cool it was like having your own private gallery moment i really valued that because i think its very rare that you would get not everywhere is necessarily busy but its very rare that you get gallery space to yourself to enjoy something so youre still part of the gallery but youre having your own experience art museums are of course commonly understood as being shared spaces it is through the sharing of space that spatial and social norms are established in this instance however carol was able to engage with the exhibit as if she were the only person there because she did not have to share the virtual space with other people leah makes a similar point you immerse yourself in what youre looking at everything else was disregarded i thought no no im having a good time forget about everybody else as elden explains the meaning of the space and the space itself is adapted and transformed as it is perceived and lived by social actors for some participants it was precisely this solipsist vantagepoint and its marked difference from the common experience of other art museums that made the lived experience feel more satisfying it was private because i feel like i have the space for myself so i was free to go to any of the pieces of work there were but its only because anyone cant see what i was doing i feel like i have more freedom without people because you can go anywhere you want without people being in the middle of it at the same time peter also touches on an interesting contextual aspect of vr peter intimates that part of this freedom was symptomatic of people not being able to see what he was doing the removal of people provided a mastery of space and autonomy that is rare in a crowded museum for debenedetti individuals who experience the museum alone benefit from total freedom in decisionmaking once inside they are free to go at their own pace and stay as long as they wish this autonomy allows the singleton to set a very personal itinerary to preserve the intimacy of their encounter with the artworks and this spatial and social autonomy can facilitate a more immersive experience i was engrossed as soon as i started doing it actually i was surprised when i took off the headset how many people there were how busy it was and knowing these people had been watching what i was doing and staring i was like oh okay when youre actually in the environment and you know you are smelling things you are seeing things you are listening to things and you are choosing where to navigate you do not think about external things i want to be in my head and with the art so im born for vr for both thomas and marcy then the sense of privacy vr provided notably allowed them to be more absorbed in the experience and therefore less conscious of their own reflexive role in maintaining tacitly agreed norms this is not to suggest however that the carapace of vr was impenetrable as many participants equally found the concrete space of the art museum continued to bleed into their experience in a variety of ways as saker and frith put it the shared norms of actual space … remain a constraint upon actions in the virtual space equally our research found that for some participants their experience of the digital space of vr was marred by an awareness that other visitors might be waiting to have their turn which resonates with common concerns associated with this setting as kat and thomas explain i am in front of a big group of people there are people watching waiting to have a go on this thing you can feel selfconscious i think it goes back to me being always selfconscious of not being in the way of people so it is like in a restaurant when there is a queue and you dont feel welcome to stay because there is somebody else waiting for the table so in this experience i knew somebody else was waiting even if it was him waiting for the headset for kat her attentiveness to people waiting meant that she could never fully transcend the physical space of the gallery and inhabit the digital space of the virtual we suggest here that the fractional immersion of vr might intensify this experience as any sense of a queue building beyond the headset is in part at least imaginary for other participants it wasnt necessarily the temporality of the vr experience that led to the shared space of the art museum seeping into the digitality of the experience but rather a concern for how their actions might be perceived by others here the prophetic anxiety provoked by the practice of watching other people engage with this exhibit as detailed above moved beyond mere contemplation and actually shaped the experience from within the headset i didnt know if someone was laughing at me when i was touching the box and nothing was there and i was like wearing the goggles and reading the explanation from the buildings i dont know i felt kind of foolish because even what i was watching the guy before me i was just there thinking he looks so funny but he is just getting on with it and then when i put it on i thought oh i look funny if you could see yourself doing it you would be like oh my god i look like an idiot while the private experience became more personal for some participants then for others the public space of the art museum intensified and affected their experience of the virtual this is perhaps in large part due to the unease that accompanies the feeling of being watched which resonates with sartres suggestion that the intrusive other shatters the illusion of mastery initially enjoyed by the solitary viewer and turns him into the spectacle of anothers gaze for other participants however an awareness of being observed was intensified precisely because they had not come to the gallery alone of course traditionally speaking companions readily share their experience of art museums through dialogic interaction our research found that while participants still conversed with other people during this exhibition the inclusion of vr notably reshaped how this sociality was experienced it is difficult to interact with someone or something when you dont see what you are thinking yeah i agree its hard to interact when youre not seeing other people so you know theyre there but you dont know which direction to speak to them for these participants then a significant difficulty encountered in vr was the inability to see what their partner was thinking precisely because the digital space of vr was necessarily dislocated from the concrete setting of the gallery and for some participants the inability to experience this exhibit with someone else was seen as being unfavourable i actually quite naturally thought wed experience it together it could have made it better to interact with someone seeing the same thing as a corollary to this dialogic interaction had to occur after the scents of shad thames instead of during the experience consequently for these participants the social bonding commonly confirmed through imminently shared actions observations and reflections became markedly fragmented conclusion this article has examined the effect vr might be having on established spatial and social norms within art museums specifically focusing on the vrbased exhibition scents of shad thames at anise gallery in london uk between june and july 2018 established spatial and social norms include peoplewatching the physical navigation of space and the experience of this environment as a shared and social space three main inferences can be made about the impact of vr on the experience of this environment from our data first the process of people watching became notably less casual and more active participants were aware that they were observing users perform physical actions that were necessarily dislocated from the physical environment they were inhabiting as a corollary to this the practice became more contemplative with participants not only thinking about how they might react to this digital space themselves but also trying to envisage the digital environment overlaying the physical space of the gallery second established norms for physically moving through the art museum influenced how participants interacted with the virtual setting of the exhibition in part participants did this to help contextualise and make sense of the exhibit at the same time we would also suggest the serious sensibility adopted by some participants was indicative of the physical space of anise gallery as sherman et als posit the venue or setting in which the vr system resides can have a great impact on how an event is experienced third the public and private duality of the art museum was amplified through vr participants experienced a sense of being there that felt markedly more private for some participants this meant that they ostensibly had the exhibition to themselves which provided a more satisfying experience for other participants however this meant that they became more conscious that other visitors were waiting their turn for galdieri and cazzozzino however this is not indicative of vr per se but rather the consequence of a system that only enables one user at a time in other words this is symptomatic of scents of shad thames and the decision for it not to be a multiuser experience here our data support the suggestion that presence is a psychological reaction to technology while the technology involved can create immersive environments this does not mean all visitors will have the same experience in a similar vein the dislocation of participants from their physical setting impacted social connections for some participants this meant they were unable to share the experience with their companion consequently established practices of sociality within this setting fractured with the dislocated space of vr in sum then while vr has the potential to create a different kind of spatial and social relationship with art museums for the most part the physical setting of art museums seemingly limits the transgression of established norms however as visitors become more comfortable with this technology and emerging applications surface that allows multiple users to inhabit these digital spaces at any one time it is very possible that different spatial and social norms might still develop that are not as firmly governed by the laws of physical space likewise with the mounting popularity of modern systems like the oculus quest and the multitude of applications available people are now able to experience vrbased exhibits in environments that are not art museums which raises interesting questions about the kind of interactions these exhibits might forge given the incongruous physical settings involved in either case one thing seems fairly clear vr is set to continue permeating multiple industries in the coming years additional research is therefore encouraged to gain a broader understanding of the spatial and social effects of this unique technology within the field of museology

art museums implicate established spatial and social norms the norms that shape these behaviours are not fixed but rather subject to change as the sociality and physicality of these spaces continues to develop in recent years the reemergence of virtual reality vr has led to this technology being incorporated into art museums in the form of vr based exhibits while a growing body of research now explores the various applications uses and effects of vr there is a notable dearth of studies examining the impact vr might be having on the spatial and social experience of art museums this article therefore reports on an original research project designed to address these concerns the project was conducted at anise gallery in london uk between june and july 2018 and focused on the multisensory and vrbased exhibition scents of shad thames the research involved 19 semistructured interviews with participants who had just experienced this exhibition drawing on scholarly literature that surrounds the spatial and social norms pertaining to art museums this study advances along three lines first the research explores whether the inclusion of vr might alter the practice of peoplewatching which is endemic in this setting second the research explores whether established ways of navigating the physical setting of art museums might influence how users approach the digital space of vr third the research examines whether the incorporation of vr might produce a qualitatively different experience of the art museum as a shared social space

introduction lung cancer has the highest mortality rate of all cancers worldwide 1 socioeconomic status has been associated with lung cancer in several studies with people from lower socioeconomic backgrounds having the highest incidence rates 2 3 4 5 6 7 8 ses reflects ones position in societal hierarchies and is generally assessed by the interdependent dimensions of education occupation and income ses is linked with healthdisease through multiple interacting pathways in terms of material and social resources physical and psychosocial stressors and healthrelated behaviors 910 ses is strongly associated with smoking behavior 11 the most important risk factor in the etiology of lung cancer however many studies on lung cancer and ses do not adequately control for smoking behavior 12 and findings about the extent to what ses is explained by smoking are not consistent 371314 we investigated whether ses is a risk factor for lung cancer and to what extent the association is reduced by consideration of smoking we operationalized ses by two different occupationbased concepts first we measured ses by application of the international socioeconomic index of occupational status 15 isei was originally constructed to create an internationally comparable socioeconomic index by combining data on education income and occupation as the three main dimensions of ses the different isei scores for occupations were calculated by assuming that occupation represents an intermediate factor which converts education into income 15 second we used the european socioeconomic classification which categorizes social positions on the basis of typical employment relations and conditions of occupations 16 we applied these two concepts to different job periods to investigate variations of occupational ses and lung cancer associations additionally we explored whether the relationships between ses and lung cancer differed by histological tumor subtype and conducted subgroup analyses to explore effects according to study region occupational exposures smoking status education birth cohort study control type and city size of last residence considering biological as well as social differences between men and women with regard to lung cancer 17 we stratified all analysis by gender materials and methods data availability we analyzed data from the synergy study database detailed information on the synergy project has been published previously 1819 and is available at the study website briefly synergy is an international collaboration to study the role of occupational exposures on lung cancer risk all included studies solicited detailed information on the participants occupational biography coded industries and smoking history individual participant data from 16 studies and 22 study centers conducted between 1985 and 2010 are currently included in synergy the ethics committees of the individual studies approved the conduct of the study as well as the institutional review board of the international agency for research on cancer study subjects or in the case of deceased subjectstheir relatives gave written informed consent to participate in the study we included studies from europe and north america and used data from 12 studies conducted in 18 study centers we excluded two studies because of missing information the morgen study did not contain data on the time since smoking cessation for former smokers and the paris study did not have information on education and was restricted to smokers participants were excluded if they had no isco codes in their occupational history to derive occupational ses these included for example housewives participants working exclusively in the military or lifetime unemployed participants with missing smoking history were also excluded cases were histologically confirmed lung cancer cases categorized into lung cancer subtypes small cell lung cancer adenocarcinoma otherunspecified information was available on several further variables which either constituted the exposure variables or covariates this included gender age geographic area of residence smoking history education and occupational history the occupational history was used to create the exposure variables and to create an indicator of potential exposure to occupational carcinogens indices of socioeconomic status in order to classify the ses of study participants we used two indices that can be assigned by the participants occupation namely the isei 15 and the esec 16 the isei is a continuous independent research institute of the ruhruniversita ¨t bochum the authors are independent from the german social accident insurance in study design access to the collected data responsibility for data analysis and interpretation and the right to publish the views expressed in this paper are those of the authors and not necessarily those of the sponsor this does not alter our adherence to plos one policies on sharing data and materials status score for occupations derived by ganzeboom and coworkers based on age education and income the minimum score was 10 the maximum 90 we used each participants job history in conjunction with the isei score for the occupations to assign an isei score to each job we categorized subjects into categories in two ways first by dividing the entire isei range into four equal subranges and second by calculating frequency distribution quartiles based on the genderspecific distribution of scores among control subjects the esec is a derivative of the eriksongoldthorpeportocarero scheme 20 in contrast to the continuous isei scale esec defines discrete categories of social positions occupations are classified according to their typical employment relations and conditions referring to the labor market and work situation 21 we applied the esec with 3 classes which shows a hierarchical order unlike the original scale of 9 classes the condensed version is recommended by the esecauthors when additional information about employment status and size of organization is missing 21 for the assignment of the indicators we utilized instruments available on the authors websites 2122 we assigned scores based on each participants longest first and last held job period and additionally the lowest and highest score ever reached jobless periods due to unemployment were assessed separately we categorized the maximum duration of unemployed periods and for comparison the sum of unemployed years for each participant we further categorized participants in those who ever or never worked in blue collar jobs by the first digit of isco codes education was categorized as follows no formalsome primary education primarysome secondary education secondary educationsome college university covariates the smoking history was parametrized by means of multiple variables smoking status years since quitting smoking and packyears nonsmokers were defined as participants who smoked less than one packyear smokers were considered former smokers if they had quit smoking at least 2 years before the interviewdiagnosis otherwise they were considered current smokers 23 former smokers were subdivided into categories of 25 610 1115 1625 2635 and more than 35 years since quitting smoking to indicate occupational exposures to lung carcinogens we used a classification of occupations developed by ahrens and merletti 24 on the basis of occupational categories and industrial sectors the list of occupations with potential carcinogenic risk is known as list a and includes among others jobs in metal production and processing construction mining the chemical industry asbestos production 2425 participants were classified as ever or never having worked in a list a job we combined countries to the following study regions northerncentral europe eastern europe southern europe and canada we differentiated whether controls were recruited populationbased or in hospitals we categorized birth cohorts and city size of last residence statistical analysis we estimated odds ratios with 95 confidence intervals by unconditional logistic regression models and used the longest held job for the main analyses categories with the highest ses were set as reference we adjusted for log and study center in model 1 and added smoking variables in model 2 we stratified analyses by gender restricted in some cases to men because of insufficient numbers in women we calculated tests for trend for all analyses to quantify the difference of ors between the two models we applied ã 100 1326 we additionally adjusted models for educational level as a second ses indicator and list a to study the impact on the association of occupational ses and lung cancer to investigate whether the seslung cancer associations differed by histologic type we conducted separate analyses in the main histological subtypes of lung cancer subgroup or sensitivity analyses were conducted to elucidate possible effects by education study region city size of last residence birth cohort employment in list a job employed in a blue collar job smoking status and type of control recruitment we calculated correlations between the selected job periods and correlations with education by spearmans rank correlation coefficient for isei and by crame ´rs v for esec we used randomeffect metaregression models to examine heterogeneity between study centers the luca study was not included in the metaanalysis because adjustment for smoking was not possible due to missing cases in the reference category all statistical analyses were carried out with sas version 93 except for metaanalyses which were performed using comprehensive metaanalysis version 22027 software results characteristics of the study population altogether 17021 cases of lung cancer and 20885 controls were included in the final analysis the characteristics of the study participants are shown in table 1 approximately 80 of cases and controls were male lung cancer cases less frequently held jobs in the highest occupational categories had lower education were more frequently smokers at time of interview had smoked more packyears and slightly more often experienced unemployment than controls fractions of participants with higher occupational ses higher education and nonsmokers were lower among men the maximum duration of periods of unemployment was higher for women than for men when combining the upper categories of isei to high ses and the lower categories to low ses current smokers represented 47 of men and 36 of women with low ses compared to 34 of men and 31 of women with high ses nonsmokers accounted for 12 of men with high ses and 20 of men with low ses in women the proportion of nonsmokers was equal for low and high ses the distribution of ses among the controls varied by study center in particular with a higher proportion of lower ses in capua and higher ses in toronto of selected job periods of isei and esec with corresponding tests for trend associations between ses and lung cancer the average reduction due to adjustment for smoking habits in men was 50 for isei and 26 for esec and in women 34 for isei and 9 for esec unemployment with a maximum duration of 510 years and 10 years was associated with an increased risk of lung cancer for men similar results were observed for cumulative unemployment of 510 years and 10 years the results for either isei categorization based on the scorerange or the genderspecific control distribution showed similar ors we also observed similar associations between ses and lung cancer for the longest and last job periods and the highest ever reached isei on the one hand and for the first job and the lowest ever reached isei on the other hand the job periods within these two groups were highly correlated additional adjustment for education further reduced risk estimates on average by approximately 50 whereas adjustment for list a resulted in a slight reduction occupational ses correlated moderately with education when stratifying the data by histological tumor subtype we observed increased ors for sqcc and sclc and slightly reduced risks for the lower sescategories for adc in women adjustment for smoking behavior increased ors for sqcc and sclc in the lower ses categories subgroup and sensitivity analyses metaanalysis table 5 shows results for the subgroup analyses the effect estimates remained unchanged for participants who never or ever worked in a list a job and for male nonsmokers of the lowest ses category ors were comparatively higher for population than hospital controls lower for participants most recently residing in an urban area and also for men who never held a bluecollar job when exploring last residence in urban area for the younger half of the study population ors increased marginally for women stratification by study region revealed higher ors in northerncentral europe and lower ors in the other regions with a negative association for women in eastern europe in comparison to the scorebased categorization of isei applying genderspecific iseiquartiles attenuated associations for women except for canada and increased ors in men for southern europe ors increased in the birth cohort of 19301939 for men and especially in the middle ses categories in the birth cohort 1939 for women the lung cancer risk of the lower sesgroups decreased when stratifying for education especially in the strata of higher education metaanalyses showed slightly lower overall ors than the corresponding pooled ors the stronger the association of lung cancer and ses the higher were the proportions of heterogeneity with above 60 for at least the lowest vs highest sescategories discussion in this study we confirmed a social gradient for lung cancer with greater risk associated with lower occupational ses that persisted after adjustment for smoking habits and was higher among men smoking habits reduced only up to half of the lung cancer risk of lower ses additional adjustment for education further attenuated the ors despite regional differences lung cancer risks were still elevated especially for the lowest ses categories with exception of women in eastern europe unemployment was not associated with lung cancer except for subjects who experienced unemployed periods 5 years and this finding was restricted to men strengths of this study are primarily based on the large international synergy database with participants detailed occupational and smoking histories smoking information was nearly complete which allowed for a detailed control of smoking behavior as recommended in the literature 14 the iscocoded job biographies permitted the assignment of international validated ses indicators to nearly the entire dataset limitations include the validity of the ses indicators isei was developed based on data restricted to men esec was developed for comparisons of european countries additionally isei and esec are occupational indicators restricted to gainfully employed subjects even though we analyzed the influence of being unemployed due to loss of job or periods of illness we could have missed possible influences of activities outside of the workforce such as housework parttime work retirement which could have underestimated socioeconomic differences 27 this concerns not only nonoccupationally active periods but also participants without any gainful employment in their job history who were excluded from the analysis unfortunately for lifetime housewives we did not have information on the husbands occupation for derivation of the ses we also could have missed effects of early retirement as a hidden form of unemployment even though our classification of education was based on an international classification it generally remains problematic to capture the countryspecific implications of time spent in the educational system and corresponding educational attainment another limitation concerns residual effects of smoking behavior due to misclassification stratification by histological subtypes revealed higher ses risks for the smokingassociated subtypes and reduced ses risks for adc which is the histological subtype of lung cancer showing the weakest association with smoking 19 furthermore regional differences as well as elevated risks in the younger female birth cohort in our study correspond to the international patterns of the international smoking epidemic observed with regard to ses and lung cancer 6 the smoking epidemic describes the historical prevalence of smoking that differed by countriesregions gender and ses 28 we identified elevated risks for male nonsmokers which could be due to our definition of nonsmokers that also includes occasional smokers measuring smoking in packyears as cumulative lifetime dose may underestimate the role of smoking duration in relation to smoking intensity 29 despite evidence for the accuracy of selfreported smoking habits across various occupations and industries 30 recall bias and differential misclassification of smoking cannot be ruled out given the several indications and possibilities for residual effects of smoking we assume that we rather overestimated the effects of ses on lung cancer third the possibility of selection bias was implied in our analysis because the association between lung cancer and ses was stronger among population than hospital controls in populationbased studies subjects of lower ses tend to show lower participation 31 and casecontrol studies on lung cancer and ses with populationbased controls revealed higher ors for low ses 12 sesrelated nonresponse bias ie less participation of cases with high ses and of controls with low ses was observed in one study which was also included in synergy 32 however in our study hospitalbased recruitment was mainly done in study centers from eastern europe making it difficult to distinguish between regionspecific and recruitmentbased effects further limitations include that we did not have information on other risk factors for lung cancer eg environmental tobacco smoke 33 or residential air pollution 34 we analyzed the city size of the last residence as a proxy for air pollution but in contrast to the assumption of increased associations in more urban areas we found risk estimates to be reduced this also included the subgroup of participants 63 years of age indicating the absence of a mobility effect among senior citizens potential confounders of the association between smoking and lung cancer which we did not include could have also affected our results in terms of mediatoroutcome confounding 35 an important fraction of lung cancer has been attributed to occupational carcinogens 36 but their role in explaining the association of ses and lung cancer has not been fully disentangled yet 437 we considered occupational risk factors by adjustment for list a occupations and alternatively by excluding participants never working in a list a job and did not identify strong differences in the association between ses and lung cancer between these subgroups however list a only lists jobs with a possible exposure to occupational carcinogens and does not include information about exposure probability intensity or duration bluecollar jobs may include occupational exposures which are not included in list a in contrast to subgroup analyses by list a occupation we found slightly higher risk estimates for low ses among ever blue collar as compared to workers never employed in a blue collar job however blue collar workers also include participants who were not exposed to occupational carcinogens finally the applied concept of ses reflects a variety of healthrelated circumstances and behaviors but disregards inconsistencies as well as changes of status indeed we recently analyzed social mobility based on occupational prestige in synergy and observed slightly increased associations between lung cancer and downward prestige trajectories over the work life 38 here we measured ses on the individual level with historical information on occupation and additionally education but extended concepts of ses should involve the entire life course 39 and include incomewealth and areabased measures 40 we found that adjustment for smoking reduced estimates for the association between ses and lung cancer by up to 50 this is similar to the findings of scottish 3 dutch 41 and european studies 13 and the results for men in a study from eastern europe and the uk 7 in contrast in a canadian study the association between ses and lung cancer disappeared after fully adjusting for smoking habits 14 in our study the remaining risk estimates were comparatively higher than in most studies on occupational ses and lung cancer but similar after adjustment for education 12 however we focused on the results without education to avoid over adjustment as education is an indicator of ses in early life that remains stable and determines the following ses indicators such as occupation and income 42 the extent of reduction of ors due to adjustment for smoking was distinctly lower when we applied esec as compared to isei this could point to the different underlying concepts of ses implying different exposures and pathways to lung cancer additionally esecespecially in the condensed version we appliedas well as isei categorize iscocodes which comprise a hierarchy of occupational skill levels applying three esec categories may therefore have led to dilution of effects in comparison to the four isei categories a subsequent possible attenuation between ses categories may also have attenuated the effects of smoking in the esec categories our analysis of occupational ses was primarily based on the participants longest held job which might reflect durations of possible exposures as the longest job was highly correlated with the last job and associations with lung cancer were even slightly elevatedin contrast to the first job the last job might be an appropriate choice in similar studies lacking complete occupational histories the lung cancer risk we found for unemployed men was nearly equal to a large study in five nordic populations 43 which did not control for smoking behaviors the observed gender differences in the association of unemployment and lung cancer point to different careers patterns of men and women our data confirmed the trend of an increased proportion of adc at the expense of sqcc and sclc when comparing diagnosis before and since the year 2000 and our analysis of histological lung cancer subtypes supported previous findings which showed that lung cancer risks for low ses were lower for adc than for sqcc 6 or sqcc and sclc 8 socioeconomic inequalities in cancer incidence are greatest for lung cancer 8 and our study shows that these inequalities were not explained by smoking behavior to explain the observed excess risk of lower ses groups approximately 60 of female nonsmokers of the two lower isei categories would have had to be misclassified as current smokers with corresponding packyears however assuming 90 of misclassification for men an or of approximately 15 would have remained for low ses when we additionally classified former as current smokers still an or of 12 persisted for low ses this confirms the need to explore the pathways from ses to lung cancer first the effect of exposures to occupational carcinogens via job based ses on lung cancer needs to be further studied despite minor effects when considering list a jobs in this study occupational ses directly reflects occupational hazards most occupations such as workers in asbestos production or truck drivers for which elevated lung cancer risks were demonstrated were assigned to low ses as these occupations were traditionally held by men they may account for the higher ors for men in this study this is supported by the reduced ors for men who never worked in bluecollar jobs further ets is also a workrelated risk factor for lung cancer 44 and could be particularly linked to occupational ses as smoking prevalence is higher in lower ses groups other possible more speculative pathways can be derived from the association of ses and health in general because occupational and other ses indicators mainly education and incomewealth are interdependent as shown eg for education 45 faster biological aging may be associated with low ses conclusion our study showed a persistent ses gradient for lung cancer even after adjusting for smoking behavior and education there was some evidence for residual effects of smoking due to misclassification and at least a part of the regional variance of the association of ses and lung cancer may be explained by these residual effects still the strong associations we found in this study in particular for men emphasize the continuing need for the exploration of the pathways from ses to lung cancer clarifying these pathways could then contribute to further understanding of lung cancer etiology and shape prevention approaches s2 fig forest plot of odds ratios by study center data are from the synergy study which comprises several single studies whose authors may be contacted at others would be able to access these data in the same manner as the authors the authors did not have any special access privileges that others would not have supporting information s1

an association between low socioeconomic status ses and lung cancer has been observed in several studies but often without adequate control for smoking behavior we studied the association between lung cancer and occupationally derived ses using data from the international pooled synergy studytwelve casecontrol studies from europe and canada were included in the analysis based on occupational histories of study participants we measured ses using the international socioeconomic index of occupational status isei and the european socioeconomic classification esec we divided the isei range into categories using various criteria stratifying by gender we calculated odds ratios or and 95 confidence intervals ci by unconditional logistic regression adjusting for age study and smoking behavior we conducted analyses by histological subtypes of lung cancer and subgroup analyses by study region birth cohort education and occupational exposure to known lung carcinogensthe analysis dataset included 17021 cases and 20885 controls there was a strong elevated or between lung cancer and low ses which was attenuated substantially after adjustment for smoking however a social gradient persisted ses differences in lung cancer risk were higher among men lowest vs highest ses category isei or 184 95 ci 161209 esec or 153 95 ci 144163 than among women lowest vs highest ses category isei or 154 95 ci 120198 esec or 134 95 ci 119152 ses remained a risk factor for lung cancer after adjustment for smoking behavior

introduction leprosy is a chronic disabling infectious disease caused by mycobacterium leprae an intracellular bacillus that attacks schwann cells causing their destruction and leading to severe neuropathies that cause deformities and physical disabilities 1 2 3 4 leprosy an endemic member of the neglected diseases group 5 mainly affects developing countries constituting a serious global public health problem in 2015 the global leprosy detection rate was 32 cases per 100000 inhabitants with 16 countries accounting for 92 of all cases of the disease india brazil and indonesia reported more than 10000 cases comprising 81 of new cases of the disease during the period 6 brazil is the country with the second highest number of cases with a detection rate of 1406 cases per 100000 inhabitants in 2015 7 the world health organization has launched the global leprosy strategy 20162020 which aims accelerating towards a leprosyfree world which aims to detect leprosy early and provide immediate treatment to prevent disability and reduce transmission of the disease in the community 8 this strategy aims to reduce the prevalence of leprosy by improving the capacity of health services to diagnose cases in the early stages of the disease to provide timely treatment aimed at a cure and to eliminate sources of infection 9 one of the main obstacles in the elimination of leprosy concerns the social inequalities faced by people in developing countries caused by poor housing conditions low levels of education low incomes deficits in health services and migration to urban centers 1011 endemic areas with unhealthy housing conditions lacking basic sanitation human agglomeration the sharing of collective spaces especially dormitories with shared beds and sleeping nets are risk factors for the transmissibility and development of the disease 1213 so understanding the social determinants that influence the risk of leprosy transmission is of fundamental importance for the development of actions and strategies that aim to accelerate the process of elimination of the disease in brazil 14 for the who 14 social determinants of health include individual behaviors and living and working conditions as well as the relationship between the economic cultural and social structure chaptini marshman based on this premise grouped social determinants into three dimensions these being socioeconomic environmental and gender determinants 10 a review of the literature using the descriptors social determinants and leprosy found few studies with this focus in brazil among the studies that proposed to test the relationship between social determinants and leprosy risk 15 16 17 18 none were found that considered spatial dependence or incorporated it into their analysis by definition spatial dependence is understood to be the tendency that the value of a variable associated with a particular location resembles the value of its neighboring samples more than the rest of the locations of the sample set it also becomes the concept of neighborhood which is formulated on the basis of the property of proximity in which the events that are closer together tend to be more similar to each other than distant events 19 thus a case of leprosy in a given region tends to influence the epidemiological situation of its neighbors therefore not being a random event the quantification and appropriate use of methodologies to deal with this characteristic are also considered to be a knowledge gap since the majority of traditional epidemiological studies tend to ignore this effect there is also a lack of studies in border areas of brazil where these diseases tend to be more critical or more difficult to control due to the fragility of the services in monitoring the dynamics or migration of populations between the different countries 20 therefore this study aimed to analyze social determinants and their relationship to the risk of contracting illness due to leprosy as well as the temporal trends of leprosy cases in a triborder region in latin america methods study design this was an ecological study 13 scenario the municipality of foz do iguac ¸u is on the triple border between brazil paraguay and argentina situated in the extreme west of parana ´ it has a total area of 618353 km 2 being the seventh most populous city in the state it is organized in 327 census tracts 320 in the urban area and seven in the rural area the population of the municipality of foz do iguac ¸u is approximately 263915 inhabitants with 992 of the population residing in the urban area 21 table 1 presents the main socioeconomic information regarding the municipality it reveals important social indicators such as an equality of income distribution of 0545 which represents an unequal income distribution and a human development index of 0751 close to the national average a critical social condition observed was that only 753 of the households had an adequate sewage system 21 which constitutes a risk factor for leprosy 10 in the context of healthcare foz do iguac ¸u has 388 health facilities 61 public 321 private and six nonprofit institutions the municipality has 30 primary health units 25 specialized clinicsoutpatient clinics two emergency care units three psychosocial care centers 46 diagnostic and therapeutic support units 10 mobile units 44 polyclinics four hospitals two health surveillance units and one central laboratory 22 study population this comprised cases of leprosy that were diagnosed between 2003 and 2015 and residents of the urban area of the city study variables and data source the study variables selected were diagnosis date date of birth sex racecolor level of schooling address new case pregnancy clinical form operational classification number of skin injuries and disability grade at diagnosis and at cure these variables were obtained through the disease notification information system regarding the social determinants data from the demographic census of brazilian institute of geography and statistics were used these included general characteristics of the household and people personal income household income colorrace age gender and level of schooling following the theoretical framework of chaptini and marshman 10 the social determinants were grouped into three dimensions a socioeconomic determinants proportion of households with monthly income per capita proportion of literate people and proportion of people according to racecolor b environmental determinants proportion of households according to the number of inhabitants and housing and basic sanitation conditions c gender determinant proportion of households without a female resident data collection data were gathered from the health surveillance department of the health bureau in foz do iguac ¸u brazil data analysis exploratory data analysis was performed using statistica version 120 software calculating absolute and relative frequencies for the categorical variables such as sex schooling race operational classification clinical form and degree of disability at diagnosis the continuous variables age and number of lesions were categorized according literature 489 the number of cutaneous lesions were classified following the criteria defined by who 8 in other words up to five lesions the authors considered paucibacillary and more than five lesions were classified as multibacillary the incidence rate was estimated considering the number of cases in the population in the middle of year this was multiplied by the time of observation 7 the size of population was obtained from ibge the technique of georeferencing new cases of leprosy by geographic coordinates according to the address of the residence was applied in order to obtain geographic information latitude and longitude google earth pro open access software was used considering the utm projections for south america after conversion of the database to csv format and its configuration terraview version 422 software was used for the geocoding itself which corresponds to the linear interpolation of the complete address to a point in the corresponding segment of the street cases with incomplete addresses were excluded from the study thematic maps were produced through the digital mesh in the shapefile extension of the census tracts provided by ibge arcgis version 105 software was used for this analysis the relative risk or risk of illness due to leprosy for each census tract was obtained through the spatial scan statistic 23 using the discrete poisson model with age and sex as covariables through satscan version 93 software in this analysis it was defined a window of 50 of the population at risk with the statistical significance tested for 999 interactions the risk was estimated within a grouping divided by the estimated risk outside and within a given area calculated based on the expression 24 rr ¼ ce½c ðc à cþðe½c à e½c ¼ ce½c ðc à cþðc à e½cð1þ where c is the number of cases observed within the cluster and c is the total number of cases in the data set e c c with the analysis being conditioned to a total number of observed cases the thematic maps were developed in arcgis version 105 software investigation of the spatial dependence of the social determinants and of the risk of illness due to leprosy was carried out by calculating the global moran i index using geoda 16 software this analysis shows the degree of spatial autocorrelation where the values vary from 1 to 1 positive values indicate direct correlation and negative values inverse correlation ie dissimilarity among neighbors the value zero indicates that there is no spatial dependence the global moran i index was obtained using the formula 25 i ¼ p n i¼1 p n j¼1 w ij ðz i à zþðz j à zþ p n i¼1 ðz i à zþ 2ð2þ with n representing the number of areas z i the value of the variable considered in the area i z the mean value of the variable in the study region z j the value of the variable considered in the area z and w ij the neighborhood matrix in this type of matrix units with common boundaries or vertices are defined as neighbors the neighboring unit being defined as w ij 1 while elements that have no neighborhood relation are defined as w ij 0 25 to test the association between social determinants and the risk of illness due to leprosy the authors used bivariate global moran followed by multivariate analysis for the variable statistically significant in the first phase calculations of the bivariate moran index were performed using the geoda 16 software and the permutation of the neighboring attributes approach was used in evaluating significance as described by anselin 26 in the multivariate analysis the ordinary least squares regression was considered initially in an attempt to explain the global relations between social determinants and risk the diagnoses of an ols model were followed by examination of multicollinearity and the residuals quantifying the variance inflation factor values and in cases where vif was higher than 10 this indicated multicollinearity the gwr local model was used to analyze the relationship between social determinants and risk of illness due to leprosy for each area this technique consisted of a localized multivariate regression that allows to make an estimate of the parameters of a regression and then how they have changed and ranged locally 27 the adaptive kernel was chosen in this phase the adjusted coefficient of determination and akaike information criterion obtained for ols and corrected akaike information criterion calculated for gwr were used to compare the ols and gwr models according to the procedure carried out by lin and wen all these analyses were performed using esri arcgis 1051 and r 342 software for the determination of the temporal trend the annual incidence coefficient of leprosy was considered as the predictive variable and the time the outcome variable the annual incidence coefficient was converted into a logarithm which provides the reduction of the heterogeneity of the residual variance of the linear regression analysis 28 temporal trend analysis was performed through the praiswinsten regression 28 based on the coefficients of annual detection of new cases of leprosy in the period studied the confidence interval of 95 was used which results in the annual rate of increase 29 the rate trend was classified as increasing stable or decreasing in a rate with a positive value the time series was considered to be increasing a negative rate was considered to be decreasing and when there was no significant difference between the value and zero it was considered to be stationary these analyses were performed using stata version 13 software for all tests in the study type i error was set at 5 statistical significance ethical aspects results epidemiological profile of cases a total of 840 new cases of leprosy were identified of which 427 were females 685 were white racecolor 624 were people between 15 and 59 years of age and 504 were those with incomplete high school education regarding the operational classification in table 2 648 cases were multibacillary and 192 were paucibacillary the predominant clinical form was dimorphic followed by the lepromatous form with regard to the number of cutaneous lesions 441 had five or fewer lesions and 342 had more than five cutaneous lesions with a zero degree of disability of the 840 cases included in the study 765 cases were geocoded of the excluded cases 50 did not have a full address and 25 cases were not located through the google earth pro open access software table 4 shows the results obtained from multivariate analysis applying weighted ols regression where the variables proportion of households with monthly nominal household income per capita greater than 1 minimum wage and proportion of people of brown race were statistically significant associated with risk of illness due to leprosy social determinants and their relationship with the risk of leprosy fig 2 shows the maps obtained through gwr analysis from this figure it is possible to observe the distribution of r 2 and β of the variables the results of gwr are really clear in the map and confirmed the gwr was more suitable than the ols and2c the spatial variations in parameter estimates for variables proportion of households with monthly nominal household income per capita greater than 1 minimum wage and proportion of people of brown race are shown respectively in fig 2e and2f fig 2e demonstrates that negative coefficients values ranged from 012 to 023 from which it is evident that the risk is lower or nonexistent in areas where the income is higher than 1 minimum wage turning to fig 2f the parameters were from 004 to 035 which means there is a positive value in association of brown race to risk of illness due to leprosy temporal trend table 5 presents the results of the temporal trend as revealed through the praiswinsten regression in the annual detection rate of new cases of leprosy discussion the aim of this study was to analyze social determinants and their relationship with the risk of illness due to leprosy as well as the temporal trends of leprosy cases in a region of the triborder region in latin america income and brown race were found to be determinants associated with the risk of leprosy there was also a decreasing trend in the detection of leprosy in the region of the study of the order of 43 in the period investigated which was found to be significant using the praiswinsten regression initial exploratory analysis of the data revealed that there was a predominance of patients of white racecolor in the age group of 15 to 59 years and in those with incomplete elementary education these results are similar to those found in other brazilian studies 20 30 31 32 33 34 35 regarding age the majority of the patients were in the economicallyactive age group which is of concern since the nondiagnosis of the disease can lead to the development of lesions and further evolve into disabilities and reactional states which may impact on the family and wider local economy 9 patients under 15 years of age were also observed in the patient population this is a serious finding that indicates delayed leprosy diagnosis and a possible failure in primary care 58123637 it is interesting to compare this result with table 4 where the leprosy detection rate was identified as decreasing in the region since 2003 therefore it is likely that cases of disease are underreported or not found by the health care system which might be due to a weakness of primary health care in active casefinding and decentralization to general practitioners without support from a reference center for the diagnosis and treatment of leprosy 38 this epidemiological situation is evidence that brazil is really far from achieving the goal of whos global strategy for leprosy 20162020 which aims for zero children diagnosed with leprosy and visible deformities 8 also according to the results most of the patients had incomplete elementary education which is an important characteristic also found by chaptini and marshman 101836 whose studies reported that low levels of literacy are associated with higher rates of leprosy this relationship is due to a reduction in seeking and understanding clinical information regarding the disease and an association with low income santos castro and falqueto 39 also found that people with low levels of education have greater difficulty in accessing health services and understanding health promotion actions and disease prevention measures regarding the operational classification of leprosy the multibacillary form the most infectious form of the disease was observed predominantly this may indicate late diagnosis of the disease in the study region contributing to the leprosy transmission chain and to the increase in the degree of physical disabilities 29 a prevalence of the multibacillary classification has also been reported in other studies 3034354041 regarding the association between social determinants and risk of illness due to leprosy it was possible to detect a negative association with the proportion of households with monthly nominal household income per capita greater than 1 minimum wage this finding has been confirmed by other studies 24 42 43 44 45 46 one important issue that has been shown by the literature is that income is a social protection factor in the development of neglected diseases that are related to poverty such as leprosy 47 it can clearly be observed in fig 2c where the relation between higher income and lower risk of leprosy is expressed represented in the dark red color in the mapping chaptini and marshman 10 stated that leprosy is associated with poverty due to a multiplicity of factors including the effect of lower income and unemployment which reduces access to health services to purchase necessary medicines poorer housing and overcrowding of homes another aspect that is linked to low income is access to adequate food since poor nutrition is related to an increased risk of developing leprosy 1248 through multivariate analysis it was found that areas with a predominance of people with brown racecolor presented an increased risk for leprosy which demonstrates the relationship of this disease with this social determinant castro et al 49 also found a correlation between racecolor and the risk of the occurrence of leprosy biologically there is no evidence that color race is a risk for the development of leprosy however in brazil these characteristics are more related to social inequality due to reasons of history people of brown racecolor have less access to elementary school high school and higher education they have lower income when compared to white people and also fewer opportunities to participate in formal work and to live in houses with basic sanitation 50 however there is a strong politics of quota in brazil to improve the access of these people in an attempt to give underprivileged people better chances of getting free higher education and thus access to better opportunities the politics of quota in brazil addressed to colorrace have changed in recent years and class criteria have become more acceptable than race for reducing brazils social and racial inequalities however there is much discussion about the appropriate policy solutions for the problem 51 this study may contribute with this debate once it is evidenced that areas with a higher proportion of brown racecolor patients have a higher risk of leprosy it is important to highlight that the characteristics of the space where these people are living is what is associated to the leprosy risk which means that is not necessarily these individuals are getting sick or have been affected by the disease the association was found in the ecological level a phenomenon that is classically known as ecological fallacy the results also show a decrease of 4 per year in the rate of detection of new cases of leprosy which is similar throughout the entire state of parana ´ 2252 this result leads to the question of whether the apparent decrease reflects the actual epidemiological situation of leprosy or possible underreporting considering the social inequalities that increase the risk of leprosy found in the study the second hypothesis is more likely to be confirmed because it is a border region where there is a major flow of people between the three countries the control of communicable diseases is highly complex it is difficult to precisely determine the areas of risk due to the very dynamism of this population 205455 however the study advances knowledge by highlighting the social determinants of the risk of leprosy serving as a reference for future studies that include spatial dependence in their structure notably those that test relationships between social determinants and diseases of poverty such as leprosy the elimination of leprosy goes beyond merely knowing what the social determinants of leprosy are and medical technology for diagnosis and treatment will only have an impact if there are significant advances in social areas although there have been improvements in social conditions in brazil due to large investment in government programs this has not yet been enough to overcome the sanitary conditions where leprosy is spread control of the disease includes the dimensions of sanitation living conditions and income as well as the inequalities that still exist among people of the brown racecolor and lower income as according to the findings of this study they are at higher risk of illness due to leprosy inclusion policies can be a measure to reduce the differences in risk latin america achieved a detection rate of about 27 new cases per 100000 inhabitants taking second position in the world in terms of cases numbers brazil was included in the priority list for leprosy elimination even though the number of cases detected has substantially decreased during the last decade it is important to emphasize that in latin america brazil presents the largest number of cases followed by paraguay and argentina 56 an issue is the migration between these countries likely influences in leprosy incidence and prevalence in the region studied however it was not possible to estimate its impact due to data from paraguay and argentina were not available the study has shown that leprosy is spatially determined this being relevant for studies that aim to understand the dynamics of the disease using more robust methodologies mainly through gwr which resulted in better models than traditional methods the study advances knowledge about the distribution of the disease in the triborder region of brazil paraguay and argentina presenting evidence for improvement in health policies for control of the disease castro et al 49 reinforce the associative nature of the disease and social inequality demonstrating that leprosy is not limited to illness process individual but essentially from social factors accumulated in the life course of a population since intrauterine growth until later adult life which is really complex to analyze in a single study other issue is that leprosy is not limited to social stressor factors within a single generation but should intertwine biological and social transmission of risk across generations which also requires more complex and dynamics approach for future study it would be interesting to develop a prospective study and also including data from paraguay and argentina through a data collect in loco the inclusion of data from both countries was not possible because all their registers were still handwritten they do not use computerized systems for monitoring leprosy cases based on the findings of the study it can be concluded that the leprosy elimination strategy must transcend the technological apparatus of the health sector which is often focused on diagnostic technology and treatment and must include essential aspects of human development and welfare the study contains limitations related to the use of the secondary data obtained from sinan which may present data instability and incompleteness due to failures to complete the data in the notification form another limitation was the difficulty in selecting the variables related to social determinants these were based on the literature 1015434553 but the number of studies using such an approach for leprosy is still limited the methodology also addresses the issue of areas identified as protection actually being areas of underreporting formal analysis

brazil is the only country in latin america that has adopted a national health system this causes differences in access to health among latin american countries and induces noticeable migration to brazilian regions to seek healthcare this phenomenon has led to difficulties in the control and elimination of diseases related to poverty such as leprosy the aim of this study was to evaluate social determinants and their relationship with the risk of leprosy as well as to examine the temporal trend of its occurrence in a brazilian municipality located on the triborder area between brazil paraguay and argentinathis ecological study investigated newlydiagnosed cases of leprosy between 2003 and 2015 exploratory analysis of the data was performed through descriptive statistics for spatial analysis geocoding of the data was performed using spatial scan statistic techniques to obtain the relative risk rr for each census tract with their respective 95 confidence intervals calculated the bivariate moran i test ordinary least squares ols and geographically weighted regression gwr models were applied to analyze the spatial relationships of social determinants and leprosy risk the temporal trend of the annual coefficient of new cases was obtained through the praiswinsten regression a standard error of 5 was considered statistically significant p 005

reorienting health services and developing personal skills while there is recognition of and some research on health inequities as they relate to black communities globally often addressing these unique inequities gets subsumed into a general focus on marginalized or vulnerable populations it is comforting for some of us to assume that as a field we are doing enough because we hold good intentions but the reality as demonstrated by almost any measure of health or wellbeingeg life expectancy disease prevalence maternal mortality rates is that however wellintended we are in our approach health promotion is not affecting meaningful change for black communities quickly enough clearly it is not sufficient to hold an unspoken intentionto research and publish about health inequities or to craft piecemeal interventions to patch up the divide experienced in black communitieswithout centering race as a primary and legitimate determining factor if we are to make any significant difference we need to bring to the fore the knowledge methods and strategies we have honed over the last 34 years we must move to intentionally dismantle oppressive structures and address the historic injustices of colonialism and slavery the resulting intergenerational trauma as well as racist laws and policies institutional practices rooted in racial biases and the economic deprivation that continues to harm black communities this perspective article has been written through collaborative intergenerational and transnational discussions among a group of members of the international union of health promotion and education we situate ourselves variouslyas academics frontline workers researchers students and activists as new and established members of the formal health promotion field as differently abled gendered aged individuals of various racial identitieswho share a commitment to questioning how the field of health promotion has been blind or complicit in perpetuating antiblack racism scholarship and practice and challenging ourselves to remain silent no longer we offer our thoughts with the intention that they are part of an essential conversation within a field such as ours which is designed to value and uphold human dignity equality and action the black lives matter movement emerged out of a historical and urgent need to reflect on the realities of black communities and their own understandings of how both structural and interpersonal racism experienced daily and for the past 400 years under the many cloaks of colonial rule is unique to africans the african diaspora and people of african descent through this article we outline the intersection of social determinants of health and antiblack racism we describe how in the first 8 months of 2020 black communities around the globe have been disproportionately affected by covid19 while also having to respond to new instances of police brutality we assert that the time has come for health promotion to stop neutralizing the specific needs of black communities into unspoken good intentions instead we offer some concrete ways for the field to become outspoken intentional and honest in acknowledging what it will take to radically shift how we promote health and wellbeing for black people black lives and the disproportionate death toll due to covid19 the impact of the covid19 pandemic on the health and economic wellbeing of people around the world has been devastating and even more so for black communities the pandemic has exposed inequities that have existed for hundreds of years between the descendants of enslaved africans and those of european descent in all contexts tracking such data black communities experience disproportionate numbers of infections more severe complications and higher death rates than other racial or ethnic groups for example analysis of federal data in brazil reported that of those hospitalized with covid19 one in three black brazilians had died compared with one in 44 white brazilians this pattern holds to a greater or lesser extent in other countries with significant black populations in the usa a recent report highlights discrepancies indicating that black people are 23 times more likely to die of covid19 than white and asian people the ageadjusted rate is 37 meaning that younger black people are dying much more frequently than white and asian people of the same age this may reflect the concept of weathering which was originally observed among young africanamerican women who experience early health deterioration as a consequence of the cumulative experience of ongoing social economic andor political exclusion and which may take the greatest toll among black people in racially charged contexts who must engage in higheffort coping mechanisms canada has not historically collected or reported racebased health data this practice is being challenged in the context of the covid19 pandemic as various sources have called attention to the disproportionate impact the pandemic has had on black and brown communities in response jurisdictions have begun to collect racebased data in relation to covid19 a press release from toronto public health of a small sample of respondents for example found that 83 of people with reported covid19 infection identified with a racialized group research suggests that personal support workers one of the groups at highest risk for covid19 infection in ontario are disproportionately visible minorities and immigrants looking at proportionsblack people make up 124 of the us population and 233 of the covid19 deaths in south africa which has the fifth highest number of cases worldwide covid19 is hitting the black townships harder than areas predominantly occupied by white people for example in midjune nearly 12 of total infections were found in khayelitsha a large and predominantly black township in cape town in spite of it having just 6 of the provinces population in contrast stellenbosch which makes up about 4 of its population had just 1 of total cases these patterns hold even in country contexts with relatively homogenous populations such as norway where the somali community especially in oslo has been disproportionately affected by covid19 accounting for 6 of all casesor more than 10 times that of the general population higher risk of infection and complications while the black community must contend with disproportionate death rates due to covid19 the risk of infection is also greater due to increased exposure to the virus the world over black people are overrepresented in jobs that expose them to greater risk of persontoperson transmission on the frontlinessuch as health care and personal support work taxi driving housekeeping grocery store clerks factory and farm workers it is also likely that black people in lowincome jobs and the large numbers working in the informal sector still comprising more than 60 of the worlds employed population and 86 in africa lack access to paid leave and are unable to stayathome when ill or after exposure to an infected person workers across the spectrum have been impacted by covid19 in trinidad and tobago for example nurses and sanitation workers have been protesting for increased wages including hazard pay and better working conditions as a result of the increased risks posed in their daytoday work due to covid19 african countries with predominantly black societies have not been spared from racist and capitaldriven measures that have weaponized the fears of a community spread outbreak as the pandemic took its toll on zambias economy reports began to emerge about chinese business owners who allegedly did not allow local workers to return home to their families and kept them onsite during the pandemic to increase the factorys productivity zambian workers were made to sleep in small containers with up to six people on mattresses on the floor in response to this gross example of human rights violations factory owners claimed that workers were not being held against their will but that these measures protected them from the pandemic housing also factors into increased risk of exposure housing in black communities is a complex modern and historical issue with widereaching health consequences for instance in south africa township layouts which are a legacy of the apartheid regime limit safe housing options within black communities poor black families are squeezed into overcrowded onebedroom shacks where adherence to strict lockdown measures such as social distancing and regular hand washing is nearly impossible this pattern holds true in other african countries with similar histories of legislated segregation including the former portuguese colonies of angola and mozambique similarly in the usa redlining policies beginning in the 1930s created unequal geographies through racially discriminatory lending practices segregation and underresourced tenement housing in predominantly black neighborhoods and cities these environments by design are more likely to provide unsafe housing typically defined through higher prevalence rates of crime and homelessness which are often a direct result of systemic racism and intergenerational povertyfurther exacerbated by a lack of dedicated resources for community development these housing environments and community spaces frequented by black communities are neglected by the state because of their socioeconomic status and are hotbeds for covid19 transmission even beyond the compromised conditions of black neighborhoods the location of these housing settlements also increases the likelihood that black people have to rely on public transportation to get to work and commute to city centers further increasing their risk of exposure black people are not only more vulnerable to infection but are also more likely to have complications once infected with covid19 due to a lack of adequate care and preexisting conditions those individuals with underlying medical conditions are generally at an increased risk of being hospitalized due to covid19 however black individuals often face these medical conditions at a much higher rate than white individuals in the usa for example black americans are 60 more likely to be diagnosed with diabetes than nonhispanic white people are more likely to suffer with hypertension with a much earlier onset of symptoms than other racial groups and more likely to live with asthma and other respiratory diseases these complications are reflected in the overrepresentation of deaths due to covid19 worsened by the fact that black americans face significant barriers to accessing adequate care contributing socioeconomic factors include a lack of health insurance among black populations and the biased attitudes of healthcare workers which routinely leads to symptoms and pain being ignored or undertreated many black americans have understandably lost trust in the healthcare system because of these negative experiences and developed helpseeking avoidance behaviors further compromising their care health communication messages have also failed to meet the needs of black communities for example the somali population in norway a small proportion of the population has been disproportionately affected by covid19 they are at greater risk of exposure due to their work as taxi drivers or as health and service industry workers and their living situations still despite this disproportionate risk most official information about covid19 was presented in norwegian and english galvanized by these gaps in the state response members of the somali community mobilized key gatekeepers to initiate a collaboration with the public health institute to develop an inclusion strategy comprising targeted outreach and the production of knowledge products in somali this community response revealed critical oversights in the norwegian health system and strengthens the humanitarian call for equitable flexible and inclusive strategies to be applied in emergency responses to ensure equal access for all in the context of covid19 specific guidance has been developed around the dissemination of health information for migrants and refugees in the appropriate languages given the higher healthrelated risks and vulnerabilities of these communities despite this the challenge still remains in health and other field to disseminate track monitor and ensure compliance for protocols that are handed down by development agencies groundup approaches that allow people to become aware of and challenge their own biases like the example in norway build a strong foundation toward lasting change police brutality uprisings and covid19 on 25 may 2020 in minneapolis minnesota george floyd was killed while in police custody when an officer kneeled on his neck for nearly nine minutes cutting off the air to his lungs the horror of this incident is indicative of the rampant brutality experienced by black people at the hands of police in the usa dating back to the era of slavery the murder of george floyd which was witnessed firsthand and shared globally via social media prompted uprisings in major cities across the country and solidarity marches worldwide in the usa thousands gathered across the nation braving the risk of contracting the virus to protest the brutality that countless black people continue to face the response from law enforcement highlighted the inhumane treatment black people and their allies endure when fighting for racial justicefrom the coordinated physical attacks on protestors with tear gas and pepper spray to the destruction of water and firstaid supplies in the midst of a viral pandemic that directly threatens human respiratory functions this reaction from the state ultimately jeopardized the capacity of medical facilities that were already overwhelmed with the unrest sparked by various direct actions of the blm movement black people throughout the diaspora have experienced increased levels of violence death and maiming at the hands of police examples from the caribbean include the june 27th police shooting of three black men joel jacobs israel clinton and noel diamond who could be seen with their hands in the air surrendering to the police at the time of their shooting which was captured by a neighbor on his mobile camera and also picked up by nearby cctv cameras these extrajudicial murders triggered widespread protests throughout trinidad and tobago that lasted three days during this time protestors were beaten tear gassed and to the countrys horror a 30yearold pregnant woman ornella greaves was killed by a stray bullet when an officer allegedly discharged his gun into a crowd of peaceful protestors who were gathered in their own community and if this story wasnt tragic enough 7 years earlier in 2013 ornelles brother christopher greaves was also killed by police while walking home from the corner store in south africa people also took to the streets in the spirit of the blm movement and in protest of police brutality in townships the violence with which covid19 lockdown regulations were enforced brought the culture of abuse and nonaccountability of the south african police service into sharp focus in the first three days of lockdown three people were killed by police and within a month the un human rights office had received reports of excessive use of force by security officers including the use of bullets tear gas water bombs and whips to enforce social distancing particularly in poor and informal settlements due to mounting pressure from civil society several court orders were issued to compel authorities to prevent police and army brutality during the enforcement of lockdown measures since april the canadian civil liberties association has been tracking and visualizing the massive and extraordinary expansions of police power in response to the covid19 pandemic and the unequal patterns of enforcement that may arise as a result through their policing the pandemic mapping project the stated aim is to highlight covid19 related patterns of police intervention to help understand who is being targeted what justifications are being used by police and how marginalized people are being impacted in trinidad and tobago police arrested scores of lowerincome black people during lockdown citing the breach of covid19 regulations the intentions of police and circumstances around these arrests have however been scrutinized given the state and police narrative that gang leaders were attempting to destabilize the country versus an organic uprising of citizens affirming their right to peace and freedom from violence this type of discursive reframing much like the performative paternalism of the chinese business owners in zambia and the more visceral brutality of the south african police all demonstrate how the pandemic has been racialized and politicized resulting in detrimental effects for black peoples health and safety globally the overlapping and intersecting realities of black communities are laying bare the harsh realities that black people have endured since the dawn of the transatlantic slave trade when they were stripped of their right to be considered human how can we in good conscience assert that this history has no impact on the social determinants of health antiblack racismhistorical and current structural and interpersonalhave unique and devastating consequences on the health and wellbeing of black people today the reckoning of historic violence economic deprivation under and precarious employment underinvestment in education inadequate access to food environmental injusticeall now manifest in covid19 infection complications and deathare juxtaposed with the profound presentday violence inequity and injustice faced by black communities the life and death threat posed by police violence has motivated people out into the streets to fight for their lives and to rise up in opposition to generations of structural violence the response has been more police brutality violence and exposure to covid19 so the question is fellow health promoters what are we going to do about it and of course i am afraid because the transformation of silence into language and action is an act of selfrevelation and that always seems fraught with dangeraudre lorde dismantling racism within our profession the structural racism described in this editorial dates back to the slave trade and colonization of africa and involved not only the theft and forced displacement of people their land and wealth but also the trojan horses of education health services and religious indoctrination the education and services ushered in by missionaries and other colonial actors very rarely served african people but instead were instrumental in stripping away indigenous identities and knowledge and privileging western ways of knowing which has had devastating consequences for instance in hiv prevention work and countless other examples indeed chattel slavery was a system of extreme violence where the black body was considered property and animalistic meant only to reproduce for the sake of creating more workers and forced to work under the most dehumanizing conditions once african countries achieved independence from this iteration of colonialismnew forms of domination were devised and mainstreamed through neoliberal financial dependence as implemented through economic institutions like the world bank and international monetary fund these policies included predatory trade agreements and structural adjustment programs that mandate unfavorable currency manipulation vulnerable cash crop economies and the gutting of social and health infrastructure the first who conference for health promotion organized in ottawa in 1986 coincided with an expansion of privately provided social and health services in the wake of neoliberal trade and structural adjustment policies that emerged around that time and remain largely intact as governments were forced to scale back their services nongovernmental organizations swooped in to fill in the gapsat times employing health promoters as a part of those efforts as health promoters it is important that we understand how the field of health promotion was ushered in along this timeline our field is indelibly part of a colonial history and therefore demands that we be transparent reflective and explicit in our attempts to actively dismantle these systems as a profession we must share our commitment to promote equity and dismantle racism and engage collaboratively far and wide to echo the title of this article it is high time for health promotion to become authentic and outspoken in acknowledging what it will take to radically shift how we advocate promote and demand inclusion in our field that prioritizes the health and wellbeing of black people to that end we offer the following suggestions to fight antiblack racism on at least three planes health promotion policy work to dismantle structural racism health promotion interventions to fight antiblack interpersonal racism and critical selfreflection on antiblack racism as a core tenet of our professional preparation and ongoing development dismantling structural racism we have covered many aspects of presentday structural violence and racism as illustrated through the current covid19 pandemic we have described ways in which the historic and modern deprivation of all the prerequisites for health including peace shelter education food income a stable ecosystem sustainable resources social justice and equity impact black communities the precise policies processes and practices that dictate this deprivation vary from context to context but the universality of antiblack racism and its effects are undeniable health promotion the action arm of public health has honed powerful tools for promoting health through policy change at state and institutional levels and we need to work collectively to harness the full potential of these tools to identify and uproot policies and practices that harm black communities inevitably what can be unearthed by this process is a fundamental recognition that the injustices faced by black communities influences every aspect of their health and wellbeing and so armed with this information we must act in nearly every country where black people exist there are organizations already working to bring about positive change with most of the heavy lifting already being done by communities of color we can find the alignment of our goals and seek partnerships that leverage our skills resources and platforms to meaningfully collaborate with existing initiatives led by black organizers dismantling structural racism requires among other things linking health promotion research to decolonization efforts and equality struggles the research we do influences intersectoral structures and the social determinants of health through our technical advice to policy makers contributing to professional preparation and guiding practice it is incredibly important that health promotion research asks some fundamental questions whose worldview is prioritized in our research who funds the research and what does that buy them whose questions are being asked what methods are being used who gets to analyze the data what knowledge are we creating and who is it for are there critical andor indigenous methodologies that might be more appropriate to apply is this particular research addressing questions that will illuminate dimensions of intersectionality of how this issue is experienced who is conducting this research and who will benefit from the findings we also need to fundamentally question the status quo and what we are willing to accept as normal during the pandemic there have been lots of discussions of a new normal or returning to the normal way of doing things covid19 has presented the world with a new opportunity to rethink the utility of the ways things were and who the beneficiaries of these handed down systems really are significant harm has resulted particularly harm to black communities in the reinscription of the status quo as evidenced by premature reopening strategies that have caused disproportionate depredation relevant questions to ask during this pandemic but also more broadly are is normal just who does normal serve and at whose expense as we look at the actions of governments and companieswho seems to be expendable in a pandemic fighting against antiblack interpersonal racism the first step to becoming an ally to black people and practicing antiracism requires admitting that racist structures exist are reproduced and enforced through conscious andor unconscious interpersonal racial bias we all live in a world that was built on the subjugation of black people regardless of our location the next step requires the intentional processes of uncovering naming and preventing the violence that flows from this socialization health promotion is not new to such work there are many examples of antiviolence work in our field eg our use of critical pedagogy in genderbased violence programs it is important for us to recognize that as much as any individual behavior change is part of a health promotion agenda antiracist education must also be considered a fundamental objective of health promotion practice employing relevant strategies such as the settings approach is particularly relevant for teaching antiracism in schools universities workplaces prisons etc we need to build on and develop theories and models that support this work some promising examples that health promotion can adopt include critical race theory theories of whiteness and decolonial approaches we can also learn from the groundbreaking work of aboriginal and indigenous scholars who have been promoting health in diverse contexts and challenging harmful western approaches of exclusion professional preparation and development to address antiblack racism in our profession and within ourselves lastly it is incredibly important to recognize as described above that our field has roots in colonial dynamics and that those dynamics continue in our daytoday interactions as professionals funding for research and programs is largely provided by former colonizing countries whose medical and health fraternities may not have always had the best intentions or practices around race research eurocentric education and professional training reinforces the notion that northernwestern episteme and social ideals are superior to other ways of knowing not only do funds and ideas from predominantly white countries dominate the field of health promotion white people dominate our ranks the lack of representation of black health promoters in the field reifies racist power differentials and is a fundamental hindrance to appropriately serving black communities how can we meaningfully change the dynamics of white dominance if the majority of health promoters are white this raises important questions for our approach to professional preparation and outreach how can we recruit and retain black health promoters how can we encourage black students to see themselves in these spaces can universities design recruitment campaigns or summer pipeline programs for standout black talent in scientific and other fields what outreach can we do to engage high school students or to host visit the university days that target schools and communities that are generally overlooked can we provide compensation or recognition for black professionals who mentor black students and young professionals what alumni networks exist and how can early career professionals find black colleagues with whom to connect we must also look deeply at our health promotion degree programs and curricula especially those curricula that claim to explore global contexts while exclusively focusing on the exploitation and deficits of nations within africa these courses often fail to apply an equally rigorous critical lens to nations within the global north specifically nations with the economic ability to provide comprehensive social services and continue to not do so we can no longer run the risk of reinforcing racialized power structures that fuel antiblackness in our class or staff rooms as knowledge producers who also have the power to influence the thought and action of future generations there are a number of questions we need to ask ourselves including who is teaching our classes what are the topics we privilege over others are we examining the histories of the institutions we occupy to better understand the sources of inequity what authors are we reading and requiring others to readand where are they from how are we demanding diversity in our faculties who is represented in our leadership within the field what critical and selfreflective practices are being taught and at which levels indeed selfreflective praxis is important for all of us but it is particularly crucial for white health promoters who must be at the forefront of challenging racism in the field we must be continuously engaged in ongoing selfreflective practices we must constantly seek to learn about the neglected buried and ugly histories that have been minimized and erased largely to enable our retention of positions of power and authority we must question our motivations learn about and reflect on our own positionality within the discourses and materiality of white privilege white fragility white saviorism white silence white exceptionalism white apathy antiblackness and unconscious bias which extends beyond the singular category of race we must also cultivate unflinching honesty and humility and hold ourselves accountable first these efforts must be everpresent not only in our thinking but in our daily practices as well every project initiative course we plan must be interrogated according to these critical ideas we are ethically compelled as white professionals to question the hegemony within which our work is situated returning to the question of normalwhat are the normal takenforgranted assumptions embedded in our health promotion programs is it normal to ignore questions of race how have normal health promotion programs worked for black communities so far are we willing to do what is required to achieve equity for black communities are we willing to dismantle systems we personally and collectively benefit from it is important to end by saying that while this commentary has laid out only a fraction of the ways in which black communities and people have been deprived of fundamental access to health and wellbeing historically recently and profoundly in the current moment defined by covid19 the intention of this commentary is not to frame this work as some kind of new rescue effort but to affirm the humanity of black people as a radical and necessary act of solidarity as health promoters we must acknowledge that modern societys dominant and postcolonial ways of working educating policing and caring are harmful to black communities and it is our responsibility to work toward correcting those wrongs dismantling these structures requires the reenvisioning and repurposing of existing health promotion tools and approaches but most importantly it requires imagination we need new ideas new goals new knowledge new models and new leadershipleadership that is not only different from but that directly challenges neoliberal and postcolonial frameworks and ways of thinking it is time to turn toward the unrelenting strength resilience courage and leadership of our black colleagues in health promotion and related movements and become outspoken that black lives matter in our words and in our deeds anything short of that is complicity your silence will not protect youaudre lorde

racism is a public health crisis black communities including africans the african diaspora and people of african descent experience worse health outcomes as demonstrated by almost any measure of health and wellbeingeg life expectancy disease prevalence maternal mortality rates while health promotion has its foundation in promoting equity and social justice it is clear that however wellintended we are not affecting meaningful change for black communities quickly enough through this article we outline the intersection of social determinants of health and antiblack racism we describe how in the first 8 months of 2020 black communities around the globe have been disproportionately affected by covid19 while also having to respond to new instances of police brutality we assert that the time has come for health promotion to stop neutralizing the specific needs of black communities into unspoken good intentions instead we offer some concrete ways for the field to become outspoken intentional and honest in acknowledging what it will take to radically shift how we promote health and wellbeing for black people

introduction the onechild policy ie of having only one child per couple has been the essential family policy in china since its adoption in 1979 and it has effectively controlled the trend of rapid population growth in china the policy has also significantly influenced chinas economic and social transformation through the nations progress of urbanization and modernization however the opposite side of this policy has also been apparent since the beginning of the 21st century 1 and has given rise to the problems of special families under the onechild policy caused by the death or disability of families only children in current policy and regulations the national population and family planning commission of china defines special families under the onechild policy or in another phrase the family planning policy as those families whose only child is disabled or deceased and who have not given birth to or adopted another child this study used the concept of special family according to the official definition raised by chinas health and welfare commission rather than another popular definitionthe shidu family an expression used in academic areas to refer to a family that has lost its only childbecause the concept of special family includes and is broader than the lostsinglechild family and not only the shidu family but also the families in which the only child has a severe disability are targeted as recipients of some special welfare policies and the concept of the special family serves better if it involves those who have unique experiences and interpretations about the implementation of these welfare policies while we also used the concept of shidu family sometimes in the article according to the context some scholars estimate that the number of special families will reach 45 million by 2050 2 while the issue of how to provide them with the necessary support services and solve their difficulties caused by the loss or disability of their only child has gradually become an unavoidable welfare concern for the authorities and the society as a whole in 2021 the chinese government introduced a policy allowing couples to have three children this may solve the problem of low fertility rate to a certain extent and eliminate the possibility of special families in the future however we believe that the threechild policy will not diminish the importance of special family research but make it more realistic and urgent because the special families are now at risk of being ignored and forgotten by the society in 2006 the state council of the central committee of the communist party of china issued a decision on comprehensively strengthening population and family planning work to solve population problems which explicitly proposed to actively explore the establishment of a support system for families with disabled and deceased only children on the basis of that decision in 2007 the national population and family planning commission and the ministry of finance issued the pilot program of national support system for families whose only child died or is disabled officially implementing a pilot program that established a support system for special families in some provinces and soon spread throughout the country since then the social support system for special families has been continuously improved with the contents of the social support being developed from an initial limited financial compensation and material support to the inclusion of psychological support and spiritual consolation and with its provision of social support gradually being institutionalized and systematized 34 however a large concern remains that the welfare demands of special families are not being fulfilled effectivelyspecifically that the standards and level of support are a little low the supply of social support services is insufficient to cover all of the special families in need and the capacity of social support services is not able to satisfy the demand that special families have for professional social support services 5 in response the primary policy recommendations have called for increasing the investment of support funds raising the standards and level of support and increasing the number of personnel and the professional capacity of the social support services 6 the existing research focused largely on the issue of special families from a macrosocial level with fewer studies having been concerned with the experiences and interpretations of those families our research is a qualitative study that we conducted in jinan city shandong province in which we attempted to explore and analyze the subjective welfare experiences of the parents in special families the research question is what is their welfare experience and how do they interpret it being the recipient of the special family support policies which were developed specially for them according to our findings the special families support system meets their needs for social support in many ways but there are still a large number of cases that do not receive the social support they deserve some special families refuse to accept certain support provided by the government and society because they feel the services are presented negatively toward their special status while other families insist on special support arrangements because of their special status and some of them even insist on special support activities that go beyond what the government and society can provide from our qualitative analysis of our indepth interviews the participants experiences and interpretations of achieving related welfare policies are shown to be complicated and we have attempted to explore and understand the complications on one hand these special families need to be provided with special services but on the other hand they are still ordinary older people who also need general and despecialized services thus the dynamic between the specialization and despecialization dimensions of the services approach poses a serious challenge to the authorities efforts to provide welfare services for special families literature review although other countries also have special hardship families formed by older parents who have suffered the death or disability of their children and there are some researches on families who lost a child which mostly focused on issues such as poor physical and mental health 7 low economic wellbeing level 8 and high subsequent fertility 9 special families under chinas onechild policy are a unique social problem because the chinese government has strictly implemented the family planning policy of only one child per couple for more than 30 years the general twochild policy implemented in 2015 signaled the end of the onechild policy in china which made many onechild families especially the special families feel that they had become victims fooled by the onechild policy and were about to be forgotten by the welfare system this led to some collective rights protection actions of special families with the aim of obtaining welfare support from the government which aroused the high attention and concern of government and society 10 in addition in just the past 20 years the number of special families has considerably increased which has attracted attention from academicians who have mainly focused on the welfare demands of special families and related policies as coping strategies the welfare demands of special families under the onechild policy from the existing knowledge the analysis of the welfare demands of special families has been presented as a process of development from one simple dimension to a situation with multiple dimensions and from focusing on material needs to attending to spiritual needs researchers gradually have clarified that the needs of special families are multifaceted multidimensional and differentiated rather than being just a simple need for homogeneous economic or material support specifically studies have found that the older parents who had lost their only children asked not only for financial compensation but also for spiritual comfort 1112 the death of an only child brings unbearable psychological trauma to the family creating needs both for medical services and for spiritual consolation 12 the social support needs of the special families comprise not only financial compensation and material support but also social support and oldage care and the social support needs of the special older adults are different 13 the vulnerability of the special older adults is manifested in various respects and their demands are allround 14 the social support needs of the special older adults are affected by their gender age household registration marital status class structure health status reasons for loss of independence and the presence or absence of their third generation 1516 scholars paid attention to the differences in the social support needs of special families in urban versus rural areas and determined that their demands for older individuals care services tended to increase from rural areas to general urban areas and then to more developed cities 17 rural special families have the highest level of demand for health care services followed by material and economic needs followed by spiritual and recreational needs and then by needs for life care services 18 current research analyzed the welfare demands in special families in terms of targeted needs such as the need for psychological guidance due to grief over the loss of their child 111219 and the need to strengthen their social capital in response to the breakdown of their social networks 20 the existing studies about the demands of the special older individuals emphasized their targeted needs as older people without children and paid less attention to their general welfare needs thus the research findings based on the literature and secondhand studies with rare empirical studies raise the urgency for further exploration of the experiences of these special families the welfare policies for special families under the onechild policy in conjunction with the evolution of the welfare demands of special families under the onechild policy the related welfare policies for special families have also undergone a transformation from focusing only on financial compensation and material support to providing the families with diversified stratified and differentiated types of social support some studies focused on how to provide the necessary economic support and social security for special families under the onechild policy 21 while other scholars gradually stressed the importance of establishing a more comprehensive social support system for these special families and have emphasized the need for an economic relief mechanism for them 1222 scholars highlighted that these special families are an unintended consequence of onechild related policies and should receive comprehensive welfare support in response to their needs 19 in order to provide for the special families diverse welfare demands some scholars suggested the establishment of a fiveinone mechanism for social support involving a collaboration of the government the family the market society and the community 17 another group of scholars emphasized that the government should take the lead in establishing a caring community model that can build a more compassionate and caring social environment by integrating and directing various public and social resources 23 other scholars expressed the concern that interventions should instead focus on agerelated issues 24 it was demonstrated that existing support policies improved the living conditions of special families to some extent 25 while it was also suggested that special support policies overemphasize the special nature of loss of independence which may have a labeling effect and even lead to extreme cases of overreliance or nonuse of the policies by special families 26 the narratives of special families under the onechild policy in addition to investigating the welfare demands of special families and the related policies that exist for them we reviewed studies on the subjective experiences of special families that focused primarily on those families identity and marginalization the sudden withdrawal of their family role at the loss of their only child made the parents unable to orient themselves and created temporary barriers to emergency interactions 27 furthermore the changes in the parents family structure caused their longestablished family identity to disappear and their selfcognition to appear to be chaotic 28 the shidu status is a new starting point for special families in their effort to rebuild themselves and it can become their main identity 29 studies highlighted that some special families are more resistant to their special shidu identities however reporting that those respondents give avoidancetype responses to collective emotional compensation for special family groups and to statustargeted benefits such as early retirement 30 31 32 in the studies of marginalization of special families some scholars suggested that their marginalization includes both structural and psychological dimensions 29 and that their individual marginalization follows a psychologicalstructural path in which the special families gradually form a psychologically marginalized identity that changes their thoughts and actions in social interactions and ultimately affects their interactions with the outside world and individuals leading to structural marginalization 31 from the perspective of psychological marginalization they are desperate and selfisolated due to the influence of traditional cultural concepts such as many children many fortunes and four generations in one family and they actively separate themselves from their normal families 3334 they may also reject sympathy and compassion from others manifesting themselves as being disassociated from friends and community interactions 27 from the perspective of structural marginalization special families gradually dissolve their original social interaction system due to the denial of selfworth 2731 they gradually develop inwardlooking interactions form ingroups and consciously alienate themselves from the general group 2732 the dramatic decrease in social interaction due to low emotional energy and the accumulation of a large amount of negative emotions contribute to their pathological reputation which easily invites social rejection 31 scholars also noted that the mindset of avoiding bad luck led to the exclusion of special families by normal families reinforcing the structural marginalization of this group 35 some scholars are concerned that the existing studies with their suffering narratives and social redemption narratives as the main narrative approach have labeled special families as stigmatized thus strengthening their marginalization at the social structure level 36 research methods this study adopted an interpretivist paradigm and qualitative research method to explore the welfare experiences of the parents who lost their only child and we attempted to present the subjective narratives and the inductive qualitative themes of welfare experiences of those special families this study belongs to a program of promoting the service system for special families under the onechild policy delegated by the national health commission the research team conducted their empirical qualitative study in huaiyin district jinan city performing 33 indepth interviews in january and february 2022 jinan city was chosen as the study site mainly because it is a pilot site of special families welfare policy which was awarded the national warm heart house demonstration site by the authority moreover it is also the location of the study team which provided convenience for conducting the study data collection in this study 33 interviewees were selected by following the purposive sampling method as we sought to gain a comprehensive and deep understanding of the welfare experiences of special families under the onechild policy sixteen participants from special families were selected by following the sampling criteria including being a citizen living in the huaiyin district they have lost their only child the semistructured indepth interviews were conducted and the questions were centered around the following subjects the special families welfare demands for community support services their status of satisfaction with whether their demands were met and their further requirements for support services the current situation experiences difficulties and challenges faced by communities in carrying out support services for these special families additionally the other 17 were providers of related welfare services who could elaborate the welfare experiences of the special families and enrich the understandings of the researchers they were selected by following the purposive sampling of recruiting the direct welfare providers under the current welfare system including managers of a planning family support committee for the streets and community fulltime or parttime social workers in the community related staff members of the district civil affairs bureau and the person in charge of special family support from the national health commission the semistructured indepth interviews were also conducted the questions focused on the opinions on the current welfare system and policy suggestions for improving support services in the future the codes of the interviewees and related specific information are shown in table 1 the study took the appropriate ethical considerations including requiring all participants to complete an informed consent form following the noharm principle and keeping all of the participants anonymous all of the interviews were audiorecorded and were fully transcribed each interview lasted 12 h data analysis the qualitative data analysis software nvivo 12 was used for our qualitative interview analysis and among other things it provided inductive themes that emerged from the data analysis the nvivo 12 software has powerful coding summarization and visualization functions that are especially suitable when the number of textual materials is large and that helped to improve the accuracy and efficiency of the analysis and ensured the objectivity and truthfulness of the research findings 3738 on the basis of the purpose of the research which attempted to analyze the welfare experiences of the special families the grounded theory qualitative method was adopted as the data analysis method we conducted the grounded theory analysis following the guidelines laid by corbin and strauss 39 which included three stages open coding axial coding and selective coding specifically the coding process of this study was divided into the following three steps first at the open coding stage materials from the 33 interviews were imported into the software the original materials were carefully read and open coded and the interview materials were open coded as comprehensively as possible forming 59 free nodes and 1043 information reference points related to the welfare experiences that the special families reported with regard to family planning next at the axial coding stage the open codes were summarized and the logical relationships were extracted to form summarized categories such as specific welfare demands reliance on the government excluding themselves from normal life feeling afraid of specialized treatment and so on then at the last selective coding stage we conducted a selective and theoretical analysis for the existing categories and we attempted to present a deep interpretation and reflection of the interviews and build inductive theoretical themes the deployment of the specialization and despecialization dimensions of welfare experiences the dynamics between those two dimensions were also discussed findings specialization of welfare experiences a dimension characterized as being identityoriented targeted and comprehensive there is an old saying in china that refers to yang er fang lao the death of the only child who was supposed to grow up and assume many family functions such as supporting the parents when they are old carrying on the family line and providing financial support for the family has an irreversibly negative impact on the structure and function of the family compared with ordinary families the special families in our study tended to need special care in order to maintain a normal life and we defined those needs as the specialization of welfare experiences which were shown to have the characteristics of being identityoriented targeted and comprehensive chinas onechild policy is said to be the boldest and largest experiment in population control in the history of the world 40 meaning that the special status of special families was created in a specific social context in the context of social identity an individuals psychological status is closely related to his or her family members status 41 and special families tend to define their selfperceptions and welfare needs on the basis of their special shidu identity status the worry of our shidu families was that if something else happens there is nothing we can do we have no child to rely on to put it in a bad way we lost our family next is to rely on the communist party i hope it will care more about our care auntie lu called two days ago and said that i still have a big brother to take care of me but for her there is really nothing she can do if something happens this is the biggest worry in the temporal dimension the welfare experiences of special families exist in different forms that have different impacts on their identity construction at different life stages with traces of transformation and continuity constructed by society during their life course 42 taking the loss of their only children as the starting point the special families continued to play socially prescribed roles and practices in their subsequent life course which can be divided into the early stage which is characterized by selfisolation and sensitivity the middle stage which is characterized by despondency and requests for changes and the late stage which is characterized by a reestablishment of order the early stage of shidu we also have this which is a kind of severe depression people simply do not want to see people so we can only go through his relatives and friends to understand his recent situation the middle stage of shidu its definitely not the best but its definitely necessary at first you first have to have a process that makes them want to get out of the house and after they get out of the house you can only integrate them into normal activities if they see themselves as normal people the late stage of shidu after the first phase of the project the older individuals saw you with tears in their eyes but now they are laughing and happy to see you coming from far away in the past they used to watch the performance on stage but now they are performing on stage for you before he was waiting for others to help him but now he comes out to help others the trauma of losing an only child or having a disabled only child cannot be healed and the welfare experiences of special families permeate all aspects of their lives and remain with them forever in sorting through the data we found that the welfare demands of special families related mainly to economic support psychological counseling medical care ageing care and daily life care the welfare needs of special families were twofold the comprehensive needs of ordinary older families and also their own unique targeted welfare needs according to the data special families varied in age health status and economic level and they were influenced by multiple factors and had different combinations of needs differentiated needs are the source of precise welfare experiences whereas an adequate connection between the supply and demand sides is a necessary guarantee for subjective welfare experiences 4 thus requiring comprehensive and also targeted services from the government and social organizations old age i think you are able to do with what you have we can move he can send us food at noon it is okay the other issue is the future needs the main thing is that we dont know how to pay for doctors appointments and we dont know how to escort people although i have this child he is still small the last time i almost called 120 at night i didnt dare to call 120 i had money but no one taught me how to pay the bill the second year after the death of the child this thing hit really big at that time i was as numb as if this thing was not true but after six months and a year our pain came just think ing of the child and those things feel ing so regretful if anyone can forget despecialization of welfare experiences a dimension characterized as being identitydenied excluded and hidden as we mentioned earlier the loss of a familys original identity as parents brought deep and intense grief that lasted for a long time and that persistent grief had a serious and negative impact on the physical and mental health of family members from our analysis of the interviews we found that the loss of the only child forced special families to face the deconstruction of their original identity and the reconstruction of their existing shidu special identity as we discussed above the special families asked for special and targeted welfare when they were in their specialidentityoriented stage and it was not expected that they could reconstruct and accept that identity peacefully identitydenied excluded and hidden characteristics also emerged from the subjective welfare experiences and we defined this dimension as despecialization there are significant differences among the acceptable ways and outcomes of identity reconstruction in grief 19 and different special families have contrasting attitudes toward and perceptions of reconstructed special identities the special families are regarded as similar to the fiveguarantee households and the disabled groups that are included within the governments list of the most vulnerable groups in need of policy support at present in china the label of shidu has rashly classified families from different backgrounds into one special category and the identity of a disadvantaged group is not something that all special families can openly accept after my husband died i was left on my own at home my brother would sometimes come over to take care of me i cant walk very well and i dont participate in many activities so i find it quite troublesome i have not been in contact with people for special families before but i may have had two phone calls with xiao chen the traditional chinese confucian culture suggests that there are three forms of unfilial conduct of which the worst is to have no descendants and in ancient times the premature death of a child was also associated with some taboos and curses in feudal thought 43 that stigmatized ideology has been preserved in the course of social development and in community life that cultural tradition influences the interpersonal interactions of special families with their friends and neighbors a social worker who provided services for special families mentioned he was in city l before but now he has moved to city h the reason he moved here is that he wanted to leave his familiar community and after he came here no one knew he is a person who lost his only child during the interviews some special families were satisfied with their current life and the benefits they had received and did not ask for additional special attention differences in the levels of needs were present within the overall group of special families on one hand a low level of needs existed objectively for some and was influenced by the economic status life background and family structure of some of the special families on the other hand a high level of needs of special families can be hidden with the causes of a hidden high level of needs being explained from the individuals and societys perspectives from the individuals perspective special families tend to have low selfesteem and the welfare system provides support for their retirement and livelihood while on the spiritual level it also carries the burden of worrying about bothering others from societys perspective the culture of the community and the services used to help special families are closely related to the welfare experiences of special families the emphasis on special status that staff and providers sometimes promulgate raises the risk of creating a secondary victimization for special families whose dissatisfaction with the welfare that is provided can gradually cause them to tend to hide their true needs and marginalize themselves some years ago some social organizations signed contracts with community committees to organize regular activities for us to participate in such as spring excursions crafts etc and also organized us to visit their agencies those activities were so targeted that only our special families participated and gradually no one want ed to go the dynamics between specialization and despecialization in different special families family members and family lifecourse periods in the process of providing support and assistance to special families an overemphasis on the unique dimension of being special families as the whole unit and a failure to account for the differences among different special families and different family members can play the role of labeling and can lead to the two extremes in which the families are either overly dependent on welfare and or have become welfare resistant 26 by examining the interview data a dynamic between the specialization and despecialization dimensions of welfare experiences as presented above occurred within different special families and also across the life courses of the family members the complexity of welfare demands among different special families and family members all special families experienced the trauma of their only childs death and suffered the ensuing irreversible shocks and traumas in their family structure and functioning however as we have noted significant differences also existed among their welfare experiences according to our study and the welfare demands of special families can be divided into two groups one group of families that are welfare dependent and another group that are welfare resistant the welfaredependent special families regarded being special families as the outcome of a collectively created traumatic event during the implementation of the onechild policy and they believed that the support they lacked due to the loss of their only child should have been compensated by the government and related services in recent times due to the general aging of the population china is no longer limiting the nations population growth through the fertility policy and the onechild policy is gradually receding from the historical stage in the interim special families continue to make their voices heard through petitions and other means hoping to receive attention and obtain a version of targeted welfare we also found that nationwide these people were actually a hidden or potential group of petitioners who felt they responded to the national onechild policy by themselves now i am not given any other protection policy because of the loss of independence what about my next generation the third generation what will happen to them if they are gone therefore they have created a kind of petitioning group in contrast welfareresistant special families believed that their needs for welfare services were similar to those of the general older adults with needs in common that included medical care ageing care caregiving and psychological comfort thus different special families have different welfare needs just as other ordinary older people do special families are ordinary families who have had the misfortune of losing their only children and they may need some special support to help them through a tough time but ultimately they need to go on with their normal daily life in the process of implementing the special family welfare policies an overemphasis on their specialness as a group not only ignores the differences among them but it also makes it harder for them to live their life as ordinary older people and that can be the cause of their resistance community workers considered the concerns of welfareresistant special families in their services and in planning activities for them and the workers optimized their support methods without treating special families differently i never said this is an event for these families specially i always said that our residents are invited to come i never tell them that its for shidu families but that its a warm heart house or from our family planning association or a little something from our street so they wont be uncomfortable coming life course approach to the special families we found that special families often gradually shifted from the specializationcharacterized welfare attitudes to despecialization characterized welfare attitudes over their life course with some special families gradually accepting their specialness as a shidu family and at the same time rebuilding their identity as normal older people in the early stage of shidu special families tended to be more inclined to spend time together in similar groups while in the middle and late stages of shidu their social support networks expanded and their identity diversified so that they were not only special families they also were part of many ordinary older age groups this change revealed from their welfare experiences was not only a continuation of the special familys life course but also a reflection of their improved mental and physical health and the effectiveness of the welfare provisions they were receiving in fact at the beginning these families are inferior and it is certainly more appropriate for such people to be together they are in the same situation they can share the pain there is also more common language they also huddle for warmth in the healing process the real wound healed they can gradually get over this hurdle as discussed earlier the specialization and despecialization dimensions of welfare experiences can coexist within the special families special families wanted to both make a difference in and gain a positive influence from normal social networks while they also regarded themselves as essentially different from other older adults and feared that their negative emotions might become a burden to others trying to join new groups is an important step in expanding their social support networks but the social stigma of being a special shidu family is invisibly internalized 44 one particular family member said it works to go out all day long people are not in the same situation as me and i dont bring my kind of unhappiness to that group of people who can influence meim happy when people are happy but when im not happy i go home if im not happy im not going to influence people discussion and implications this study adopted a qualitative research method to analyze the welfare experiences of special families in jinan city shandong province the findings of the study were based on a generalized analysis of interviews with special families and related service providers which connected the specialization dimension of welfare experiences with identityoriented targeted and comprehensive characteristics and the despecialization dimension of welfare experiences with identitydenied excluded and hidden characteristics the study also revealed the complexity of welfare experiences and the dynamics between those two dimensions in different special families different family members and different lifecourse periods some special families and some members of special families preferred more specialized welfare benefits which were provided only for them some special families and some members of special families preferred more despecialized welfare benefits which were provided for them not just because they were special families but because they were people who needed the benefits and some special families and some members of special families wanted to receive specialized welfare benefits while refusing to be labeled or stigmatized there were some special families or members of special families who gradually shifted from the specializationcharacterized welfare attitudes to despecialization characterized welfare attitudes over their life course the following discussion and implications from the studys findings are categorized into the theoretical and practical domains in the theoretical domain the positive social welfare theory from giddens 45 suggests that no responsibility means no rights and holds that responsibility and rights are inseparable in our study as beneficiaries of welfare benefits special families were labeled as lost and alone which lead to a distinctive focus of attention on them from the outside world that excessive attention was a manifestation and unintended consequence of the alienation of these special families social rights and it was different from the responsibilities that they were supposed to assume and their own initiative that they were expected to bring into play although the different tendencies that accompany specialization and despecialization are subjective interpretations at the individual level the stigmatization brought about by the label of lost only child is a construct of the mainstream social discourse and cultural environment furthermore the stigmatizing consequences of another label dispossessed are constructs of the dominant social discourse and cultural environment and have proven to be a transmissible social process 46 the dynamics between the specialization and despecialization dimensions and their effects on special families is a social problem arising from the operation of social mechanisms and welfare policies rather than a personal problem of special families this study attempted to understand the different characteristics of the two dimensions and to elucidate the inherent tension between the assignment of a specialized status and that of a despecialized status which is better understood as a complex social problem of social welfare policies for disadvantaged groups involving the concepts of rights labeling and stigmatization than as simply negative consequences for special families themselves moreover the stigmatization of this group should be eliminated on the macro social level in the process of realizing their rights special families are forced to bear the consequences of being stigmatized and this additional result of alienation is neither within the scope of responsibility they should bear nor should it exist after the loss of their only child some nuclear families face a crisis of disintegration while relatives and friends gradually reduce their frequency of communication social support networks weaken and social stigmatization leads to both a real life crisis and a psychological crisis in the practical domain the policy makers and service providers should realize that while supporting special families the implementation of social welfare policies may also label and stigmatize special families and become structural and cultural factors that cause the marginalization and isolation of special families from society the government should optimize the welfare services designated for the special families including offering them additional professional service providers more elaborate service content and processes and more refined support services first we should optimize social welfare policies for special families by taking into account their specialized and despecialized welfare needs the policy for special families should fully consider their specialized and despecialized needs and the tension between the two dimensions it should not only provide policies and services to meet the specialized needs of special families but also provide support and services to meet their despecialized needs so as to help them overcome the pain of the death or severe disability of their only child and return to normal life second the process of providing social welfare services to special families should be improved to meet their differentiated specialized and despecialized welfare needs service providers for special families should have a full understanding of and be sensitive to their specialized and despecialized needs and the tension between the two dimensions in the process of providing services they should provide targeted specialized or despecialized services for different special families and family members special families in different living conditions and different life course to meet their differentiated specialized or despecialized needs third a related policy package should be provided to the special families as instrumental guidance including special social welfare policies available only to them and general social welfare policies for their age groups and follow their autonomies to choose to receive specialized and despecialized social welfare services when they need them this research had certain limitations first the study was conducted in jinan only and mainly in urban communities so it cannot reflect the nationwide situations of community welfare experiences of special families and their needs and interpretations especially in rural communities second the issue of special families under the onechild policy is a unique problem to a degree and the findings presented were based on an understanding of both the specialization and despecialization dimensions of the families subjective experiences less consideration was given to theories about losing ones child in normal situations and that perspective should be included in further studies data availability statement not applicable funding the authors disclose receipt of the following financial support for the research authorship andor publication of this article this study was funded by the national health commission of the peoples republic of china grant sk200356 institutional review board statement all procedures in the study involving human participants were carried out in accordance with the ethical standards of the institution and the national research committee the 1964 helsinki declaration and its later amendments or comparable ethical standards informed consent statement informed consent was obtained from all individual participants in the study

the onechild policy ie of having only one child per couple was adopted as the essential family policy in china from 1979 and since the beginning of the 21st century it has given rise to problems of special families under the onechild policy caused by the death or disability of only children the existing research focused on the issue of special families from a macrosocial level and analyzed the welfare demands and welfare policies of those families whereas less research has been concerned with the families individual experiences and interpretations this study adopted a qualitative research method and conducted indepth interviews with 33 participants to analyze the welfare experiences of special families in jinan city shandong province the findings of the study were based on generalized analyses of the interviews including the specialization dimension of welfare experiences with identityoriented targeted and comprehensive characteristics the despecialization dimension of welfare experiences with identitydenied excluded and hidden characteristics the dynamics between the two dimensions among different special families different family members and different periods in the families lives were also examined we present a discussion of the studys findings and their implications categorized into the theoretical and practical domains

i introduction the coronavirus was made in military labs do not go to chinese stores or chinese restaurants because many products come from the wuhan area and therefore may contain the virus and you might get infected hospitals are full of infected people but health officers dont say it openly to avoid panic coronavirus is a big pharma commercial operation designed to sell the related vaccine these are just few examples of fake news that have been circulating on social media since the health emergency was launched at the beginning of january 2020 fake news has always existed and will always exist because people love such stories umberto eco the famous italian semiotician who wrote the name of the rose once said that traditionally the creators of fake news never hurt anyone because they were listened to by just few friends but he blamed social media to amplify their voice by giving them the opportunity to make proselytes on a global scale thats why we have many people who believe in a flat earth and in airplanes that release chemicals to infect people in theories that state that big pharmas create diseases in labs to sell vaccines in aliens ruling the world and so on from a cultural phenomenon fake news have become a dangerous threat to our society when the focus moved to public and personal health issues 1 3 healthcare institutions have been trying to warn the public for years that social media can give rise to misinformation that on social media there are people without any competence who disclose and create false information 4 6 however if you look for disease information on any social media platform you will find both interesting discussions and exchanges of views 7 8 and a different parallel world having less and less trust in institutions and relying in improvised gurus who use social media to amplify their thoughts 9 11 you will likely find conversations about useless treatments nonexistent diseases denial of official medicine apotheosis of alternative medicines cancers that can be treated with a good mood diabetes that heals by drinking a glass of hot water at wakeup time 12 some of such remedies might rise smiles but the issue is serious because personal health choices might affect in a negative way the welfare of the whole society 13 with the covid19 pandemic being just the latest example indeed the world wide web provides an abundant source of medical information and this information has the potential to increase the anxieties of people who have little or no medical training 14 for example the increasing number of social media posts that talk about measles vaccinations is decreasing the measles vaccination coverage 15 and vaccineskeptical websites create communities of people that disseminate misinformation 16 in various fields social media are exploited to improve the realworld scenario indeed business intelligence analyses try to identify influencers 17 peoples sentiment 18 users behavior 19 20 to promote tv programs 21 22 and even mathematical models to predict the future 23 in the health sector although social media are changing the way individuals transmit and receive health related information 24 the voice of the health authorities seems to be dominated by the conversations produced by ordinary citizens in this context motivated by the high number of news circulating on the web and in social applications about the covid19 pandemic we have tried to understand how fake news affects the knowledge that people have about this virus the research question we asked ourselves is how much do fake news affect covid19 perception to address it we focused on news related to the origin spread treatment and effects of the covid19 coronavirus we selected 40 different news true allegedly true or blatantly false taken form both authoritative health sources and unknown sources to understand how people perceive every single piece of news we designed a 7point psychometric likert scale and we asked 293 volunteers of different ages and with different educational backgrounds to express their opinion among strongly agree agree somewhat agree neither agree nor disagree somewhat disagree disagree strongly disagree we defined the awareness index to weight every single opinion and provides a degree of the knowledge that participants have on each individual news results show that fakenews do affect the knowledge related to covid19 for instance people believe that the virus is due to the chinese culinary tradition the study also highlighted a communication problem of health institutions news related to medical aspects do not reach people a clear evidence of the wrong or incomplete communication of health authorities the remainder of this paper is organized as follows section ii describes the research question and the proposed awareness index section iii shows and analyzes the obtained results main findings and conclusions are drawn in section iv ii the investigation the main research question that we address in this study is how much do fake news affect covid19 perception we considered news related to four topics concerning coronavirus • origin the origin of the coronavirus • propagation the diffusion of the coronavirus • treatments the treatments against the coronavirus • effects the effects of the coronavirus on the human body we browsed the web and collected 10 different news related to each topic some news were taken from healthcare authorities and some others were taken from social networks andor social applications the selection was made in order to have some true statements and some false statements as for the latter we established they were false by searching among authoritative sources either the news was explicitly denied or was given no mention at all it is interesting to note that sometimes news concerning on going studies or theories yet not proven by the scientific community have been divulged even by newspapers as if true we collected the 40 news that are listed in table ii we investigate users perception using a 7point likert scale for each statement the user is asked if she strongly agree agree somewhat agree neither agree nor disagree somewhat disagree disagree strongly disagree we consider the 7point scale because it is considered the most accurate of the likert psychometric scales and it gives a better reflection of the respondents true evaluation 25 to understand the degree of knowledge of the participants on each individual statement we introduce the following awareness index aindex n i1 likertn 1 where news is the considered news n is the number of participants u ser i is the i th participants likert returns a value ranging from zero to six a zero score means the participants has a completely right perception of the news ie if the news is false the strongly disagree option returns zero and if the news is true the strongly agree option returns zero conversely a six score means the participant has a completely wrong perception of the topic reported in the news table i shows the values returned by the likert function therefore the more the value of the awareness index is closer to zero the higher is the participants right overall perception towards the considered news iii perception analysis the invitation to fill the questionnaire has been posted to our universities forums and to many different whatsapp groups it has been posted on april 11 2020 and it stayed online up to april 26 we had 293 people who answered the questionnaire 57 female and 43 male the age group of the participants is the following 1620 2130 3140 4150 5160 no knowledge 25 news perception fig 2 news perception according to the awareness index figure 1 shows the awareness index for each individual news to deepen the analysis we consider the following categorization • fullknowledge news with aindex smaller than 1 • somewhat knowledge news with aindex between 1 and 2 • noknowledge news with aindex larger than 2 we divided the 40 news according to such categories • fullknowledge news the category contains 19 news 1 4 5 6 8 10 11 14 15 17 18 21 24 25 26 29 31 37 38 • somewhat knowledge news the category contains 11 news 2 12 16 19 22 23 27 30 32 34 35 • noknowledge news the category contains 9 news 3 7 9 13 20 28 33 36 39 40 figure 2 shows the cardinalities of the three categories it is to note that in general participants showed no really good perception as only half of the news were correctly perceived a random choice is expected to give the same result however only one fourth was really badly perceived and there are only two news scored more than three meaning that no news misled the large majority of participants in the following we analyse the news in each category with a deeper interest in the most critical noknowledge one indeed understanding why participants ended up with a wrong perception about certain news might help delivering a better communication to people in the future fullknowledge news the news with lowest aindex below somewhat knowledge news this category contains some of the most controversial news in particular those that seem to be supported by scientific evidence the real issue is that scientific knowledge about the virus is continuously evolving many studies are set up to test different hypothesis on virus origin propagation and treatments and very often news report ongoing researches as if they already were confirmed results once such studies are concluded even if they prove their initial thesis to be wrong people already got a distorted perception for example news 30 appeared on italian newspapers since the end of april 2020 citing a scientific study conducted at the university of torino 26 however a deeper investigation conducted at the time we prepared the questionnaire revealed that the document was a preliminary study that did not undergo any review process yet at the time we are writing this paper the peerreview version of that article has been published 27 however the evidence that the news is true is still hypothetical indeed the abstract of the paper states that higher vitamin d 3 doses might be useful randomized controlled trials and large population studies should be conducted to evaluate these recommendations another example concerns news 16 stating that scientific studies proved that covid19 survives on surfaces at the time we posted the questionnaire it was only known that the sars virus did survive on surfaces however given that the covid19 virus belongs to the same virus family of the sars virus hypothesis were that also covid19 survives on surfaces at the time we are writing this paper scientific results did show that covid19 might survive on surfaces but participants were convinced the news was true even before any scientific solid result was delivered noknowledge news the news in this category mainly fall into those concerning the origin of the virus and effects of the virus participants do not have a clear idea about the origin of the virus news 3 news 7 likely the perception has been influenced by an italian politician who blamed the chinese culinary tradition of eating alive mice to be the origin of the coronavirus covid19 spread 29 30 this news likely affected the knowledge related to the first covid19 infection although science has no explanation so far of how the first covid19 case happened participants believe the opposite figure 3 shows details of news 9 there is no substantial difference between men and women whereas there is a difference with the educational background surprisingly participants with a phd believe in a correlation between the origin of the virus and the chinese culinary tradition participants do not know how the transmission of the virus works news 13 so far as we already mentioned there are scientific evidences that covid19 might survive on surfaces but no studies refers to clothing shoes or hair likely the underlying idea is that studies talk about surfaces in general and therefore participants are confused and derive a wrong knowledge on the topic figure 4 shows details of news 13 there is no substantial difference between men and women whereas the educational background produces different perceptions participants with a phd have a correct knowledge in general participants know how to deal with the virus with the exception of news 28 so far science stated that there is no evidence that walking surfaces are involved in transmission of the virus moreover spraying hypochlorite could increase the amount of harmful substances in the environment street cleaning with conventional soapsdetergents is still advised 31 likely people confuse a simple suggestion with a necessity figure 5 shows details of news 28 there is little difference between men and women and there are large differences among people with different educational background although participants with a phd have a higher knowledge than people with other educational background the aindex is remarkable even for people with a phd participants have little knowledge about covid19 effects news 33 news 36 news 39 and news 40 the poor knowledge towards covid19 effects concerns very detailed medical aspects this shows a weakness in health communication indeed very detailed medical aspects hardly find space in the big newspaper headlines or in the main tv news reports therefore people without medical background are often unaware of the consequences of the virus what really surprises is news 33 indeed during the lockdown almost daily italian media have repeated over and over again that the majority of patients that contracted covid19 did not need hospital treatment and that a period of isolation at home was sufficient the lack of knowledge about this news could be due to a lack of trust in the institutions and their communication figure 6 shows details of news 33 there is little difference between men and women and there are no substantial difference among people with different educational background also in this case surprisingly people with a phd do not believe that most of the people do not need to be treated in hospitals iv main findings and conclusions confusion and ignorance are surely normal but fake news contributed to confuse peoples perception on what is true and what is not with respect to covid19 in this regard the study highlighted that men and women behave similarly whereas it surprised that people with the highest educational qualifications have less knowledge in many of the considered news the study also highlighted a communication problem of our institutions news related to medical aspects do not reach people a clear evidence of the wrongincomplete communication of either health authorities or politicians in conclusion the obtained results showed that in half of the cases people have not been influenced however some news has managed to breach the general confusion surrounding the virus a possible approach to fight this misinformation is to increase the presence of health authorities in social channels

covid19 is a virus developed to rule the world is just one of the many fakenews published on the web in this pandemic period the web is flooded with real news allegedly true or blatantly false to understand how fake news is affecting the covid19 perception we selected 40 news either true or fake related to the origin diffusion treatment and effects of covid19 and we asked 293 volunteers to express their opinion on the truthfulness of the news then we propose an awareness index to compute knowledge degree of the volunteers the results highlight a large ignorance on medical news ignorance that goes beyond educational background the study highlights the need for health institution to enter social media platforms in order to clearly explain what is true and what is false on covid19

ancestry and sociocultural influences one of the methodologies used for the characterization of the human brain has been morphological neuroimaging analysis which consists of the implementation of computational analysis methods of brain magnetic resonance imaging aimed to identify the structural characteristics of the brain highlighting analysis of volume and area such as cortical surface area and cortical thickness brain volumetry is a measure that includes surface area and cortical thickness the former being a parameter of cortical folding and gyrification and the latter a parameter of density and dendritic arborization neuroimaging studies have been implemented to identify brain morphometric differences due to educational level socioeconomic status gender and age nevertheless few neuroimaging studies are designed to explore brain morphometric differences related to racial identity in this sense it has been reported that african american persons diagnosed with hypertension and cognitive impairment commonly referred to as a decline in memory and cognition performance have lower insular thickness compared to white persons with the same diagnosis moreover isamah et al implemented a volumetric analysis using magnetic resonance imaging in neurotypical white and african american persons after controlling for variables such as age sex years of education and total brain volume they reported that african american participants had a greater brain volume of the left orbitofrontal cortex than white participants these authors agree that morphometric studies in populations with diverse racial identifications will reduce the underrepresentation of ethnic minorities as well as the comprehension of the influence of these variables on the differentiation in specific brain structures and the prevalence of neuropsychiatric diseases among different populations racial identity has generally been used as a demographic variable and not as a variable of interest in neuroimaging research which contributes to generalization bias of brain findings based on persons with high educational and socioeconomic status belonging to majority racial groups furthermore studies including minority racial groups are mainly implemented in small samples and in populations with cognitive impairment thus our study aimed to identify morphological brain variability among distinct racial identities in a representative sample of neurotypical young adults we analyzed brain morphometric data from the human connectome project our selection criteria indicate that white and african american racial identities were the most representative samples in the hcp database in this regard we expect to identify differences in brain morphometry between people identified as whites or african americans methods in order to access participants racial identity information all authors accepted the terms of data used to access restricted data of the hcp database after the request was accepted by the wuminn hcp consortium the database from 1206 participants was downloaded from the connectomedb a webbased user interface from the hcp apart from racial identity information restricted data included demographic clinical psychiatric and morphometric brain information for each participant data were filtered to exclude participants with psychiatric symptoms substance use and abuse disorders endocrine disorders irregular menstrual cycles neurological abnormalities and technical issues in the acquisition or preprocessing of their structural brain images in the filtered database participants identified as hispanics were discarded due to unbalanced sample representation between the selected racial identity groups beyond this classification ethnic identity was not considered for further analysis racial identity categories referred to whites and african americans were taken from the hcp demographic data based on the nih toolbox and us census classification 1 three hundred thirtyeight participants identified as whites m age 2912 sd ±360 m education 1515 sd ±169 and 56 subjects identified as african americans m age 2925 sd ±362 m education 1441 sd ±190 satisfied the inclusion criteria from the filtering process of the original hcp database although age t 02533 p 0800 was not significantly different years of education between groups resulted in significant differences t 2760 p 0007 moreover three participants identified as whites were excluded from the permutation analysis because of missing education and economic income information summary statistics of freesurfer morphometric measures from the hcp database previously processed by hcp investigators were analyzed these preprocessing methods consist of a prefreesurfer pipeline which was implemented to preprocess highresolution t1w and t2w brain images for each participant to produce an undistorted native structural volume space the pipeline aligned the t1w and t2w brain images executed a b1 correction for each volume and coregistered the participants undistorted structural volume space to mni space subsequently a freesurfer pipeline was executed to divide the native volume into cortical and subcortical parcels reconstruct white and pial cortical surfaces and perform the standardized freesurfers foldingbased surface mapping to their surface atlas volumetric cortical thickness and surface area brain measures were grouped by participants racial identitywhites or african americans before applying statistical analysis volumetric results for each participant were standardized by dividing the raw volumetric scores by intracranial volume due to unbalanced samples between groups ancova permutation analyses adjusting for age sex education and economic income were implemented to identify differences between groups for each brain morphometric measure the estimation of value of ps was based on the criterion in which iteration stopped when the estimated standard error of the estimated proportion of the value of p was less than onethousandth of the estimated value of p a maximum of 5000 iterations were selected for the analysis adjustment of value of ps for multiple comparisons were implemented by the familywise error rate method s4 ancova permutation analyses corrected for multiple comparisons on the same morphological parameters described above were implemented for this subsample the ordering of the database data filtering and statistical analysis was carried out in the programming language r version 363 mounted on the rstudio software version 125033 ancova permutation analysis was implemented by the aovp function of the lmperm package in r the pipeline used for the statistical analysis can be consulted at results brain volumetry differences between groups volume comparisons resulted in significant differences in cortical and subcortical brain structures volumetric measures were obtained from a volumebased stream where mri volumes are labeled to classify subcortical and cortical tissues based on subjectindependent probabilistic atlas and subjectspecific measured values of voxels anatomical visualization of brain regions with significant statistical volumetric differences is represented in figure 2 similar results were found on the paired subsample volumetric measures nevertheless after multiple comparisons correction the bilateral and total cortical white matter the left cerebellar white matter the bilateral thalamus and the anterior section of the corpus callosum maintain significant differences differences in cortical thickness between groups cortical thickness results indicated significant differences in frontal temporal parietal and occipital brain regions cortical thickness measures were obtained from the mean distance between the white and the pial surfaces of the cortex anatomical visualization of brain regions with significant statistical cortical thickness differences is represented in figure 4 similar results were found on the paired subsample cortical thickness measures nevertheless after multiple comparisons correction the right banks of the superior temporal sulcus left cuneus cortex the right middle temporal gyrus the right supramarginal gyrus and the right lateral occipital cortex maintain significant differences differences in cortical surface areas between groups cortical surface results indicated significant differences in frontal temporal parietal and occipital brain regions cortical surface measures were obtained from the sum of areas of triangles from the tessellation of the brain surface anatomical visualization of brain regions with significant statistical cortical surface area differences is represented in figure 6 similar results were found on the paired subsample cortical surface area measures nevertheless none of the brain regions presents significant differences after applying multiple comparisons correction discussion social educational and economic inequalities have impacted the health and human rights of ethnic and racial minorities causing their underrepresentation in biomedical studies leading to bias in the effectiveness of clinical treatments and misconceptions of genetic and environmental diseases affecting these groups according to some estimates reducing such disparities would have saved the united states more than 12 billion in direct and indirect medical costs even though the white nonhispanic population has been steadily declining in recent years african americans and hispaniclatinos only represent 5 and 1 of participation in human research while whites represent over 70 in this regard racialethnic identity is essential to contextualize neurophysiological and neuroimaging results on structural inequities in society in neuroimaging research this underrepresentation bias may be responsible for the reproducibility generalizability external validity and inference crisis in brain research which exacerbates the disparities and inequalities of minorities in neuroscience data sharing and open access to multimodal brain imaging in consortium repositories have been proposed as research opportunities to diminish racial disparities and methodological bias consequently some advantages of using the hcp database are its public accessibility a large ethnicracially diverse sample preprocessing methods highresolution structural brain imaging and demographic and clinical information of participants based on the hcp database our results indicate volumetric brain differences in white matter structures subcortical regions plexus choroids and total subcortical grey matter between participants identified as african americans and whites differences in subcortical brain volumetric regions were identified in the bilateral caudate left thalamus right globus pallidus and right ventral diencephalon moreover differences were identified in other brain structures such as the optic chiasm the white matter of the right cerebellum and the corpus callosum in their anterior and posterior portions in contrast with isamah et al s study where differences in bilateral amygdala and total cerebral volume between persons identified as african americans and white were found we identified volumetric differences in the bilateral caudate and total cortical white matter differences in regional brain volumes in cortical and subcortical structures such as the bilateral caudate have been identified between white and chinese populations moreover brain differences in total cortical gray matter volume total cortical white matter volume total gray matter volume estimated intracranial volume and cortical regional volumes have been reported between indian and white persons furthermore our results indicate surface area differences in frontal parietal temporal occipital and frontal brain regions between african american and white racial identities specifically cortical thickness differences were identified in the bilateral cuneus cortex left fusiform gyrus bilateral permutational ancova brain volumetric results between whites and african americans with significant differences after applying multiple comparison correction test brain volumetry is standardized as the ratio of cubic millimetersintracranial volume cc anterior anterior subregion of corpus callosum cc posterior posterior subregion of corpus callosum wm white matter gm gray matter asterisks indicate significant results at a value of p of 0001 and a value of p of 005 figure 2 brain regions representing volumetric differences between whites and african americans cc corpus callosum wm white matter gm gray matter brain images were created with brainpainter software 103389fnint20231027382 frontiers in integrative neuroscience 06 frontiersinorg jha et al identified cortical thickness differences in the bilateral postcentral gyrus superior parietal lobules precuneus supramarginal gyrus right precentral gyrus insula inferior parietal lobule supplementary motor area and rolandic operculum in a large cohort of neonates of african american and white mothers furthermore in middleaged cognitively impaired hypertensive persons differences in insular cortical thickness were identified between african americans and white people similar to our results kang et al identified differences in surface area and cortical thickness in frontal parietal temporal and occipital subregions however these results were based on an analysis of brain surface morphometry between older chinese and white adults the us census has created racial categories that include white and african american people allowing the selfidentification of individuals in groups that represent their community and cultural background in a segregated society racial identity has emerged as the sense of collective identity based on a perceived common heritage with a racial group promoting wellbeing and protection against racism in african americans in this sense afroamerican identity is constituted by an african conscience that establishes behaviors spirituality and ancestral knowledge affecting selfconcept selfesteem and selfimage moreover racism and oppression rooted in a historical background of environmental and interpersonal adversity have caused a mental and physical pathologization of their identity in contrast white american identity is rooted in social and economic privileges that establish racial attitudes beliefs behaviors and experiences in a racially hierarchical society from this perspective racial identity is defined and addressed as a social construct from which racial groups are socially created to attach differences between groups in this sense the descriptive results in our sample related to years of education indicate that participants identified as african american reported less years of education than white participants moreover whites tend to report higher economic income than african americans these results may reflect the inequalities in education and socioeconomic status between white and african american people low socioeconomic status has been associated with reduced cortical gray matter thickness in middleaged persons in addition diverse studies have indicated that socioeconomic status and parental education strongly influence cerebral cortical thickness surface area and volume during childhood particularly average cortical thickness in neonates of african american mothers although our analysis was adjusted for economic income and education these are only dimensions of socioeconomic status that also imply prenatal and postnatal factors such as biological risks psychosocial stress variability in cognitive and linguistic stimulation and parenting practices during childhood our results referred to differences in volume cortical thickness and surface area in diverse brain regions between distinct racial identities may be due to these prenatal and postnatal factors anchored in racial inequalities in this figure 3 permutational ancova cortical thickness results between whites and african americans with significant differences after applying multiple comparison correction tests asterisks indicate significant results at a value of p of 0001 and a value of p of 005 figure 4 brain regions representing cortical thickness differences between whites and african americans brain images were created with brainpainter software atilanobarbosa and barrios 103389fnint20231027382 frontiers in integrative neuroscience 08 frontiersinorg regard it has been reported that african americans compared to the white population have a higher risk of developing alzheimers disease due to exposure to air pollutants access to healthcare and educational disparities moreover racism and discrimination have been related to higher levels of blood pressure preterm infant birth and stressful life experiences furthermore the recent study by fani et al identified that racial discrimination experiences of afroamerican women were associated with functional activation of the middle occipital gyrus ventromedial frontal cortex middle and superior temporal gyrus and cerebellum assari and mincy have reported that racism may impact the volume brain growth of african american children accordingly with these studies the morphological variability identified between white and african american identities in our study may also be related to racism and oppression mostly affecting the african american community due to historical racial segregation in this regard acknowledging inequalities in education health justice and socioeconomic status between whites and african american people is fundamental to acknowledge that racial identity implies social and environmental factors that can impact in human development and brain morphology most studies in human cognitive neuroscience come from majority identities such as the white population in contrast to hispanics asians and african americans who have been markedly underrepresented in this sense our results suggest brain morphological variability between overrepresented and underrepresented samples supporting the accordingly it is important to consider the human brain as a multilevel ecological system that regards social and biological factors from which it is necessary to develop crosscultural sampling methods and multidisciplinary collaboration to improve the generalizability of neuroscience studies and the comprehension of individual differences in the human brain neuroimaging research groups have developed structural mri brain atlas and templates based on specific populations due to differences in brain morphology while contrasting with weird samples permutational ancova cortical surface area results between whites and african americans with significant differences after applying the multiple comparison correction test asterisks indicate significant results at a value of p of 0001 and a value of p of 005 figure 6 brain regions representing cortical surface area differences between whites and african americans brain images were created with brainpainter software atilanobarbosa and barrios the african ancestry neuroscience research program has emerged as an initiative to reduce health disparities in the african american community and to promote focused brain research in this population to treat brain disorders by developing personalized therapies and treatments the evidence of morphological brain variability in our study could contribute to understanding brain disorders and psychological factors affecting african americans and the prospect of developing brain templates for this population although our study was based on a large sample from the hcp database some limitations must be considered first the sample is unbalanced due to the overrepresentation of persons identified as whites compared to persons identified as african americans according to the original hcp database 2 even though the hcp project is focused on neurotypical young adults this database includes participants with heavy consumption of tobacco alcohol and recreational drugs moreover we identified participants with psychiatric symptoms endocrine disorders irregular menstrual cycles and neurological abnormalities as well as technical issues in the acquisition and preprocessing of their structural brain images in this sense we consider implementing exclusion criteria to discard these confounding variables that could affect morphological brain results in large neuroimaging data nevertheless these considerations maintain the imbalance of our sample between whites and african americans persons which reduces the possibility to apply parametric statistical analysis in this regard we implement a method of subselection of persons identified as white and african american paired in age sex economic income and education to overcome the confounding bias finally racial identity was defined from the selfidentification of participants however genetic ancestry information could have contributed to a more careful characterization of the sample from which specific genetic sequences and geneenvironmental interactions could be analyzed to further interpret brain morphological results conclusion the human brain is constituted in a unique genetic social and experiential domain that is embedded in global hardships such as poverty and discrimination in this regard morphological brain differences in persons identified as african americans and whites may be embedded in historical inequalities oppression and racism in american society that may impact brain structure in this study white matter forebrain midbrain and hindbrain structures display morphological variability between racial groups which could be relevant for understanding neurological or psychiatric disorders differentially affecting these 2 graphicdataforhcpyoungadult populations due to the recurrent misrepresentation of ethnic and racial minorities in neuroimaging research their inclusion in further studies is fundamental for the comprehension of human brain morphometric variability data availability statement publicly available datasets were analyzed in this study this data can be found at publicdatahcpwikipublicdata ethics statement the studies involving human participants were reviewed and approved by data restricted access by the washington university university of minnesota consortium of the human connectome project the patientsparticipants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher supplementary material the supplementary material for this article can be found online at full supplementarymaterial

in a segregated society marked by a historical background of inequalities there is a consistent underrepresentation of ethnic and racial minorities in biomedical research causing disparities in understanding genetic and acquired diseases as well as in the effectiveness of clinical treatments affecting different groups the repeated inclusion of small and nonrepresentative samples of the population in neuroimaging research has led to generalization bias in the morphological characterization of the human brain a few brain morphometric studies between whites and african americans have reported differences in orbitofrontal volumetry and insula cortical thickness nevertheless these studies are mostly conducted in small samples and populations with cognitive impairment for this reason this study aimed to identify brain morphological variability due to racial identity in representative samples we hypothesized that in neurotypical young adults there are differences in brain morphometry between participants with distinct racial identities we analyzed the human connectome project hcp database to test this hypothesis brain volumetry cortical thickness and cortical surface area measures of participants identified as whites n 338 or african americans n 56 were analyzed nonparametrical permutation analysis of covariance between these racial identity groups adjusting for age sex education and economic income was implemented results indicated volumetric differences in choroid plexus supratentorial white matter and subcortical brain structures moreover differences in cortical thickness and surface area in frontal parietal temporal and occipital brain regions were identified between groups in this regard the inclusion of subrepresentative minorities in neuroimaging research such as african american persons is fundamental for the comprehension of human brain morphometric diversity and to design personalized clinical brain treatments for this population

introduction this article will draw on the work of pierre bourdieu to suggest a new theory of purity and impurity these are powerful themes which have been acknowledged to be under theorised the central claim that will be put forward is that purity and impurity should be interpreted as an assessment of the correspondence of a phenomenon with its essence a pure person or thing is in short selfidentical the zinc in front of you is pure if it is completely comprised of zinc as one of the basic mendeleevian elements the citizen in front of you is racially pure if you believe that he instantiates solely the nation as a biological and cultural essence to jump for pure joy is to jump in a way that manifests no other animating principle that corresponds simply and truly to the emotion joy that stands behind and within its instantiations what makes purity and impurity such significant discourses bourdieus writings show is that they can be used to performatively construct the essence against which they merely appear to compare phenomena or forms of subjectivity to call you a dirty slut for example is not simply a categorisation of you as an individual but also imputes an essence to femininity from which your behaviour indicates you have departed perhaps the main theory of purity and impurity currently available to scholars in the social sciences and humanities for considering the topic is mary douglas purity and danger douglas claims that classifications of purity and impurity are activated by an innate ordering mechanism in the human mind and help to preserve the social order of society as a whole by marking that which is anomalous to this order as impure douglas suggested that themes of impurity become attached as a spontaneous byproduct of an instinctual human drive for order to that which is rejected from our normal scheme of classification she presents a functionalist account that this process operates for the overall advantage of society at large yet there have been repeated calls for further theoretical reflections on the topic of purity and impurity beyond purity and danger including from douglas herself since the publication of purity and danger a variety of scholars across the social sciences have criticised douglas theory for making unmediated explanatory links between categorical systems and the social structure of society as a totality valeri posits for example that bypassing the realm of social practices leads purity and danger to speak of the system of form or of order as if they were one monolithic thing in fact there are many coexisting orders of classification what is residual to one may be central to another each of these orders of classification is marked by a dynamic interplay of relations of power purity and impurity are not the result of a single homeostatic process hetherington also criticises douglas theory in ways that that agree with valeri he argues that the anomaly theory of purity and impurity offers a flawed analysis of processes of categorisation this has been largely because douglas presumes that the classificatory system is a stable and representable thing and prior to the anomalies that it designates as a result she misses the ongoing way in which order is made as uncertain process douglas herself agreed with her critics that the two central issues with the anomaly theory which cause its flawed account of power and categorisation were the assumption that society is a unitary whole and the assumption that there exists a unitary ordering mechanism within the human mind in an informal seminar in 1997 douglas retracted both assumptions furthermore as a logical consequence of these retractions douglas further admitted that there is no universal intrinsic value to purity for either the individual or for society the only thing universalistic about purity is the tendency to use it as a weapon or tool douglas herself concluded that there exists a pressing need for further social theoretical reflections on the topic the subsequent year douglas publically retracted the claim that there is a universal human or societal urge for a complete and ordered cognitive system she asserted that the most common response to social or cognitive anomalies tends to be simply to tolerate ambiguity taking a more historicist approach than douglas to the topic in moral purity and persecution in history barrington moore jr insists upon the foundational importance of themes of purity and impurity to the form taken by western civilisation he suggests that from their biblical origins these concepts have indelibly shaped western society contributing to intolerance and extremism through the absolutist worldview that they mandate he expresses exasperation that given their pressing importance purity and impurity have received so little attention from social scientists and social theorists he contends that the western notions of purity and impurity have served as an indispensible antecedent to moral catastrophes such as the wars of religion in the sixteenth century and the rise of nazism and stalinism in the twentieth century whilst we do not wish to follow moore in suggesting that discourses of purity and impurity have endured over millennia at the beating heart of a western civilisation we do think that they have great importance for many modern western societies in this article we will present a new interpretation of bourdieus writings excavating an account of purity and impurity other theorists could have been chosen elsewhere one of us have examined the work of kristeva girard and agamben considering their contributions to the social theory of purity and impurity other contemporary thinkers have also looked for resources for theorising the topic of purity and impurity karakayali for example recommends simmels work on the figure of the stranger as apposite to the study of representations of dirt and impurity we have chosen to engage in an interpretation of bourdieu here because of what we see as his particular acuity in examining the role played by discourses of purity and impurity in the differentiation of both fields of practice and forms of subjectivity he does not examine the stark dichotomy between us and strangers as do kristeva girard agamben and karakayali instead he explores the incremental classification of subjects embedded within a plurality of fields at any given time as pure or impure prior commentators on bourdieu have failed to draw out his insights into this topic however as fowler rightly states these insights often remain at the level of hints in bourdieus texts yet as we aim to demonstrate interpretation could productively bring this theme into focal attention purity impurity and practice in the genesis and structure of the religious field bourdieu presents a general account of the origin of purity and impurity discourses he hypothesises that appeal to a realm that transcends ordinary life initially occurred through magic before the advent of institutionally organised religion he follows weber in defining magic as the direct attempt to master nature through symbolic practices for the purposes of immediate utility 399400 403 he suggests that in early agricultural societies everyday life was firmly embedded in nature with its cyclical patterns spatial dispersion and immediate needs this worked against the production of abstract rationalised thought and hence against a separate cultural field for organised religion drawing on marx and engels description of structural differentiation in the german ideology bourdieu proposes that the emergence of the city and with it an early form of the division of labour meant that consciousness is in a position to emancipate itself from the world and to proceed to the formation of pure theory theology philosophy morality etc following this line of reasoning bourdieu theorises that appeals to moral purity are facilitated by the material and practical differentiation of social fields yet following weber 53640 bourdieu treats the relations between religious professionals between professionals and the laity and between the laity as crucial for the production of discourses of moral purity and impurity whereas functionalist perspectives treat purity and impurity discourses as a unmediated reflection of society as ordered or in chaos bourdieu argues strongly that this position misses out the role played by social practices within relatively differentiated fields as a crucial intermediary factor according to bourdieu the systematisation and moralisation of religious practices and representations to form organised religion as an arena of social practice was associated with a transfer of the notion of purity from the magic order to the moral order whereas magic had operated through the unsystematic enactment of rites and prohibitions which appealed to purity and impurity the relatively autonomous religious field became structured by a continual discursive appeal to the essence of the world modelling his account on chapter 7 of webers ancient judaism which describes the monopoly the priesthood possess on access to salvation bourdieu argues that the priesthood have a monopoly on the legitimate appeal to god this monopoly operates through theological discourses appealing to purity and impurity as symbols of sin and redemption which grant the priests a continuous authority over the laity religion contributes to the imposition of the principles of structuration of the perception and thinking of the world and of the social world in particular insofar as it imposes a system of practices and representations whose structure objectively founded on the principle of political division presents itself as the naturalsupernatural structure of the cosmos the religious field comes to define itself through the repression of worldly interests such that these factors continue to operate but in a masked form that is understood to express a purer meaning bourdieus analysis of the religious field suggests that the particular appeals that facilitate purity and impurity discourses are those that impute an essence as the ground for reality comparing the artistic and religious fields bourdieu for instance suggests that both are places in which competition occurs over the control and definition of phenomena taken to express the origin the spirit the authentic essence bourdieu is attuned to the fact that purity may mean different things in different contexts there are a variety of essences against which to compare phenomena however bourdieus writings also indicate certain commonalities between regions of practice where essence is invoked we need to be careful in suggesting such an interpretation hacking has pointed out that the term essence has become a slur word making its meaning unclear the essences that we wish to identify as particularly associated with the operation of purity and impurity discourses do not contain any heterogeneous foreign or inferior elements all of their elements are the same in some relevant sense furthermore the essences in question are understood to be situated at the conceptual or ontological ground of their instantiations besides his consideration of the religious field where this account first appears this is especially visible in his analysis of the field of cultural production and consumption written in 1971 the same year as genesis and structure of the religious field bourdieus essay the market of symbolic goods applies this analysis of the relatively differentiated religious field to cultural practices more generally like the religious field spheres of cultural practice are separated in western societies as relatively autonomous realms through the development of a public of potential consumers and an evergrowing ever more diversified corps of producers as well as the multiplication and diversification of agencies of consecration in particular bourdieu documents the discourses of purity and impurity that arose as the result of the emergence of modern high culture the domain of elite cultural production and consumption as techniques of mass production proliferated in reaction to the pressures of an anonymous market from around 1830 the romantic movement in europe proposed an ideology of free disinterested creation the artist came to be constructed as a pure creative genius as were those dominant consumers whose understanding of works of art presupposes a similar elevated and purified form of existence cultural goods that position themselves against the popular are pure because they demand of the receiver a specifically aesthetic disposition they are rare precisely to the degree that the disposition and knowledge to decipher their meaning is rare and valuable because they serve to consecrate more broadly the social and political power possessed by those with this disposition the classificatory social and cultural structures of the field of practice thereby serve as a system of conservation and cultural consecration separating different consuming publics from one another in lifestyle and seemingly in their very nature thus even sexuality which bourdieu sees as generally coded as impure in the first instance is an effective site for demonstrating elevation and refinement of taste for those whose cultural capital permits such displays for example in the form of an elevated pure love or a purely aesthetic relation with an artwork with a sexual theme the products of the field of cultural production can be mobilised as symbolic capital cultural resources that serve to tacitly naturalise relations of cultural and material stratification in society the strong association between symbolic capital and purity in western societies is caused by the fact that a common way in which these cultural resources naturalise relations of power is through making forms of subjectivity appear to be no more than the expression of or phototropic orientation towards essence such as adoration in the religious field or in love relations or knowledge in the educational and academic fields though bourdieus main focus is social class he also explores purity and impurity discourses in relation to gender generalising from his fieldwork in algeria in the 1950s to contemporary western societies bourdieu suggests that the demeanour which is imposed on kabyle women in algeria is the limiting case of what is still imposed on women even today as much in the united states as in europe bourdieu suggests that women are situated as a source from which impurity and dishonour threaten to enter with the purity of cultivated feminine nature always at risk of being breached by either an inner tendency or an external vulnerability to impurity the construction of the feminine as either pure or impure legitimates masculine possession protection and control of women to ensure that impurity does not enter masculinity is situated as relatively pure and this relative purity serves as a tacit norm against which the purity or impurity of women are compared yet alongside such generalisation in bourdieu is recognition of the way that discourses of purity and impurity have been marked by the particular history of western societies bourdieu suggests that purity and impurity should be understood as concepts originally developed in the theological tradition of christianity which have been strategically imported into the operation of other western cultural fields in ideals of beauty truth morality the natural and so on these reworked theological notions serve a concrete need in the present converting the theology of grace into a worldly society ideology of good grace and thus pinning moral responsibility for social success or failure on to the individual subject bourdieus advance douglas theorised purity as an expression and affirmation of social order and impurity as an expression of matter out of place bourdieu however argues explicitly against the reductionist theory which treats discourse as the direct reflection of social structures contained in society conceptualised as a single whole on our interpretation of bourdieu purity and impurity discourses are not the reflection of social structures mediating between the discourses and embedded social forms are the strategic discursive practices of different relational subjects acting within fields in which competing visions of the origin the spirit the authentic essence are precisely a stake in this interaction in the cultural field purity and impurity discourses are strategically mobilised in the affirmation of the specificity of the cultural field as a domain oriented towards essence in the course of strategic social practice the cultural field itself is characterised as pure compared to the economic field which is characterised as impure those areas of culture which are most oriented towards the origin the spirit the authentic essence are constructed as pure than others and those regions of the field most proximate to this essence are seen as purer than those that are considered as worldly and distant from this originary essence purity and impurity hierarchies may therefore come into conflict simply bypass or nest within one another depending upon the various ways in which essence is appealed to within social fields for instance discourses invoking purity and impurity may be deployed by prophets and other ideologues for example against the compromises that consecrated authorities must make they may also be deployed by these consecrated authorities themselves in order to designate as defiled those activities which do not correspond to what is thereby imputed as the proper form of human life in the political sphere for example bourdieu describes a dichotomy and structural conflict between ideologues and pragmatists those people that is who thus advocate a return to basics to a restoration of the original purity and on the other hand those people who are inclined to seek a strengthening of the party or again bourdieu describes the opposition between two poles of academia the applied faculties such as law and medicine affirm the public utility of the academic field those faculties dedicated to pure rational knowledge such as mathematics or philosophy affirm the autonomy of the academic field as oriented towards the disinterested search for the truth of existence bourdieus theory has been criticised for overemphasising the division between cultural producers and cultural consumers and thus for focusing too strongly on intrainstitutional dynamics whilst this issue does mark bourdieus texts on the religious cultural and political fields it is questionable whether it concretely impacts upon the interpretation we present of bourdieus account of purity and impurity classifications on this reading purity and impurity discourses are both facilitated by and contribute to the emergence of institutionalised fields able to facilitate sustained discourses on the truth of reality and on the extent to which particular phenomena or forms of subjectivity are in correspondence with this ideal this reading of bourdieu circumvents a certain strand in his thought which makes discourses of purity and impurity the necessary effect of the structural differentiation of relatively institutionalised social practice the citation from marx and engels the german ideology and certain other passages in the genesis and structure of the religious field imply a structurally determinist account in such an account discourses such as purity and impurity would be no more than reflections of the relative autonomy of a field of social practice yet bourdieu can also be read as indicating that classifications occur within various sometimes competing discourses rather than representing the superstructural reflection of material conditions in a later interview bourdieu affirms that this was his intended point in the genesis and structure of the religious field and that it represents the most important lesson that he feels that he learnt from weber on such a reading of bourdieu the material division of labour represented by the relative autonomy of fields does not spontaneously or mechanically produce purity and impurity discourses for instance the field of cultural production the scientific field and the field of national sovereignty do not naturally and inevitably produce corresponding discourses of purity and impurity the reason why they are often associated with such discourses is that at stake in each of these relatively autonomous fields is an appeal to an essence in these cases beauty truth and the nation as a timeless truth of collective identity crucial for purity and impurity discourses is less the autonomy of the field than the appeal to an essence that is often associated with established autonomous fields which have the authority to shape forms of subjectivity that are willing to make and recognise claims about the truth of existence thus in the rules of art bourdieu argues if there is a truth it is that truth is at stake in the struggle and even though the divergent or antagonistic classifications or judgements made by agents engaged in the artistic field are indisputably determined or oriented by specific dispositions and interests linked to their positions in the field and to points of view they are nevertheless formulated in the name of a pretention to universality to absolute judgement which is the very negation of the relativity of points of view essentialist thought is at work in all social universes and especially in the fields of cultural production the religious field the scientific field the literary field the artistic field the legal field etc where games which have the universal at stake are played out but it is quite clear in that case that essences are norms purity and power a concern that has been raised regarding bourdieus work generally relates to his view of the relationship between structure and agency there has been a sustained debate in the literature on bourdieu regarding whether he believes that social structures are constraining or whether agency is possible whilst in some texts bourdieu does indeed seem to argue against the possibility of meaningful agency for most subjects elsewhere he is insistent that practices are not simply the result of rules which subjects follow or express but the result of strategic agency by social and institutional actors on the topic of purity and impurity discourses bourdieus argument is quite clear they tend to support incumbent relations of material and cultural power but this does not preclude their successful use by actors for achieving greater agency or substantial social change bourdieu suggests that the more people are rich in specific capital the more likely they are to resist cooption by rightwing interests representations of purity tend to support the hierarchies of the social field and society at large by serving as symbolic capital naturalising forms of subjectivity so that they appear to be no more than expressions of an imputed essence yet they can also serve as a legitimation strategy through which particular actors can offer social critique it is possible bourdieu theorises that in the name of the values of purity freedom truth i can enter the political field campaigning for reason truth virtue bourdieu suggests that the political potency of such representations of purity in the public domain is in part because the economic and political fields are socially constructed in contemporary western societies as impure the order of the polis and politics is always seen as opposed to the free and pure those rich in cultural rather than material capital are oriented towards cultivated cults of the natural the pure and the authentic bourdieu calls these subjects the dominated of the dominant since they are less powerful than the economically and politically dominant whose forms of subjectivity are legitimated as dominant through their consumption of the goods of the fields of cultural production bourdieu thus writes of the boundary which distinguishes the pure reign of art and culture from the lower region of the social and of politics a distinction which is the very source of the effects of symbolic domination exerted by or in the name of culture dominant actors strive for and exercise their power but occlude and legitimate these actions through the mobilisation of what bourdieu refers to as ideals produced and sustained in the first instance by other purer fields such interaction between the purity and impurity discourses of different fields is missed by douglas and represents a crucial advance made by bourdieus account bourdieu proposes that dominant subjects gain legitimacy as social elites by discursively constructing themselves as representatives and guardians of these pure and transcendent ideals i am nothing but the delegate of god or the people but that in whose name i speak is everything and on this account i am everything discourses invoking purity can thereby be used to legitimate programmes of action and to impose a particular vision of the world on the national citizenry via the statist capital granting power over the different species of capital and over their reproduction the relative and vicarious proximity of the dominant to essence is unmarked and so appears to subjects as a universal potential a neutral natural norm andideal this is perhaps what douglas was identifying in suggesting that purity functions as a symbol of society as a whole however bourdieu identifies the intersecting powerrelations upon which such a function depends such a process can be seen in bourdieus discussion in the state nobility of pure activities that is activities that have been purified of all profane pragmatic and profitable purpose these pure activities are available in elite educational institutions and demonstrate the qualities of disinterestedness and endurance these qualities show that a subject is able to exercise control over nature that is to say over those who cannot control their nature the ability to rule oneself serves as a mandate to rule others 235 mastery of the cultural realm as the domain of the pure makes social power and authoritative forms of knowledge the seemingly natural possession of the dominant elite granting them a tacit and relative purity bourdieu theorises that dominant subjects in contemporary western societies are represented as possessing a tacit and relative purity by contrast an impure subjectposition is relatively attributed across human society depending on properties like class and gender and the way in which these are enacted with propriety or impropriety in the domain of consumption impure forms of subjectivity may seem to represent no more than that which is extraneous to a fullyhuman proper subjectposition however bourdieus account suggests that such a figure may in fact be part of the means through which this subjectposition is socially and materially constructed and made to seem proper and pregiven bourdieus account of themes of purity and impurity shows the important role they play in the processes through which contemporary western societies continually construct a whole relationship to animal nature to primary needs and the populace who indulge in them without restraint such as women and the workingclasses though appearing as the expression of their impure nature the actions and capacities of the dominated are in fact bourdieu insists shaped by their materially subordinate position this position practically necessitates association with matters classified by the dominant culture as impure such as physical labour dirt and lasciviousness bourdieu writes of the dominant they reduce the strength which the dominated ascribe to themselves to brute strength passion and instinct a blind unpredictable force of nature the unreasoning violence of desire and they attribute to themselves spiritual and intellectual strength a selfcontrol that predisposes them to control others on our reading bourdieus writings suggest that one of the fundamental properties of discourses of purity and impurity is that they hide their relationship with dynamic relations of power and materiality what is the mechanism through which this takes place though bourdieu does not draw this out explicitly we wish to suggest that when phenomena or forms of subjectivity are taken to be unadulterated simple expressions of their essence that is as pure they tend to be granted a moral and epistemological privilege with no heterogeneous processes impacting upon the existence of the phenomena or form of subjectivity it appears that only a universal and immutable essence stands as the ground of a phenomenon or a particular form of subjectivity bourdieu proposes that those who are dominant within a field and within society more generally can hide the historicity and the powerrelations upon which their position in society depends by presenting themselves as no more than delegates of an ideal of essence this legitimates their place in society and situates their attributes and ethos as the universal norm rather than expressing and reaffirming society as a collective entity the mobilisation of purity and impurity discourses is structured by hierarchies both within and beyond particular cultural fields as differentiated realms of social life the most pure products pure art or pure science serve what would otherwise be considered the totally impure social functions most notably distinction and social discrimination or more subtly the function of a disavowal of the social world which is inscribed douglas proposes representations of purity and impurity as an unmediated expression of the maintenance or breach of any social or cognitive categories that reflect the general social structure designations of purity and impurity regarding the boundaries of the body douglas therefore argues always mirror the internal and external social and symbolic boundaries of society as a pregiven bounded system examining virginity douglas 2001 argued that it will inevitably be coded as pure since the yearning for rigidity is in us all she explains that by this she means that through the figure of the virgin we can enjoy purity at second hand experiencing this state which we all inherently desire vicariously in the untainted body of the virgin the more general fact that themes of impurity seem to cluster particularly around both sexuality and femininity is explained by douglas 194 as simply natural to human societies as she does not believe that it can be adequately accounted for using her theory by contrast on the account presented here purity and impurity should be regarded as discourses that measure phenomena visàvis an imputed essence considered to be the selfidentical ground for true phenomena in the world impurity is invoked to classify those elements that particular discursive actors are unwilling or unable to place as expressions of the particular construction of essence representations of purity and impurity can thus serve to bridge the gap between ostensibly natural and discrete phenomena or forms of subjectivity whilst facilitating mechanisms of social stratification and of social and selfregulation thus femininity and sexuality should not be regarded as natural and inevitable sites of purity and impurity classifications a social theory that suggests such risks affirming rather than providing tools for the analysis of misogyny as buckley and gottlieb have claimed rather we wish to contend female sexuality is often described using purityimpurity classifications because it is a key biopolitical object able to be regulated and normalised through appeal to an ideal of human essence for instance the division between pure and impure forms of female sexual subjectivity is an apparatus which serves to manage and mask the contingencies that attend the material and discursive construction of racial identities as essences in order to appear to be an essence underpinning particular human instances race is indelibly dependent upon the exigencies of the reproductive choices of its members who therefore must be subject to selfregulation and social policing race appears to be a transhistorical essence that is merely instantiated by each generation of the nation however in fact the race is indelibly dependent upon the exigencies of the reproductive choices of its members who therefore must be subject to selfregulation and social policing concluding reflections as douglas predicts in purity and danger pure phenomena can sometimes appear to symbolise the order and benevolence of society and the impure its disequilibrium or disruption by anomaly bourdieu himself maintains that there is a tendency in contemporary western societies to exclude all misalliances and all unnatural unions ie all unions contrary to the common classification to the diacrisis which is the basis of collective and individual identity yet not all exclusions are classified as impure and not all that is within social or cognitive bounds is classified as pure our reading of bourdieu suggests a new theory of purity and impurity purity should be conceptualised as the adjudication of phenomena in terms of their relative identity with or divergence from their imputed essence bourdieu may focus on the economic processes that are euphemised in the cultural activities of social actors but his point regarding the role played by purity and impurity can be extended to a variety of cases it can be suggested based on his account that discourses of purity and impurity are mobilised to manage the practical tensions associated with the construction of particular subjects or phenomena as relatively corresponding to an imputed ideal standing outside of history or relations of power through the discursive adjudication of phenomena or subjects as relatively impure or pure an image is constructed of what these phenomena or subjects are in their truth impurity does not spontaneously characterise any anomaly as douglas predicts but is invoked to classify those elements that particular discursive actors are unwilling or unable to place as expressions of an imputed essence in contrast to douglas who sees power as only ever operating to ensure the homeostatic stability of the social and cognitive structure of the community as a whole our reading of bourdieu has suggested that pure processes things or people appear to be simple expressions of essence with no dependence on anything outside of themselves they are devoid of and prior to complexity and the dynamics that organise social and material inequalities this makes purity and impurity a discursive material and affective resource peculiarly adapted to facilitating social consensus and compelling a shared practical demand to protect or attain purity through the deployment of mechanisms of social exclusion and social and selfregulation purity and impurity therefore help manage and mask the tensions that would otherwise become apparent when an essence is imputed at the ground of particular phenomena or forms of subjectivity as the impure is held epistemologically and morally responsible for the distance of reality from its essential truth it is this operation which facilitates the mobilisation identified by moore of purity and impurity discourses in the justification of blackandwhite and dehumanising worldviews robbie

this article will propose a new interpretation of pierre bourdieu as a theorist of purity and impurity bourdieus writings indicate that through the adjudication of things or people as relatively impure or pure an image is constructed of their essential truth building from bourdieu we will show how themes of purity and impurity can be used to manage the tensions associated with attempts to impute an essence to human nature or to reality ensuring that moral and epistemological significance of complexity is masked this is the reason why themes of purity and impurity so often attend polarised worldviews and why they are frequently mobilised for justifying and operating biopolitical processes of social stratification and regulation

introduction gun violence remains a serious public health and safety problem in the usa in 2009 a total of 9146 people were murdered with firearms and it is estimated another 48158 were treated in hospitals for gunshot wounds received in assaults 12 furthermore exposure to gun violence and homicide is associated with a host of negative health outcomes including ptsd depression psychobiological distress anxiety cognitive functioning and suicide as well as other negative social behaviors such as school dropout increased sexual activity running away from home and engagement in criminal and deviant behaviors 3 4 5 leading social scientific explanations of gun violence commonly associate a heightened probability of gunshot victimization with individual situational eg the presence weapons drugs or papachristos is with the department of sociology yale new haven ct usa braga is with the school of criminal justice rutgers university newark nj usa braga is with the program in criminal justice policy and management harvard university cambridge ma usa hureau is with the department of sociology harvard university cambridge ma usa correspondence andrew v papachristos department of sociology yale new haven ct usa alcohol and community risk factors 6 7 8 9 yet the majority of individuals in highrisk populations never become gunshot victims indeed research suggests that gun violence is intensely concentrated within highrisk populations 1011 for example recent studies in boston found that from 1980 to 2008 only 5 of city block faces and street corners experienced 74 of gun assault incidents 12 and that 50 of homicide and nearly 75 of gun assaults were driven by less than 1 of the citys youth population most of whom were gang involved and chronic offenders 13 to better understand how gunshot injury is distributed within highrisk populations we conducted a study to determine whether the risk of gunshot victimization is related to characteristics of ones social networks studies on the health effects of social networks suggest that the clustering of certain health behaviorssuch as obesity smoking and depressionis related not only to risk factors but also the contours of ones social network 14 15 16 17 there are several reasons why the risk of gunshot victimization is related to ones social network first interpersonal violence tends to occur between people who know each other suggesting that the context of social relationships is important in understanding the dynamics of gun violence 1819 second the normative conditions surrounding gun use are transmitted through processes of peer influence especially among young men with criminal histories 20 third guns themselves are durable objects that often diffuse through interpersonal connections suggesting that obtaining a guna necessary precursor to using a gunmust also occur through interpersonal relationships 21 yet despite the growing interest in social network analysis in the study of public health no study has yet employed formal network models to understand how processes of peer influence and normative diffusion might influence the risk of gunshot injury the present study analyzes the salience of social networks on differential risks of gunshot injury among a population of 763 individuals in boston we examine several aspects of individuals social networks including network density the saturation of gang members in ones network and the social distance between an individual and other gunshot victims we hypothesize that the structure and composition of an individuals social network will influence ones exposure to and risk of gunshot injury and thereby better explain the concentration of gunshot injury within risk highrisk populations methods setting the present study examines gunshot victimization among a network of individuals from bostons cape verdean community cape verde is an archipelago of islands located off the west coast of africa that was a colony of portugal until 1975 as of 2000 boston is home to an estimated 35000 to 50000 persons of cape verdean descent bostons cape verdean population is concentrated in two communitiesthe bowdoingeneva and uphams corner neighborhoodsthat are associated with many traditional violent crime risk factors for example in the bowdoingeneva neighborhood 20 of the population lives below the federal poverty line 52 live in a singlefamily household and 42 of the population has less than a highschool diploma 22 as seen in figure 1 and consistent with prior neighborhoodlevel research 723 such sociodemographic characteristics tend to be higher in highcrime neighborhoods put another way neighborhoods with high levels of socioeconomic disadvantage also tend to have higher levels of crime and violence the study communities were selected for three main reasons first as just described the study area exhibits many of the aggregate level risk factors commonly associated with elevated levels of crime and violence second as seen in map b in figure 1 the community also exhibits some of the highest concentration of gunshot injuries in boston and in fact this area is driving much of the citys current violence problem in particular the study neighborhoods struggle with youth street gang problems fatal and nonfatal shootings involving cape verdean ganginvolved youth more than tripled from 12 shootings in 1999 to 47 shootings in 2005 24 finally although the study area is situated ecologically within the a larger predominately african american section of boston violence within the study area tends to occur almost entirely between members of the cape verdean population 25 thus the study community represents a highrisk community in a larger urban area whose violence tends to occur within an identifiable population data collection data come from two sources provided by the boston police department field intelligence observation cards and records of fatal and nonfatal gunshot injuries fios are records of noncriminal encounters or observations made by the police these reports include information such as reason for the encounter location and the names of all individuals involved since these data include only observations by the police the fio data provide a conservative measure of ones social networks as individuals have more friends and associates whom the police do not observe ties between individuals were derived for all situations in which two or more individuals were observed in each others presence by the police and recorded in fio datathose two people observed by the police in the same time and place are taken to be associates extant qualitative research in sociology anthropology and criminology suggests that hanging outstanding on street corners while associating with ones friendsis an important social behavior among young urban males as well as a key mechanism driving streetlevel violence 20 26 27 28 29 to generate the social networks of highrisk individuals in the study communities we employed a twostep sampling method frequently used in the study of other highrisk populations such as drug users and sex workers 30 the initial sampling seeds consisted of the entire population of cape verdean gang members known to the police step 1 entailed pulling all fios in the year 2008 for these 238 individuals to generate a list of their immediate associates this step was repeated to gather the friends friends of the original seeds to create a final social network of 763 individuals previous research suggests that such a twostep approach adequately captures the vast majority of information necessary to understand the underling social processes 31 the fio data were then merged with data on all known fatal and nonfatal gunshot injuries reported to the police enabling us to determine which individuals in our social network were the victims of gunshot violence in the years 20082009 during the study time period two of the individuals in the sample were the victims of fatal gunshot wounds and 38 were victims of nonfatal injuries models we use rare event logistic regression 32 to model the determinates of gunshot victimization in the sample population two sets of models are presented the first set presents the results on the entire population of 763 individuals while the second set presents the results of a subsample of 579 of the population that comprise a single larger network to account for temporal ordering the network was constructed using data from 2008 and regressed on the victimization data for 20082009 network calculations and visualizations were conducted using the statnet software in the statistical package r 33 regression analyses were conducted using stata 10 34 variables table 1 shows the mean standard deviation and range for all variables used in our analysis dependent variable the dependent variable is a binary indicator of whether or not an individual was the victim of either a fatal or nonfatal gunshot wound in 20082009 approximately 5 of the sample were victims of gun violence the current study combines fatal and nonfatal injuries analysis of only nonfatal shooting found no discernible differences in the results independent variables individual level covariates our models include several individuallevel control variables associated with gun violence age gender raceethnicity and whether or not the individual has ever been arrested age is consistently a strong predictor of violent victimization rates of homicide victimization peak between 18 and 24 and decline steadily thereafter we square age to capture this nonlinear relationship gender is measured as a binary variable the vast majority of network members are male ethnicity is measured as a binary variable indicating whether or not the subject was of cape verdean ancestry half of the study population is of cape verdean decent and the remainder is mainly africanamerican finally we include a binary dummy variable to indicate whether or not the subject has at least one prior arrest with the boston police department a full third of the sample has at least one prior arrest network measures on average any individual in the network has ties to approximately three associates though the standard deviation is equally large this distribution of ties in the networkpresented in the appendixis consistent with prior research that finds that most individuals in networks have a small number of ties while a small number of individuals have an exceedingly large number of ties 35 in the present data however some caution is in order as the ties themselves are based on police observationsie the number of ties may be influenced how police go about their duties and investigations 36 as such we weigh our sample according to this degree distribution to account for any bias attributable to policing efforts four social network measures are included in the analyses network density the percentage of ones associates who are known gang members the percentage of ones immediate associates who have been gunshot victims and the average social distance from the subject to other shooting victims network density is a basic property that reflects the overall intensity of the connected actors the more connected the network the greater the density 37 dense networks are often associated with cohesive subgroupings and cliques 38 formally network density is measured as the sum of ties that are present in the network divided by the possible number of ties 37 here we measure the egonetwork density as the density of ties in the immediate social network surrounding each individual 37 we also measure the percentage of ones immediate associates who are gang members this measure extends the prior research on the negative consequences of gang membership 39 by capturing a saturation effect greater exposure to gang members in ones social network should also increase ones exposure to gun violence exposure to gunshot violence is measured in two ways first we measure the effect of exposure to gunshot violence in ones immediate social network as the percentage of an individuals immediate associates who were gunshot victimsie someone whom they were observed associating with in public second we extend this idea to include a measure of social distance to gunshot victims measured as the average number of shortest paths from the subject to all gunshot victims in the social network 37 in large social networks individuals can be connected indirectly in many different ways and therefore information and influence can potentially travel different paths in the network between any two individuals research demonstrates that a wide variety of health and social behaviors are affected by people in the our social networks who are a few handshakes removed 1440 formally we measure social distance as the mean geodesic distance between each individual in the sample to all gunshot victims the geodesic distance refers to the shortest path between two nodes where the distance between two nodes n i and n j is measured simply as d the shortest distance then is the smallest value of d we calculated the measure in the following manner first we computed the entire distance matrix for the social network in this case a 786 by 786 matrix where each cell value represents the distance d between two nodes these data are symmetric meaning that in all cases dd next we complied a binary vector of the 786 individuals in the network indicating whether each of the individuals was the victim of a shooting finally because there are multiple shooting victims and multiple paths connecting individuals to these multiple shooting victims we calculated the mean average geodesic distance of all possible shortest distances to all shooting victims such an approach thus allows us to capture all potential avenues of indirect exposure for disconnected parts of the network we calculate this measure within each component our basic working hypothesis in this study is that individuals who are on average closer to shooting victims will be at greater risk of becoming victims themselves results the network of 763 individuals generated from the sampling method is presented in figure 2 each of the nodes represents a unique individual and each of the ties linking two nodes indicates at least one observation of two individuals observed socializing together a total of 1869 ties were extracted from the data gunshot victims are represented as the larger red nodes in the network figure 2 is comprised of 57 unique subnetworks although 76 of individuals are connected in the single large network consisting of 579 individuals the majority of gunshot victims are found in the large component the average geodesic distance between any individual in the network and a gunshot victim is 469 taken together these findings suggest that the majority of individuals in this network are connected in a single large network and on average any person is roughly five handshakes removed from a gunshot victim predicting gunshot victimization table 2 shows the odds ratios and 95 confidence intervals for models that regressed gunshot victimization on the full set of explanatory variables on both the entire network and the largest component examination of the individuallevel predictors for both models show that the odds of being a gunshot victim decreases with age and increases with prior contact with the criminal justice system as expected females in the network are less likely to be victims and those of cape verdean decent are more likely to be victims however neither of these variables attain statistical significance reflecting the gender and racial homogeneity of the sample egonetwork density in both models is negatively related to gunshot victimization suggesting that density may in fact be protective of victimization the p value of this variable however suggests that this effect is not significantly different than zero when considering only the complete network the saturation of gang members increases ones odds of being shot although the statistical significance of this effect drops when considering only the large component the magnitude of our two variables pertaining to network exposure to gunshot injuries differs slightly between the models in table 2 of immediate alters who have been shot greatly increases ones odds of also being a gunshot victim a 1 increase in the number of ones friends who are gunshot victims increases ones own odds of victimization by approximately 144 this effect diminishes in the model for only the large network and loses its statistical significance this loss of statistical significance highlights the fact that individuals in smaller networks have fewer avenues of indirect exposure and therefore direct exposure has a much more potent influence both models in table 2 support our main hypothesis that social distance is related to gun victimization the closer one is to a gunshot victim the greater the probability of ones own victimization net of individual and other network characteristics in the whole network model every one connection away from a shooting victim decreases the odds of getting shot by 88 this effect is more pronounced in the large component every one connection removed from a gunshot victim decreasing ones odds of getting shot by approximately 25 this relationship between distance to a shooting victim and probability of gunshot victimization is summarized in figure 3 where the xaxis indicates the average distance to a shooting victim and the yaxis indicates the predicted probability of gunshot injury in the largest component model in table 2 because the large component is completely connected and contains the majority of shooting victims the xaxis begins at four demonstrating that everyone in the large networks is indirectly connected to a shooting victim and the shortest average path to any victim is four connections figure 2 reveals two important features related to social distance first the association between social distance and the probability of gunshot victimization is more pronounced among gang members suggesting that gang members may occupy unique positions within such networks that place them at greater risk second for both gang and nongang members the effect of the risk begins to level off after approximately five network degrees regardless the effect of indirect exposure to gunshot injuries is pronounced for both gang and nongang members discussion our data on highrisk individuals bostons cape verdean community reveals a social network of young men with a highly elevated risk of gunshot victimization network analysis shows the existence of a social network consisting of 763 individuals the majority of whom are all connected in a single large network and on average individuals in this network are less than five handshakes away from the victim of a gun homicide or nonfatal shooting our findings demonstrate that the effect of this distance to a shooting victim greatly increases an individuals own odds of becoming a subsequent gunshot victim the closer one is to a gunshot victim the greater the probability that person will be shot indeed each network step away from a gunshot victim decreases ones odds of getting shot by approximately 25 the findings of this study are limited in three ways first our sampling clearly does not identify all individuals at risk of gunshot victimization situations not visible to police investigationsuch as unreported domestic violence incidentswould not be captured in our data second the use of fio data circumscribes our measurement of social networks to those ties witnessed firsthand by police and therefore we probably underestimate the extent of social networks third our findings may also be confined to the unique character of bostons cape verdean neighborhoods however these communities share many similarities with other highcrime and socially disadvantaged urban neighborhoods and recent research suggests that the network patterns described here extend to gang violence in chicago limitations notwithstanding these results imply that social networks are relevant in understanding the risk of gunshot injury in urban areas the contours of our social networkseven when we cannot see themaffects our behavior furthermore our findings suggest that the risk of gunshot victimization is not evenly distributed within highrisk populations in the present study those individuals in the largest social network for instance are at a much greater risk of victimization than either those in the smaller disconnected networks or of the general neighborhood population in large part because of the ways in which people are situated in social networks how and why such networks affect the ways in which we assess the risk of gunshot injury is of importance for future research and public health in particular gun violence reduction strategies might be better served by directing intervention and prevention efforts towards individuals within highrisk social networks appendix a figure 4 the distribution of the number of network ties social networks and the risk of gunshot injury

direct and indirect exposure to gun violence have considerable consequences on individual health and wellbeing however no study has considered the effects of ones social network on gunshot injury this study investigates the relationship between an individuals position in a highrisk social network and the probability of being a victim of a fatal or nonfatal gunshot wound by combining observational data from the police with records of fatal and nonfatal gunshot injuries among 763 individuals in bostons cape verdean community a logistic regression approach is used to analyze the probability of being the victim of a fatal or nonfatal gunshot wound and whether such injury is related to age gender race prior criminal activity exposure to street gangs and other gunshot victims density of ones peer network and the social distance to other gunshot victims the findings demonstrate that 85 all of the gunshot injuries in the sample occur within a single social network probability of gunshot victimization is related to ones network distance to other gunshot victims each network association removed from another gunshot victim reduces the odds of gunshot victimization by 25 odds ratio075 95 confidence interval 065 to 087 this indirect exposure to gunshot victimization exerts an effect above and beyond the saturation of gunshot victimization in ones peer network age prior criminal activity and other individual and network variables

introduction one of the most important aspects affecting a nations overall growth and development is its healthcare system for a country to develop and compete on the international stage its citizens must be educated and in good health a population that is healthy is more productive and capable of working reducing the burden of disease and enhancing overall health outcomes require access to highquality healthcare it is impossible to overstate the importance of health in a nations development it has an impact on social progress educational achievement and life quality in general sustainable development and prosperity are influenced by investments in healthcare systems disease prevention and public health good health enhances productivity and workforce participation leading to increased economic output healthier individuals are more likely to be engaged in the labor force leading to higher overall productivity this concept is wellexplained in the human capital theory 1 a healthy population requires fewer healthcare resources and expenditures this allows governments to allocate resources to other sectors such as education and infrastructure fostering overall development 2 good health is linked to higher educational attainment healthy children are more likely to attend school regularly and perform better academically contributing to a more educated and skilled workforce 3 in the early stages of economic theory gross domestic product served as the standard metric for assessing a nations economic progress it was commonly believed that development and prosperity naturally increased with a rise in gdp per capita however this narrow focus on gdp as a development indicator overlooked the wellbeing of the population high gdp alone does not guarantee greater prosperity among the people as the equitable distribution of wealth and resources plays a pivotal role in the overall benefit to society esteemed economists like paul streeten frances stewart mahbub ul haq and nobel prize laureate amartya sen have criticized gdp as an inadequate proxy for development instead they advocate the concept of human growth which led to the emergence of human development in the late 1980s championed by drs amartya sen and mahbub ul haq the crux of development lies in creating an environment that fosters long healthy and productive lives for individuals although there has been a significant rise in government healthcare spending globally increasing at approximately 6 in low and middleincome countries and 4 in highincome countries a concerning trend persists each year approximately 100 million people are pushed into extreme poverty because they are compelled to allocate over 35 of their income to access healthcare services 4 research has shown that simply increasing healthcare spending cannot guarantee universal healthcare and human development 5 banna banik et al 6 examined how the quality of governance influences the relationship between healthcare spending and human development their findings revealed that political stability and absence of terrorism had the most significant net positive impact on health expenditure contributing to the improvement of human welfare moreover they observed that the interaction effect between expenditure and the good governance index was negative but not statistically significant for lowincome countries negative and statistically significant for subsaharan african economies and positive but not statistically significant for south asian nations esen and kecili 7 examined the relationship between health expenditure and economic growth in turkey from 1975 to 2018 the study found evidence of a oneway causality running from health expenditure to economic growth in the short term as a result the study recommends that the government should prioritize increasing the allocation of health expenditure in the budget to enhance the overall health status of the population kaur investigated the relationship between health expenditure health status and economic growth in india from 198182 to 201516 the study confirmed a longterm relationship among these variables it revealed that there was a oneway causality running from health expenditure to economic growth and from health expenditure to the infant mortality rate the study also found that health expenditure significantly influenced both economic growth and infant mortality rate in india safitri 8 employed panel data from 23 districts over the period 20082014 and found only the spending on health has a significant impact on the hdi improvement arun and kumar 9 investigated the relationship between per capita public health expenditure and gdp per capita in brics countries including brazil russia india china and south africa from 1995 to 2013 the study revealed that causality ran from gdp to per capita public health expenditure but no causality was observed from public health expenditure to gdp furthermore the study concluded that economic growth played a crucial role in enhancing public health expenditure leading to the provision of improved healthcare facilities rajeshkumar and nalraj 10 conducted a study to explore the relationship between healthcare expenditure and economic growth in four indian states madhya pradesh orissa kerala and tamil nadu covering the period from 1991 to 2010 the findings revealed that healthcare expenditure and economic growth were cointegrated indicating a longterm connection between these variables additionally the study confirmed the presence of unidirectional causality with health expenditure influencing economic growth in madhya pradesh orissa kerala and tamil nadu craigwell bynoe and lowe 11 conducted a study using panel data from 19 caribbean countries their findings from the granger causality test indicated that public spending on healthcare positively influences life expectancy leading to an improvement in peoples longevity however the study did not find any significant impact of public spending on healthcare on the level of education among the population razmi et al 12 found no bidirectional relationship between health spending and the human development index in iran however their analysis using the ordinary least square approach demonstrated that public health expenditure positively contributed to increasing the hdi this was attributed to the allocation of funds for enhancing the healthcare system and promoting awareness among the population kerala is the southern indian state which has a notable achievement in human development particularly in health and education set it apart and define the kerala model despite its low per capita income and limited industrial production the states physical quality of life index surpasses the national average reflecting the irony of its development while health and education improvements are crucial unlocking economic opportunities is equally vital for sustainable development keralas case serves as a striking example of this paradox showcasing remarkable human development amid perceived poverty due to limitations on expanding productive capacity and entrepreneurial activities according to mujeeb rahman ap and bassam k 13 the human development index of the malappuram district in kerala is lower than that of the state of kerala and in order to raise it adequate steps must be taken in the areas of standard of living health and education provide more chances for incomegenerating activities to boost the per capita income theoretical framework the major theoretical innovation in the study of the demand for health care has come from grossman demand for healthcare is derived from a demand for health itself grossmans model assumes that individuals assess the benefits from outlays that will improve their health compared with expenditure on other goods and services in order to decide their optimal health stateestimates provided by grossman rosett and huang 14 and phelps and newhouse 15 all indicated a positive effect of income on health care expenditure grossmans results also indicate a negative relationship between income and the individuals number of healthy days per year education was found to be positively related to health stock leander and garciagómez in their study examined the contributing determinants of inequity in healthcare utilization in south africa the results indicate that the rich are more likely to use inpatient care than the poor given the same level of need other factors like race gender education and the consumption level also contribute to inequity statement of the problem methodology this section outlines the methodology employed to conduct the comprehensive analysis presented in this study focusing on the relationship between individual health status lifestyle factors and healthcare expenditure patterns the methodology encompasses data collection variables selection statistical techniques and analytical frameworks adopted to address the research objectives data collection primary data was collected through a structured survey conducted in 2023 within the malappuram district a diverse sample of 386 individuals was selected representing various demographic segments the survey questionnaire comprised sections that captured demographic information health status perceptions lifestyle choices and healthcare expenditure patterns the data collection process was carried out with a rigorous approach to ensure the accuracy and reliability of responses variables selection the study analyzed a range of variables to address the research objectives comprehensively these variables included religious affiliations socioeconomic factors lifestyle choices general health status perceptions and healthcare expenditure patterns analytical techniques descriptive analysis the collected data was subjected to descriptive analysis presenting frequencies percentages means and standard deviations of different variables this allowed for a preliminary overview of the dataset and highlighted initial trends anova and ttests analysis of variance and ttests were employed to explore disparities in health status and healthcare expenditure patterns across various categories such as religious affiliations income levels age groups and gender these techniques facilitated the identification of statistically significant differences regression analysis multiple linear regression was conducted to assess the relationship between lifestyle factors and healthcare expenditure patterns the model aimed to explain the variance in health expenditure based on selected independent variables coefficients significance levels and goodness of fit measures were used to interpret and evaluate the model ethical considerations ethical standards were adhered to throughout the study informed consent was obtained from all participants ensuring their willingness to participate data confidentiality and anonymity were maintained and ethical guidelines were followed in data collection storage and analysis limitations the study is not without limitations the crosssectional nature of the data limits causal inferences the selfreported nature of data introduces potential biases and unobserved variables could impact the results results and discussion within the following analysis section we embark on a comprehensive journey to explore multiple facets of healthcare within malappuram district our objectives encompass a range of factors that collectively contribute to the understanding of health dynamics and healthcare utilization patterns among the districts diverse population through rigorous examination we aim to shed light on the intricate interplay between socioeconomic variables demographic characteristics and healthcare outcomes ultimately providing insights that can inform targeted interventions and policy enhancements the objectives guiding this analysis are as follows in this pursuit we strive to unravel the health status of the districts inhabitants while carefully considering the potential influence of religious affiliations by elucidating variations in health outcomes among different religious groups we aim to contribute to a nuanced understanding of the interrelationship between cultural and religious factors and individual wellbein the table presents a religiouswise comparison of the health status of respondents in terms of both general health and mental health the health status is rated on a scale of 1 to 5 where 1 represents poor health and 5 represents excellent health upon analysis several noteworthy observations emerge firstly in terms of general health status christians exhibit a mean score of 30000 hindus at 36870 and muslims at 36502 the overall mean general health score for all respondents is 36425 the anova results reveal an fvalue of 2258 with a corresponding pvalue of 0106 this nonsignificant pvalue implies that the disparities in general health status scores across religious groups are not statistically significant this might be attributed to the notion that general health status is influenced by a multitude of factors such as genetics lifestyle environment and access to healthcare which may not be strongly tied to religious affiliation turning to mental health status the mean scores for christians hindus and muslims are 32500 37939 and 38601 respectively the overall mean mental health score for all respondents is 38187 the anova results for mental health status exhibit an fvalue of 2070 with a pvalue of 0128 similarly this nonsignificant pvalue indicates that the differences in mental health status scores across religious groups are not statistically significant this outcome aligns with the understanding that mental health is influenced by a complex interplay of psychological biological and social factors wherein religious affiliation might not be the sole determinant in summary the statistical outcomes underscore that within this dataset religious affiliation does not seem to be a significant factor influencing health status perceptions in terms of both general health and mental health dimensions instead other variables such as socioeconomic status access to healthcare and individual lifestyle choices might play more substantial roles in shaping health outcomes 7 nearly every day and 107 for several days the chisquare test is conducted to ascertain whether the differences in the distribution of interest or pleasure frequencies among religious groups are statistically significant the chisquare result is 24127 with 4 degrees of freedom and a pvalue of 0000 this low pvalue indicates that the differences in the distribution of frequencies are statistically significant at the conventional significance level of 005 the statistically significant chisquare result suggests substantial differences in the distribution of reported frequencies of feeling interest or pleasure among religious groups these differences could be influenced by various factors including cultural practices social norms and psychological wellbeing it is possible that the ways in which individuals from different religious communities find enjoyment in activities may be shaped by their beliefs traditions and communal contexts this table underscores the importance of considering not only negative mental health experiences but also positive emotions and wellbeing when examining mental health within religious contexts the observed variations in interest and pleasure frequencies can inform culturally sensitive mental health interventions that address the diverse needs of different religious communities within the realm of healthcare analysis the economic dimension stands as a pivotal focal point our mission revolves around unearthing the intricate ways in which medical expenditures are allocated across a spectrum of household income levels and socioeconomic strata through an indepth exploration of expenditure patterns our objective is to illuminate potential disparities in healthcare service access in doing so we are dedicated to championing the cause of fostering a healthcare ecosystem characterized by equity and fairness the objective of assessing variations in medical expenditure patterns based on household income levels or socioeconomic status holds substantial significance within the realm of healthcare analysis and policy development this objective addresses the vital issue of equity in healthcare access by unraveling how healthcare expenses are distributed across different economic strata by scrutinizing expenditure patterns we gain insights into potential disparities in accessing healthcare services this knowledge is particularly crucial for identifying segments of the population that might face obstacles in affording necessary medical care thereby exposing gaps in healthcare equity 17 18 19 20 nature of family the substantial difference in mean health expenditures between joint and nuclear families along with the statistically significant ttest result suggests that family structure plays a role in influencing health expenditure patterns individuals within joint families seem to allocate higher resources toward healthcare compared to those in nuclear families this disparity could be attributed to factors such as shared financial responsibilities within joint families which might lead to increased healthcare spending in sum the table underscores the intricate interplay between demographic characteristics and health expenditures these findings reinforce the need for nuanced policy responses aimed at promoting equitable access to healthcare services recognizing the differential impact of demographics on expenditure trends is pivotal for crafting targeted interventions that bridge potential gaps ultimately ensuring healthcare affordability and accessibility for diverse populations 2021 table 6 encapsulates the gini coefficient a measure used to quantify the inequality in the distribution of health expenditure across different segments of the population the gini coefficient of 092 is indicative of a substantial level of inequality in the distribution of health expenditure such a high value signifies that there is significant disparity in how health expenditures are distributed among the surveyed population the considerable gap between the lorenz curve and the line of perfect equality points to pronounced disparities this result highlights the need for focused policy interventions aimed at reducing the inequality in health expenditure distribution it suggests that a relatively small portion of the population might be shouldering a disproportionately large burden of health expenditure while others have more equitable access to healthcare services addressing this imbalance could involve targeted measures to improve healthcare affordability for vulnerable and lowerincome segments of the population thereby working toward a fairer and more inclusive healthcare system the exploration of the connection between lifestyle factors and health expenditure patterns holds significant importance for healthcare analysis and policymaking this objective seeks to uncover how choices such as diet exercise choice of food the analysis reveals that individuals who consume fast food have a slightly higher mean health expenditure of 291667 compared to those who opt for homely cooked food with a mean expenditure of 280024 however the ttest result demonstrates no statistical significance suggesting that the choice of food might not strongly influence health expenditure patterns timely food consumption the data indicates that individuals who consume food on time exhibit a slightly higher mean expenditure of 287662 while those who do not consume food on time have a mean expenditure of 260606 the ttest result also reveals no statistical significance indicating that the timing of food consumption might not be a significant driver of expenditure differences use of intoxicants the analysis shows that individuals not using intoxicants have a mean expenditure of 269906 while those using intoxicants have a notably higher mean expenditure of 322963 that smoking might not be strongly correlated with expenditure differences the tables findings suggest that while some lifestyle factors exhibit associations with health expenditure variations others may not have significant impacts the results emphasize the complex interplay between lifestyle choices and healthrelated spending patterns while certain behaviors like using intoxicants appear to be correlated with higher health expenditures other factors such as food choices and smoking seem to have less pronounced relationships these insights contribute to a nuanced understanding of how lifestyle factors can influence healthcare costs this table presents a comprehensive analysis that explores the relationship between individuals general health status and various lifestyle factors choice of food individuals who consume homely cooked food exhibit a slightly higher mean general health status of 38465 compared to those who opt for fast food with a mean health status of 37836 however the ttest result indicates no statistical significance suggesting that the choice of food might not strongly impact general health status timely food consumption individuals who consume food on time have a mean general health status of 37904 while those who do not consume food on time have a slightly higher mean health status of 41212 the ttest result indicates no statistical significance suggesting that the timing of food consumption may not significantly affect general health status use of intoxicants individuals not using intoxicants have a mean general health status of 37970 while those using intoxicants have a slightly higher mean health status of 38696 the ttest result indicates no statistical significance suggesting that the use of intoxicants might not have a significant impact on general health status the results indicated that the choice of food timely food consumption and smoking were not statistically significant predictors of health expenditure while the use of intoxicants showed a positive and statistically significant relationship the regression model demonstrated limited explanatory power in capturing the variation in health expenditure based on the examined lifestyle factors the regression results suggest limited explanatory power of the selected lifestyle factors on health expenditure the low r square and insignificant anova fstatistic indicate that the model as a whole does not significantly explain the variance in health expenditure while the use of intoxicants appears to have a statistically significant positive relationship with health expenditure the magnitudes of the coefficients are generally small the lack of statistical significance for other lifestyle factors like choice of food and smoking suggests that these specific factors might not have strong predictive capabilities regarding health expenditure patterns the hypothesis tests were conducted to examine whether various demographic factors have a significant influence on health expenditure patterns among individuals in the malappuram district the results suggest that certain demographic factors including religion income marital status occupation age gender and family structure are associated with variations in health expenditure patterns among individuals in the malappuram district these findings provide valuable insights into how these demographic characteristics influence individuals healthcare spending behaviors similarly the analysis suggests that while the use of intoxicants shows a statistically significant relationship with health expenditure the other examined lifestyle factors namely the choice of food timely food consumption and smoking do not exhibit a significant relationship with health expenditure patterns among individuals in the malappuram district 21 22 23 conculison in conclusion the comprehensive analysis undertaken in this study has illuminated various aspects of the complex interplay between individual health status lifestyle choices and healthcare expenditure patterns the study aimed to address a range of objectives including studying the health status disparities across different religious affiliations assessing variations in medical expenditure based on household income levels and socioeconomic status and exploring disparities in medical expenditure allocation based on age gender and family size the analysis of health status across religious affiliations indicated that while slight variations existed they were not statistically significant however this observation underscores the need for continued efforts to ensure equitable healthcare provisions across diverse religious communities an important dimension of the study involved investigating the economic implications of lifestyle choices while certain lifestyle factors displayed associations with health expenditure variations the effects were often modest or statistically insignificant this highlights the intricate nature of healthrelated spending patterns and the need to consider a broader range of determinants when addressing healthcare costs furthermore the regression analyses conducted to understand the relationship between lifestyle factors and health expenditure provided valuable insights the modest rsquared values and nonsignificant fstatistics indicated that the selected lifestyle factors might not have substantial predictive power in explaining variations in health expenditure however the statistically significant relationship between the use of intoxicants and higher health expenditure underlines the potential impact of certain behaviours on healthcare costs throughout this analysis it became evident that healthcare expenditure patterns are influenced by a multitude of factors extending beyond individual lifestyle choices socioeconomic factors access to healthcare and other unobserved variables can significantly contribute to the observed expenditure patterns as a result these findings emphasize the need for a holistic approach to healthcare policy and individual decisionmaking policymakers should consider not only lifestyle interventions but also broader systemic improvements to ensure equitable access to healthcare and effective cost management individual choices while impactful are just one facet of the intricate web of factors shaping healthcare expenditure patterns in conclusion this study underscores the complexity of healthcare expenditure the multifaceted nature of individual health status and the interplay of lifestyle choices with broader socioeconomic and systemic dynamics competing interests authors have declared that no competing interests exist

this study investigates the relationships between demographic factors and health expenditure based on 387 households in malappuram district between september 2021 and april 2022 rigorous statistical methodologies including anova and ttests were applied to scrutinize and quantify these relationships the findings indicate that health status variations across religious affiliations were present but not statistically significant similarly the regression analysis showed limited predictive power of lifestyle factors low rsquared nonsignificant fstatistics in explaining health expenditure variations however it did reveal a significant correlation between intoxicant use and increased healthcare costs emphasizing the influence of specific behaviors on healthcare expenses furthermore the analysis emphasized the multifaceted nature of healthcare spending influenced by socioeconomic factors healthcare accessibility and unobservable variables

asthma prevalence at lower incomes despite a long history of research on asthma the disparities still exist original research focused on the causes and treatments at the individual level more recent research has begun to investigate family neighborhood and societal factors that may influence childhood asthma this integrative review analyzes research from the year 2010 to 2016 with regard to the quick pace of developments in the field and allows a few years for the 2007 national asthma education and prevention program guidelines to be implemented neighborhoodlevel factors are being investigated using sophisticated statistics accounting for several domains in their modeling neighborhood is defined as a bundle of spatially based attributes associated with clusters of residences sometimes in conjunction with other land uses neighborhoodlevel factors include structural characteristics of buildings infrastructural characteristics demographic characteristics of residents class status characteristics taxpublic service package characteristics environmental characteristics proximity characteristics political characteristics socialinteractive characteristics and sentimental characteristics such as how residents identify with their neighborhood defining neighborhoodlevel factors demonstrated several areas that might be of interest to school nurses including schools themselves both social and physical aspects of neighborhoods affect health the neighborhood still remains an important area to investigate because it is linked with more severe asthma and greater risk of death although there is not one definitive causal factor it has been proven that residential segregation both past and present leads to disparities in socioeconomic status causing racial health disparities between african americans and caucasians racial and ethnic minority groups and those living in lowincome communities are exposed to multiple physical environmental triggers as well as social stressors related to poverty and inequality these physical and social affects have negative health consequences for children with asthma according to the naepp expert panel report 3 one risk factor for asthmarelated death is being an innercity resident or of low ses this statement emphasizes how important it is to investigate the impact of neighborhoodlevel factors on childrens asthma analyzing current research in this area will allow scientists to develop interventions to combat asthma at this level as is mentioned in previous reviews on this topic a multilevel framework would support and encourage multidisciplinary investigation in asthmarelated research this review also includes neighborhoodlevel factors that may be important for school nurses to consider when treating students with asthma the purpose of this integrative review is to analyze and critique research from 2010 to 2016 that investigated the relationships between neighborhoodlevel factors and asthma in children living in urban areas literature search method integrative reviews present the state of the science by compiling recent empirical or theoretical literature to provide a comprehensive view of a health topic the purpose of this integrative review was to critique and summarize research examining the relationship between neighborhoodlevel factors and asthma in children living in urban areas a literature search of cinahl pubmed and psycinfo databases was conducted in march 2016 with the assistance of a university librarian search terms included the medical subject headings terms neighborhood asthma child and urban see figure 1 for a screenshot of the search strategy the search was performed for the years 2010 through march 2016 articles were found from this search as well as a hand search after speaking with experts in the field and reviewing reference lists to identify relevant articles there were no restrictions on primary author discipline location of the study or methodological orientations due to the nature of neighborhoodlevel factors being relatively difficult to manipulate all of the studies included were nonexperimental the preferred reporting items for systematic reviews and metaanalyses flow diagram illustrates the search process the inclusion criteria were full text published peerreviewed and english language studies based on adult asthma trialing interventions dissertations reviews opinion articles and articles published prior to 2010 were excluded leaving 26 studies after 3 additional studies were added from a hand search the presentation of results is organized conceptually discussing research on prevalence as well as physical and social neighborhoodlevel factors that are associated with asthma the next section is a critique followed by implications for future research results articles were analyzed by the type of study method results asthma measurement inclusion of sex race and ethnicity and ses see supplementary tables 16 for a detailed analysis of each individual article during analysis articles were evaluated critically regarding theoretical and methodological features after analysis of all articles six themes emerged organically from the data the results are presented according to the theme below beginning with research of asthma prevalence followed by physical then social neighborhoodlevel factors prevalence several recent studies demonstrate that asthma prevalence varies by race as well as ses two large national studies demonstrated that asthma rates are significantly higher for children who are african american or puerto rican these studies also analyzed data by ses and one demonstrated that a oneunit decrease in the household income to poverty ratio was associated with a 7 increase in the odds of prevalent asthma a similar study was done with data from the latin american international study of asthma and allergies in childhood to analyze multiple factors relating to asthma prevalence this study also found that the gini index which is a measure of income distribution similar to ses along with crowding sanitation infant mortality rate and homicide rate explains 75 of the variability in asthma prevalence between 31 latin american urban centers this study along with the two discussed earlier utilized a crosssectional design that prevents any causational inferences to be drawn fattore santos and barreto measured socioeconomic and environmental determinants of wheezing in children in latin america as described above similarly holt theall and rabito and keet et al analyzed data on the sociodemographic neighborhood familial and individual level holt et al found that the mothers race and ethnicity childs insurance coverage childs sex allergies the physical condition of the exterior of the home and the percentage of the population with a bachelors degree were significantly associated with an asthma diagnosis by age 5 in children the variables were significant when analyzed in a multivariable model including individuallevel sociodemographic housing characteristics interviewer observed participantreported neighborhood characteristics and census tractlevel neighborhood variables keet et al sampled children living in various census tracts around the united states and found that race and ethnicity were strongly associated with asthma prevalence but in a multivariate analysis they found that neighborhood poverty and urbanrural status were not risk factors in a similar study ownby et al demonstrated that asthma prevalence when controlling for ses is similar among rural and urban african american teens these data also included asthma symptoms and demonstrated that the teens living in urban detroit reported more symptoms and hospitalizations in the past 30 days compared to the teens living in rural georgia the crosssectional data were from selfreport questionnaires that were sent out to students through public schools in each area during the years 20072008 in detroit and20092010 in georgia these two samples were taken 2 years apart and had differing sample sizes which weaken the strength of the authors argument although there have been unique findings as demonstrated by ownby et al methodologically stronger research should be done to support the evidence that urban versus rural location are not associated with asthma prevalence taken together this body of research demonstrates that asthma disproportionally affects african american and puerto rican children in the united states and it seems to correlate with ses nationally and internationally there is a discrepancy as to whether or not ones neighborhood is associated with increased asthma prevalence however being an innercity resident is cited as a risk factor for asthma mortality and it is important to continue to investigate the elements of this environment that are related to asthma prevalence and control physicaloutdoor air research of outdoor airquality ranges from analyzing pollen exposure related to asthma emergency department visits to the impact of weather and particular air pollutants on asthma and respiratory health some of the research has mixed results jariwala et al found a correlation between pollen exposure and asthma ed visits but could not demonstrate a relationship between nitrogen oxides or ozone peaks and peak visits for asthma to the ed glad et al utilized a casecrossover design to demonstrate a 25 increase in asthma ed visits for every 10 parts per billion increase in o 3 level the casecrossover design may have strengthened the method but the pollution data were obtained from a limited number of monitors and therefore did not capture variability across regions through a retrospective casecontrol study nishimura et al demonstrated a 5 ppb increase in average nitrogen dioxide during the first year of life was associated with an or of 117 for asthma this study also demonstrated that chicago and new york had the highest level of no 2 considered to be a trafficrelated pollutant the study design also addressed the temporality of air pollution but the data were analyzed as large areas rather than particular homes of the study participants svendsen et al demonstrated in texas that a 10 ppb increment increase in no 2 levels was associated with current asthma for children in public schools at elevations above 1170 m in valley schools of lower elevation the relationship was not significant the environmental data were collected in 1999 and the questionnaires from the schools were obtained in 2001 the final analyses focused on children who had lived in their current residence for over 1 year these analyses controlled for indoor sources of exposure including gas stoves and secondhand smoke buonanno marks and morawska and vieira et al were able to measure individual pollutant exposure thereby strengthening their inferences in italy buonanno et al demonstrated that children in urban areas are exposed to particle concentrations 25 higher than the overall mean exposure the author also demonstrated that home was a major contributor to daily dose of airborne particles and that there is an association between personal dose and respiratory health effects vieira et al demonstrated a lowcost method to measure no 2 and o 3 exposure among children by using small air filters in their homes balconies and hooked onto their backpacks although the sample size was small the study found that the no 2 in indoor air and personal exposure to o 3 were independently associated with asthma and wheezing at any time these data support research that air pollution in the form of no 2 and o 3 do relate to asthma and their exposure early in life may increase the odds of an asthma diagnosis overall there appears to be strong evidence supporting an association with no 2 and asthma although not as much information on o 3 and limited research on the association between pollen and asthma more research should be done on individuallevel exposures possibly by the methods used by vieira et al to measure outdoor indoor and personal exposure physicaloutdoor airtraffic in analyzing trafficrelated pollution cook devos pereira jardin and weinstein and li et al used proximity of houses to major roads and estimated traffic counts to analyze asthma they both used casecontrol studies to demonstrate increased risk of asthmarelated events such as ed visits cook et al demonstrated that in perth australia there was a 24 increase in the risk of experiencing multiple emergency contacts for asthma for every log unit of traffic exposure li et al demonstrated that in detroit mi for every 1km increase in distance away from a primary road the or of an asthma event is 097 although they used large sample sizes n 434 and n 14646 neither study took into account ses sex or ethnicity which might explain some of the variation in asthma events these data did not account for other exposures such as secondhand smoke family history or indoor air pollutants and allergens because they were deidentified from hospital records in australia and medicaid data in detroit although this information does not demonstrate causation these data about specific pollutants appear to have an association between outdoor air quality and asthma physicalindoor airtriggers and housing research investigating indoor variables and asthma includes types of housing specific triggers and behaviors aimed at decreasing triggers northridge ramirez stingone and claudio determined that there is a high prevalence of asthma in public housing in new york city after adjusting for communitylevel demographic and economic factors of those sampled those in public housing were more likely to report the presence of cockroaches compared to other types of housing this finding demonstrates differential exposure to asthma triggers by housing type the researchers analyzed questionnaires from 4853 children representative of the 5to 12yearold population of children attending new york city public schools olmedo et al used a casecontrol design to analyze high asthma prevalence neighborhoods compared to low asthma prevalence neighborhoods bed dust was tested for allergens and in hapns there were more cockroach mouse and cat allergens and lower dust mite allergens the author theorized that air conditioning was less common in hapns and therefore the dry air was less conducive to dust mites this idea was supported by northridge et al who found that public housing residents who had higher asthma prevalence were less likely to report the use of an air conditioner compared to the residents of family dwellings another asthma trigger analyzed by butz et al is exposure to secondhand tobacco smoke measured through urine cotinine levels although no significant associations were found it should be noted that children with a greater number of symptom days had the highest cotinine concentrations data also indicated a twofold increase in urine cotinine concentrations when the childs caregiver smoked as compared to other people living in the house the sample consisted of children with uncontrolled asthma so the lack of variability may have led to the lack of statistical significance the study also demonstrated that urine cotinine as opposed to passive nicotine sampling badges in the environment should be considered the gold standard for measuring secondhand smoke exposure in children martin et al also utilized cotinine data in saliva to analyze asthma trigger behaviors for puerto ricans in chicago caregivers of children with asthma were scored through questionnaire home assessment and cotinine levels to determine their trigger behavior summary score each item was coded as 1 for affirmative and 0 for negative and they included dust in the bedroom dust in the home lack of an air cleaner lack of allergen covers pets in the bedroom pets in the home presence of roaches rodents cracksholes strong cleaning smells smoke exposure fragrance andor mold the average trigger score was 60 all items on the trigger behavior summary score represent modifiable behaviors so these data have identified areas for future environmental interventions fragrance use was the most common behavior followed by presence of mold although the study by martin et al identified triggers yinusanyahkoon cohn cortes and bokhour analyzed qualitative data to address family routines and asthma management in african american families in boston ma two of the four main themes were that caregivers worked to manage the air quality in their home and frequently cleaned the home to remove triggers over half of the study sample lived above the poverty line almost half lived in twoparent houses and all had health insurance and a regular source of ambulatory care although this study may not be transferable to innercity populations it would be interesting to interview families of lower ses to understand how their family routines and asthma management differ socialoutdoorsafety measuring safety was done both directly by looking at crime data and indirectly by measuring the perception of safety gupta et al utilized surveys of children from kindergarten through eighth grade the surveys asked the childs caregiver about demographic information as well as whether the child had been diagnosed with asthma age at diagnosis if applicable current asthma status and presence of a family history of asthma in total 5908 children reported an asthma diagnosis after geocoding all addresses into 247 chicago neighborhoods they were divided into quartiles based on asthma prevalence these data were analyzed with crime data from the chicago police department criminal activity was significantly higher in neighborhoods with high asthma prevalence after adjusting for communitylevel race and ethnicity violent crime continued to explain 15 of the variation in childhood asthma these data only account for reported crime so prevalence of asthma may be underestimated this study demonstrated the utility of directly measuring crime while coutinho mcquaid and koinismitchell and vangeepuram galvez teitelbaum brenner and wolff measured perceived safety coutinho et al utilized mixed methods to analyze caregiverchild dyads and their perception of safety related to family asthma management there were significant ethnic group differences in poverty status f 649 p 01 with latino and african american dyads reporting greater poverty than the nonlatino white dyads there were also differences in perceived safety by ethnicity f 629 p 01 with nonlatino white dyads reporting higher perceived home and neighborhood safety compared to the latino and african american dyads ratings of effective family management positively correlated with home and neighborhood safety and negatively correlated with perceived discrimination and acculturative stress vangeepuram et al used crosssectional data from parents of 6to 8yearolds with asthma in new york city they found that parents who reported feeling unsafe walking in the neighborhood were more likely to have a child diagnosed with asthma an interesting finding in these data is that the neighborhoods sampled were relatively similar but it was the variation in parent perception of safety that related to asthma prevalence all three of these studies demonstrate that the direct and indirect measures of safety may be correlated with asthma koinismitchell kopel salcedo mccue and mcquaid used a mixed methods exploratory study with crosssectional data from two separate studies to analyze childrens stress perception related to their asthma children with poorly controlled asthma reported a higher rate of neighborhood stress compared to children with wellcontrolled asthma f 45 p 04 the family moving was most frequently mentioned as a stressor for respondents children with poorly controlled asthma reported higher levels of stress related to being afraid to go outside compared to children with wellcontrolled asthma f 61 p 02 the study authors reported that a limitation was that there was not a parent instrument to corroborate childrens perceptions of concepts but the mixed methods nature of the study allowed the children to explain their answers socialindoorfamily stress family stress is analyzed in several different ways taking into account the family and the parent familylevel data were obtained by koinismitchell et al and sampson et al using mixed methods the data sampson et al presented demonstrated that caregivers of children with asthma from lowincome families in detroit mi do not see caring for an asthmatic child as a source of stress rather they reported high stress with regard to asthmarelated change uncertainty control and anxiety koinismitchell et al calculated a cumulative risk index to quantify the risk factors for asthma the cri score was formulated by adding a 1 for the presence of six risk factors including neighborhood stress poverty acculturative stress discrimination asthma severity and asthma triggers within the home the study showed that cumulative risks were associated with increased functional limitation and risk for an ed visits in the past 12 months quinn kaufman siddiqi and yeats analyzed both parent perceptions of collective efficacy and neighborhood order for a sample of lowincome chicago families with a child who has asthma collective efficacy is the mutual trust between neighbors and the willingness to intervene on behalf of the public good neighborhood order was defined as observable physical and social decay operationalized as presence of littertrash graffiti vacant houses and asking about trust between businesses and residents parent health was associated with collective efficacy general health outcomes of the family including parents were associated with collective efficacy but child respiratory health outcomes were associated with neighborhood order no biological or behavioral risk factors were accounted for in the statistical analysis and the authors note that reverse causality may be a limitation since asthma may cause stress due to the crosssectional design of this study causality cannot be demonstrated both mathildachiu coull wooley and wright and otsuki et al utilized prospective designs to demonstrate temporality between maternal stress and depressive symptoms and wheeze and asthma morbidity mathildachiu et al analyzed maternal stress during the prenatal and postnatal period and then subsequent wheeze as reported by predominantly latina and african american mothers in boston ma analysis of 989 mothers revealed that children born to mothers with high stress in both pregnancy and the postpartum period were significantly more likely to have repeated wheeze compared with children of mothers reporting low stress in both periods the study followed children up to 2 years old and assumed that wheeze was a proxy for those that may be more likely to develop asthma or have compromised lung function otsuki et al analyzed data at baseline and 6 months regarding maternal depressive symptoms and child asthma morbidity this large sample of african american mothers of children with asthma demonstrated that maternal depressive symptoms at baseline predicted childrens asthma symptoms 6 months later it was shown that maternal depressive symptoms at baseline did not predict asthma ed visits at 6 months but the sample was recruited from the ed during high morbidity so these data may not be the best outcome measure discussion ses race and ethnicity and sex in general most international articles did not identify the race and ethnicity of their samples two of the four international articles did mention the ses of their sample because they were looking at social inequity as the main variable related to asthma the data from the united states also frequently accounted for ses it was operationalized in different ways northridge et al holt et al and keet et al used census data as a proxy for neighborhood ses some discussed if sample participants lived above or below the poverty line one was not able to get ses information due to the type of data they were using and several mentioned controlling for ses in analysis more than half of the studies from the united states sampled specifically african american andor puerto rican children due to the high prevalence of disease among this race and ethnicity several of the studies analyzed sex as it related to the outcome variable a few of them had small sample sizes so this stratification was not possible several of the stress studies sampling caregivers ended up with predominantly female caregivers as their sample because there was always a high percentage of caregivers who were female it was noted but data were never analyzed separately depending on the sex of the caregiver when analyzing neighborhoodlevel factors related to asthma in children it is important to account for unique contextual variables in analysis as mentioned above some of the reviewed articles did not address these key variables thus adding complexity to the interpretation of their variables method as mentioned in results section a common research design for these studies is cross sectional data were frequently obtained from baseline questionnaires of intervention studies or other types of secondary data these data can demonstrate correlations but the design prevents an inference of causation between variables they were also frequently gathered retrospectively and missing measurement of important variables the few prospective studies were helpful to analyze maternal mental health and wheezing and asthma morbidity prospective data add temporality to relationships thus strengthening the evidence but without an experimental study causation cannot be inferred the article by otsuki et al was also the only article to use path analysis to model complex relationships between several variables over time another frequent analytic technique was logarithmic regression which is appropriate given binary outcome data although logarithmic regression can test for confounding or effect modification it does not allow for modeling complex relationships like path analysis or mixed effects modeling another statistical trend was to dichotomize or group data originally gathered continuously this change in the level of statistical analysis from parametric to nonparametric weakens the strength of the evidence some authors noted this as a limitation but others accepted it as a requirement of their study due to nonnormal distributions of results sample selection also varied across studies as shown in the studies that sampled from medical records such as ed data primary care clinics medicaid data and urgent care call centers each type of medical data lends itself to a different sample and therefore results should be interpreted within that sample and are not generalizable to other samples several studies also sampled from schools that have implications depending on whether they are public versus private and the specific demographics of their students a few of the studies were explicit in their reasoning for sampling at a specific school but others neglected to present this information in their article the sampling methods differed depending on the purpose and pragmatic challenges of the study a critique of the methods for most of the airquality studies aside from the study by vieira et al was the lack of individualized data for each study participant the authors mentioned that using generalized air pollution data could inaccurately estimate the amount of exposure for an individual vieira et al used a unique and inexpensive method for attaching air filters to childrens backpacks and placing them around their homes for a more precise estimate of exposure asthma operationalization supplementary tables 16 also present how asthma is operationalized in each study some studies utilized healthcare data and international classification of diseases ninth revision or icd10 diagnosis of asthma or status asthmaticus several studies asked for parents to report whether or not their child had physiciandiagnosed asthma and their symptom frequency selfreport can be limiting if the caregiver cannot recall this diagnosis or frequency of symptoms this might happen if the child is in day care if the parent works long hours or if more than one child has asthma of note other healthcare providers nurse practitioners for example also frequently diagnose asthma some further stratified type of asthma by analyzing parent report of control severity and functional limitation another common theme was to look at ed visits for exacerbation several studies cited the naepp expert panel guidelines for how they measured asthma this resource from the national heart lung and blood institute of national institutes of health provides details on how to diagnose asthma severity assess persistence and control and provides a good universal method to operationalize this concept limitations this review has some limiting factors one possible limitation of the inclusion criteria is that articles were from 2010 to march 2016 although this time frame was justified considering frequent advances in the field some important articles might have been excluded research from 2010 to march 2016 appeared to build on previous research and allowed examination of results after dissemination of the naepp guidelines thus expanding the search time frame might not have added any significant articles there is also a chance that search terms related to neighborhoodlevel factors were not included in the search for this reason a university librarian was consulted to help design the search mesh terms as well as search terms were used to attempt to capture all of the required terms without being too specific but there is a chance that an important term was excluded another possible limitation was the use of the term urban in the inclusion criteria some of the articles in the review demonstrated that urban versus rural status may not be an important factor in asthma prevalence although this may be true the focus on this review was urban children and therefore it was a critical search term to be included implications for future research there are specific as well as general suggestions for future research in the above areas research into prevalence should be clear about what is being measured evidence presented argued that ses and not place drives asthma disparities however as the connection between ses and asthma was not the specific focus of this review analyzing more research in this area would help support or refute these findings fattore et al recommended continuing prevalence studies discriminating between phenotypes of asthma addressing the geographic and individual level and incorporating variables related to socioeconomics and urbanization on that note as it was suggested several times outdoor air pollution data need to use more individualized methods if these smallscale studies are done frequently in differing populations climates and geographic areas then a metaanalysis would help to draw conclusions about the overall risk for humans nishimura et al also reported that increased exposure to no 2 in the first year of life statistically significantly increased the odds of being diagnosed with asthma but the regions where study participants lived had no 2 levels lower than required by the environmental protection agency airquality standard this suggests the need for further research to specifically test no 2 levels current epa requirements may not be sufficient to protect the health of children and the epa standards might need to be increased the studies relating proximity to traffic and asthma also represent areas where public health indicated the requirement for changes in policy some policy changes are already underway currently the epa has a clean school bus program to reduce diesel exhaust from school buses they have developed tougher emission standards for new school buses and fund projects that reduce emissions from existing diesel engines one of the simplest ways to decrease emissions is to reduce idling in school parking lots where children are exposed this environmental health issue should be investigated further particularly in the school environment where school buses park emitting exhaust while waiting to load children school nurses should lead the charge to implement policies to reduce the exhaust exposure among school children several of the studies discussing indoor air suggest a multipronged approach to reducing home triggers there should be more research and interventions targeting the individual level whether that is smoking cessation or discussion of how to eliminate other triggers such as cockroaches and mold using integrated pest management practices as well as policy changes around housing pollution control and tobacco legislation northridge et al noted that because many of the houses are multiunit dwellings the families living inside them have limited control over the maintenance of the spaces and therefore limited ability to control triggers that affect their children therefore policy changes around housing for those on government assistance should take into account the health of children in determining what type of building meets their requirements the safety research demonstrated correlations between actual crime in neighborhoods perceived safety and asthma all three studies recommend additional research in this area to investigate the mechanisms behind the associations specific psychological measures related to violence exposure and control for potential confounders in the built environment more data are needed in this area to develop interventions to treat this problem regarding other sources of stress future research should continue to investigate the mechanisms of how chronic stress effects children over time the range of studies recommended looking at maternal depression starting in pregnancy evaluating interventions to treat the depression and further investigating the relationship between prenatal depression and future wheeze stress studies need to analyze psychological and physiological effects of stress while taking into account the other variables noted to affect asthma including the physical environment analyzing the current research in neighborhoodlevel factors affecting asthma clearly shows that the next step is multilevel research into factors associated with asthma as mentioned earlier mixed effects modeling would be the optimal statistical analysis due to complex relationships between many differing levels of variables ses for example is related to asthma and demonstrated by research in this review and previous research but it acts through different mediators such as housing to appropriately measure the relationship between ses and asthma several pathways need to be included in the model to examine multiple associations between these variables and therefore mixed effects modeling is the best statistical analysis to use with these types of data this review has analyzed the latest research on neighborhoodlevel factors that affect asthma in children living in urban environments the current research has demonstrated a gap in studies analyzing multiple levels of influence through advanced statistical methods these data can be used to better understand relationships of multiple factors as well as to influence health policy to improve the neighborhood environment for those children most affected by asthma implications for school nurse clinicians this review directly applies to school nurse clinicians who frequently monitor and care for children with asthma as healthcare providers working in the community where highrisk children reside they should be informed of the physical and social neighborhoodlevel factors that contribute to childhood asthma they have a unique opportunity to target educational and behavioral interventions as well as policy decisions toward these determinants of health this review also serves as a reminder to assess children with asthma holistically within the context of their physical and social neighborhood environment acknowledgments supplementary material refer to web version on pubmed central for supplementary material

asthma disproportionately affects children who are nonwhite and of low socioeconomic status one innovative approach to address these health disparities is to investigate the childs neighborhood environment and factors influencing asthma symptoms the purpose of this integrative review is to critique research investigating the relationships between neighborhoodlevel factors and asthma morbidity in urban children three literature databases were searched using the terms asthma child neighborhood and urban the articles included were organized into six themes within the larger domains of prevalence physical and social factors literature tables provide indepth analysis of each article and demonstrate a need for strengthening analysis methods the current research points to the necessity for a multilevel study to analyze neighborhoodlevel factors that are associated with increased asthma morbidity in urban children school nurse clinicians working within childrens neighborhoods are uniquely positioned to assess modifiable neighborhoodlevel determinants of health in caring for children with asthma

introduction schizophrenia is one of the most debilitating mental disorders for a significant portion of individuals who suffer from this disorder onset occurs in young adulthood arresting important social and educational development that is necessary for future successful labor force participation as a result schizophrenia is often associated with an eventual downward spiral ending in poverty and isolation 1 to avert this dismal future the focus on the first psychotic episode is becoming a priority for mental health care globally there is also growing evidence surrounding the low employment rates of people with fep employment rate estimates range from 13 to 55 3 4 5 reviews of the literature 36 note that there are a number of factors associated with employment along a number of dimensions 7 8 9 along with cognitive impairment and symptoms educational attainment family socioeconomic status social benefit structures and labour market conditions also potentially affect employment of young adults with first episode psychosis 3 there appears to be a complex mix of both individual and environmental factors linked to successful labour market participation although it is a multifaceted challenge there is increasing evidence for the effectiveness of interventions such as individual placement and support programs and the interventions of vocational specialists for this population 46 10 11 12 13 as such the international first episode vocational recovery group 14 released a consensus statement advocating for the right to education training and employment for young people enrolled in early intervention programs the need for the ifevr consensus statement is motivated by the mounting evidence that employment is often not a priority for providers who serve and support fep clients for example rinaldi and colleagues 6 note that few fep studies have focused on employment and education outcomes in fact employment is often discouraged by wellintentioned medical professionals and family 61015 in addition governments have been less than supportive of employment programs for people with mental illnesses 16 the purpose of this paper is to contribute to the literature about clients enrolled in first episode psychosis programs and psychosocial outcomes by examining the factors associated with paid employment among young adults who have experienced their first psychotic episode in this paper we consider the association of socioeconomic factors with employment background 21 characteristics of fep programs fep programs are designed to facilitate recovery from psychotic illnesses that first arise during youth most commonly schizophrenia and bipolar disorder and have historically been most associated with very high levels of disability 17 programs are designed to provide services to both clients and their families services include comprehensive diagnostic assessment treatment psychosocial supports as well as family education and support there is emphasis on a multidisciplinary team approach that integrates medical treatment counseling case management substance abuse treatment cognitiv behavioural therapy in addition to psychoeducation for families characteristics of the study fep programs the six fep programs included in this study were located in six regions throughout the province of ontario canada each program accepted youth who were experiencing their first episode or early stages of psychosis each early intervention program was developed to exclusively provide outpatient services five of the six fep programs reported that nearly threequarters of their clientele were males three of the fep programs engaged clients aged 14 to 35 years old while the remaining three programs limited access to people who were at least 16 years old two fep programs engaged transitional aged youth 16 to 23 years old all but one of the six programs were located in established community mental health agencies the exception was a communitybased program that was part of an acute care hospital the number of staff members in each of the six programs varied considerably ranging from three parttime positions to 10 fulltime equivalent positions each of the fep programs was developed in accordance with the guidelines and standards set forth by the international early psychosis association and other pioneers in the field 1720 fep programs and vocational outcomes there is evidence that compared to fep clients who receive usual care those enrolled in early intervention programs have significantly better educational and vocational outcomes 21 the relatively better vocational outcomes associated with fep programs may be associated with the shorter duration of untreated psychosis for these clients norman et al 22 found that shorter duration of untreated psychosis and greater social support were significantly associated with either more fulltime competitive work or fulltime enrollment in school at threeyear followup in their review rinaldi and colleagues 6 note that when compared to those enrolled in community mental health teams clients enrolled in fep program seem to experience a relatively smaller decline in employment and education they attribute this to a protective role played by fep programs major et al 5 observed a decrease in unemployment among fep clients after 12 months even in the absence of a vocational focus however there is less evidence regarding the longrun outcomes for fep programs versus usual care after 18 months the leo study did not find 21 a significant difference between clients in specialize programs versus those who were not after 5 years the opus trial did not find significant differences in employment between clients who were in fep versus usual care 23 work history and employment in the literature focusing on vocational outcomes in the adult population with severe and persistent mental disorders it has been observed that work history is one of the most consistent predictors of employment 24 however because of their stage in life young adults experiencing their first psychotic episode have not had the opportunity to accumulate labor force experience this can place fep clients at a disadvantage in finding paid employment educational attainment and employment the literature also indicates that educational attainment is significantly related to employment status people who have no high school diploma are more likely to be unemployed 2526 if young people have their education interrupted by their illness they can be faced with another disadvantage in finding employment disability benefits and employment there is also an association between receipt of disability benefits and unemployment 1027 the fear of losing disability benefits has been identified as one of the barriers to obtaining and maintaining employment for clients with severe mental illness 32428 as a result those who receive benefits often have poorer employment experiences thus there is accumulating evidence suggesting that in addition to treatment in fep programs socioeconomic factors such as educational attainment and income sources also play a role in employment outcomes this type of evidence can help to inform future directions for the enhancement of psychosocial programs in fep models interview participation criteria included willingness to be contacted by a study interviewer ability to understand and give informed consent to be interviewed and enrollment in one of the six participating fep programs data were collected using facetoface structured interviews in 2005 the participating fep programs referred 45 clients of the total 161 enrolled to be contacted by the study of these 33 were successfully interviewed they represented 20 of the total clients enrolled in 2006 106 of 302 early intervention clients were eligible to be contacted by the study there were 75 who were successfully interviewed they represented 25 of the total clients in 2007 162 of 370 early intervention clients were eligible to be contacted for interviews of these 107 were successfully interviewed these clients constituted 29 of the total early intervention clients enrolled in the six programs methods dependent variable an indicator variable was created to capture whether or not study participants had paid employment during the previous 12 months study participant characteristics indicator variables were created to capture whether the respondent was living with family sibling and spouse education gender age at time of interview receipt of provincial disability benefits as the primary income source and enrolled in school during the previous 12 months an indicator variable was also created to capture whether participants were enrolled in their fep program for more than a year three region indicator variables were created to capture the population density of the region in which the participant lived region 1 indicated that the participant resided in a region in which the population density was less than 100 peoplekm 2 region 2 indicated that the region of residence had a population density between 200 and 450 peoplekm 2 finally region 3 indicated that the region of residence had 3929 peoplekm 2 analyses descriptive statistics were used to test for significant differences in the characteristics of people who had paid employment during the previous 12 months chisquare and fisher exact tests were used to test the differences between the categorical variables logistic regression analysis was used to identify the factors associated with having had paid employment the most parsimonious model was used based on the factors described in the literature that are associated with employment for people with serious mental illnesses results about 61 of the sample had paid employment during the previous 12 months in table 1 compared to those who did not have employment among those who had employment there was a significantly greater proportion of people with at least a high school diploma 621 p 0013 and a significantly lower proportion who identified provincial disability benefits as their primary income source 2331 p 00001 table 2 contains the results of the logistic regression analysis the regression model produced 832 concordant and 166 discordant predicted probabilities and observed responses the hosmer and lemeshow goodnessoffit test the results suggest that the odds of having been employed in the past 12 months are significantly lower for people who have not completed high school and for clients who identified provincial disability benefits as their primary income source there is also a significant positive association between employment and being enrolled in the fep program for more than a year discussion in our sample 61 of respondents had paid employment during the previous 12 months this proportion is greater than that reported in the literature for example singh et al 29 observed that among the cohort of fep clients the past year employment rate was 313 similarly norman et al 22 reported employment rates of 44 while turner et al 30 reported an employment rate of 46 we also observed a significant difference between the educational attainment of those who were employed and those who were not educational attainment is a significant concern among fep clients 1011 norman et al 22 observed that 46 of clients in their sample had attained less than a high school education at time of program entry assessing the threeyear outcomes of fep clients singh et al 29 reported that 536 participants had not attained their secondary education certificates our regression results underscore one of the major problems associated with the lack of educational attainment educational attainment is associated with the ability to attain employment our results indicate that those who did not complete high school were less likely to be employed this association corroborates what has been reported in literature 531 these results echo the need highlighted by cook 32 in her review of the literature that a significant proportion of people with serious and persistent mental disorders have their education interrupted by the onset of mental disorders that is people with severe mental illness are likely to have lower educational attainment than their counterparts who have not experienced a mental disorder in turn this places them at a disadvantage to successfully compete in the labor market one of the arguments for early labour market participation is because of its effect on future employment in their longitudinal study of people with severe mental illness bush and colleagues 33 found that those who were employed at the beginning of a 10year period were more likely to remain steadily employed throughout in contrast those who were not employed at the beginning were more likely to remain unemployed throughout the period it should be noted that bush et al 33 looked at a group of people with severe mental illness it will be important for future studies to examine effects of early employment in the fep population our regression results also indicate that enrollment in a fep program for more than a year is significantly associated with employment that is clients who have been enrolled in a fep program for more than a year are three times more likely to have been employed during the year than clients who were enrolled for less than a year this is a trend that has been reported in the literature after a threeyear followup of fep clients singh et al 29 saw past 12month employment rates increase from 253 at intake to 313 at followup this could be reflective of the protective effect provided by fep programs 6 none of the fep programs that participated in this study had vocational specialists this suggests that vocational outcomes were not necessarily one of the main foci of the programs yet there was improvement in vocational outcomes at the same time compared to fep programs without a vocational focus those with ips programs and vocational specialists have reported relatively better vocational outcomes 46 10 11 12 13 thus although fep programs appear to provide a protective effect there is evidence that with a vocational focus they can be more than protective finally these results suggest that enrolment in a public disability benefit program also decreases the likelihood of being employed our results may reflect the fact that the people who receive disability benefits are too ill to be employed alternatively the results could also be related to incentives associated with receipt of disability benefits in her review of the literature cook 32 points out that few people leave public disability benefits due to employment our finding corroborates findings that disability benefits are inversely associated with employment rates that is as disability benefit levels decrease employment rates increase and the use of unemployment benefits decreases 34 this suggests that publicly funded benefits may inadvertently create disincentives to work for example people might perceive that they will be penalized for working in ontario the province in which this study was conducted when people are employed and also receive benefits from the provincial disability support program the program calculates half of the clients net monthly earnings deducts part or all of hisher monthly child care and disabilityrelated work costs and subtracts this amount from the clients total income support 35 although in theory the earned income should substitute for income support people who receive disability benefits and who work will see their disability income support decreased but not necessarily associate the decrease with their pay check at the same time the provincial disability benefit program also seeks to create an incentive for paid employment by offering clients an additional monthly 100 workrelated benefit 35 if they are employed in a paid position yet the incentive to work may not be sufficient if people are unsure about their longterm ability to maintain employment there may still be a fear that if they lose their disability benefits they will be without a safety net if they lose their jobs 36 37 38 it will be important for future research to explore the mechanisms of designing safety nets that ensure that when people are unable to work they will have income while encouraging employment when it is possible it will also be a challenge for fep programs to design programs that help clients to receive training for jobs in business sectors in which they can earn a living wage 32 and that can accommodate episodes of illness so clients can accumulate successful employment histories limitations the results of this study should be considered in the light of its limitations one of its major limitations relates to its generalizability the clients who participated in these interviews may not necessarily be representative of all clients in fep programs given that only clients who were able to provide informed consent were asked to participate those who were the most sick would have been omitted thus our results are a conservative estimate of the proportion who were unemployed if the most severely ill were more likely to be unemployed likewise the regression results reflect associations for less severely ill people and may differ for the more severely ill however the latter group may also be less likely to be seeking employment in addition the sample only included people who were enrolled in early intervention for psychosis programs results may be different for people experiencing their first psychotic episode who do not receive services from a program specializing in first psychotic episode cases conclusions there is little in the literature focusing on employment in the fep population examining the contribution of socioeconomic factors to employment status the results of our analyses indicate that receipt of public disability benefits and high school education are important factors related to employment they also suggest that if paid employment is to be used as one measure of psychosocial outcomes it is an outcome that may require crosssector collaboration among health education and social services

schizophrenia is one of the most debilitating mental disorders for a significant portion of individuals who suffer from this disorder onset occurs in young adulthood arresting important social and educational development that is necessary for future successful labor force participation the purpose of this paper is to contribute to the literature about clients enrolled in first episode psychosis programs and psychosocial outcomes by examining the factors associated with paid employment among young adults who have experienced their first psychotic episodes in this paper we consider the association of socioeconomic factors to employment our results suggest that in addition to treatment socioeconomic factors such as receipt of public disability benefits and educational attainment are associated with employment status these results can help to inform future directions for the enhancement of psychosocial programs in fep models to promote paid employment

background approximately 68000 indigenous farmworkers from mexico currently live in oregon national data suggest that about 20 of farmworkers are women but there are no reliable estimates of the number of female indigenous mexican farmworkers indigenous farmworker women often do not speak english or spanish but one of many indigenous languages like zapotec mixtec and triqui which are common in villages in southern and western mexico in recent years female farmworkers in oregons willamette valley have reported sexual harassment and sexual assaults at the workplace to local community service providers and farmworker advocates in april 2009 the equal employment opportunity commission and the oregon law center filed a sexual harassment lawsuit against oregons willamette tree wholesale company in response to complaints of sexual harassment and rape eeoc filed the lawsuit in oregon after successful prosecution of a sexual harassment case against a farm in california that resulted in a large settlement for the latino woman farmworker the verdict was reaffirmed on appeal in 2008 1a review of the scientific literature on sexual harassment of indigenous mexican farmworker women revealed no results a wider search on sexual harassment of farmworkers yielded a 2010 qualitative study by waugh on sexual harassment among immigrant nonindigenous mexican farmworker women highlighted a lack of workplace protections against sexual harassment women reported engaging in tactics including ignoring or even pretending to consent to harassment worried that reporting the behavior would lead to losing their jobs a broader search included important work by krieger et al which demonstrated high prevalence of sexual harassment among low income workers and places it in a continuum of harassment and other structural sources of oppression that can result in health problems like high blood pressure because of this lack of information about the problem and strategies for prevention and intervention community and academic partners collaborated to implement a communityacademic participatory research study to investigate the experience of sexual harassment among indigenous mexican farmworker women in the willamette valley of oregon2 methods communitybased participatory research the study methods follow the goals of communitybased participatory research where the research team includes community members who are integral to all aspects of the research process community and organization members and researchers engaged in a process that was designed to ensure shared decisionmaking and mutual ownership of the research procedures and results indigenous farmworkers were already permanent members of partner organizations working as community educators they served an essential role in this study by participating in all planning activities of the study and by moderating focus groups they also participated in data analysis and interpretation data collection interested women were invited to participate in focus group interviews that were held at nonworkplace sites in the area and occurred in the evening or other nonworking hours confidentiality was protected when language was not a match for participants and the facilitator interpreters in additional indigenous languages joined the group interpreters and group leaders were longterm members of the study team and many were indigenous former farmworkers themselves each focus group was audiorecorded and transcribed into spanish from the indigenous language if the focus group discussion was not in spanish then all spanish transcripts were translated into english participants received 25 grocery cards for participation institutional review board approval was given by oregon health science university university of pennsylvania and johns hopkins university measures table 1 shows questions moderators used to lead focus groups corresponding to the aims of the research analysis the analysis used techniques of open and theoretical coding from grounded theory analysis the group of collaborators reviewed all transcripts individually and through multiple discussions the group developed themes and interpretations in a collaborative and iterative effort moderators did not regularly poll participants in answering questions since group members were promised anonymity and were thus not necessarily identified in transcripts instead moderators encouraged open discussion in response to interview questions as a result it was not possible to code individual responses and produce an exact number of responses to questions results there were seven focus groups five were held in 2006 and 2 in 2008 49 women participated in the 2006 groups 38 indigenous and 11 latina there were 10 participants in the 2008 groups 7 indigenous and 3 latina table 2 shows details of group composition with the languages spoken of the 49 participants 20 women required translation from an indigenous language to spanish themes knowledge about workplace policies relating to sexual harassment now if we get hurt cut ourselves we have to let somebody know so they can dress the wound and not get blood in the fruit we have to report that but it doesnt say anything about sexual harassment no all the women reported receiving some kind of supervision in the workplace usually by spanishspeaking foremen foremen were usually former farmworkers who were trained to oversee workers directly at work the women usually reported to a foreman although in the absence of such a person they would report directly to the supervisor of the field or workplace women reported receiving training about safety and other workplace policies and many spoke about the workplaces greater concern for the farm product than for their own welfare the trainings were conducted in spanish none occurred in any indigenous language workplace policies sexual harassment where i work sexual harassment is never explained the only rules we hear have to do with the chores that we have to do but they have never explained anything about sexual harassment women in the focus groups sometimes reported sexual harassment training but most of the women in the groups had not heard of any training one woman reported an anonymous reporting system using papers put into a closed box where women could name harassers another woman saw a video in spanish explaining company policy about reporting of sexual harassment others reported bosses encouraging them to report sexual harassment to them directly not to foremen perhaps because they viewed foremen as potential offenders experience and witnessing of sexual harassment of indigenous women farmworkers the foreman does not treat us all the same he notices a few younger women and sometimes may force them or grab them as i said it hasnt happened to me but ive seen it happening those who give into it get an easier job and i get a harder one because i dont give into it many women had seen sexual harassment and a common manifestation was that of supervisors picking a favorite woman and giving her lighter work women expressed feelings of resentment and anger both towards the supervisors and to the women who play along the women reported feeling bad and that it was unfair that we have to do the rest while focus group participants spoke with frustration about the women who really dont work very hard and like to chat with the men they also spoke about women who for fear of losing their jobs participate and pay attention and chat using dirty words fear and intimidation surrounded sexual harassment that women officially complained about when it comes to supporting each other they are afraid despite this sometimes the women provided glimpses of hope here one described support from her manager despite death threats she had received what happens is that the new manager is a good person he did not have to believe us because he saw it and kept it confidential so he knew how to handle it because he watched from a distance and that man had no way of denying it later they said they were going to kill us once they were to find out who said it i said it did not matter and i was going to speak up anyway that he was going to hit her i told her she had to talk to the manager because you cant keep silent backed by a manager who responded promptly and dealt with harassment appropriately the woman who witnessed harassment spoke up and encouraged another woman to report abuse other women identified single women with children as a particular target for sexual harassment while not a consistent finding throughout all of the groups a few women spoke about single mothers vulnerability because of their need to stay at a job despite harassment and aggression they experience there in the group of triqui women moderators asked whether or not the women had experienced sexual harassment and received resounding nos when moderators asked for womens specific experiences the women spoke more moderator lets say that men are saying vulgarities what do you think about that sometimes we feel that we cant feel comfortable at work because they are talking about us all we tell our husbands is that those people sure use dirty language and continue with our work so we dont get behind they talk like that but we keep working what we hear they are telling us is that we are ugly no we dont know any no when the moderators used the term sexual harassment women did not seem to know what it was when other terms like vulgarities were used triqui women could identify examples indirect effects of sexual harassment voice 4 yes they say something like wanting to get better hours and going with the foreman i only hear people talking i dont know how that works one can talk with more coworkers people can help most women reported that they had experienced or witnessed sexual harassment women reported damage to goodwill in the workplace community even when they had no direct experience of harassment as one woman complained the hard work is for those other ones who are ugly then he started doing it to me too and i went to tell the manager and he wanted to fix things in private i never found out because i was pregnant and i left they did not listen to us they did not do anything and i think that man is still there harassment direct experience moderator so at the end you had to leave so that you would not have to put up with the situation voice 12 yes i left women described situations of unwanted sexual advances and even menacing behavior as seen in the passages above some women recounted stories of assertive behavior that relieved the abuse like the woman in the first quotation captioned above more frequent however was the kind of story in the second quotation where women who experienced harassment often faced disbelief and inaction leaving the worksite was a common response aim 3 attitudes about increased risk of sexual harassment of indigenous mexican women farmworkers moderator do you believe it is worse for indigenous women yes because its like i tell you because of how they see us because we dont speak spanish well or they may think that they can say things to us and we are not going to understand and then it inaudible easier so inaudible obey or sometimes just so they can work right for the money or out of necessity i think i dont see it but i have heard we see it sometimes because we cant speak spanish well like she says or we just arrived and dont know or because we dont know english we cant speak right no other way i have to obey and if they fire me well they fire me in every group the consensus held that indigenous women who did not speak spanish were more vulnerable to sexual harassment partly because of language women also mentioned that indigenous women are less educated leading to vulnerability they dont know how to read and write and barely recognize money participants linked sexual harassment to threats of losing or needing to leave farm jobs they often referred to the double burden of language isolation and a desperate need to work in these data the two contributed to indigenous farmworker womens sense of increased vulnerability to sexual harassment discussion in these focus groups farmworker women reported widespread awareness of sexual harassment behaviors that they might not label as sexual harassment they did however recognize the behaviors and saw the deleterious effects of harassment on their lives when women experienced harassment directly it caused distress and disruption when they witnessed it it could lead to workplace conflicts in general women reported that these experiences made the workplace feel unsafe and unfair while there was evidence that some workplaces provided sexual harassment training many women reported that they had no idea how to deal with sexual harassment at work and the company did not inform them what to do women in these groups said that the vegetable or fruit product was more important than their own safety and welfare at the workplace women felt discouraged from speaking up because they did not know with whom to speak or report regarding sexual harassment or did not think they would be believed language isolation and poverty were consistent themes in the farm work setting women who did not speak spanish or english were more vulnerable to harassment sexual and otherwise poverty was identified as a key reason why women tolerated sexual harassment in order to better their situation at work farmworkers social networks and traditional societal norms may have also isolated women who experienced harassment these data demonstrate that social and economic pressures interacted with social networks to amplify the impact of sexual harassment in the agricultural workplace limitations focus groups by their very nature are designed to solicit general attitudes and opinions of participants but in this study do not provide quantitative information about these attitudes and opinions this is as expected for focus group studies rigor in this research is assured by transparency of analysis and confirmation of findings with community partners and review of developing codes with partners and qualitative experts within the advisory group in addition purposive sampling as employed here ensured that the target community is sampled because this is not probability sampling results cannot be generalized to the entire community of indigenous farmworker women either locally or nationally new contribution to the literaturethis research demonstrates the strengths of communitybased participatory research to illuminate a problem facing a vulnerable and hardtoreach community in particular it shows the importance of using the right questions when querying women about sexual harassment women in this study knew what sexual harassment was but often did not use these words to describe it this is essential information for planning services and future research on this topic with this population this study has implications for practice and policy clinicians and service providers need to be aware of and plan for communication issues arising from language and social dynamics in the workplace that limit conversation about sexual harassment among indigenous farmworkers policy should be implemented to create provisions for requiring appropriate training about sexual harassment for farmworkers in their own languages with sensitivity towards womens fears of reporting or even acknowledging harassment workplace protections against sexual harassment and abuse must be monitored by law enforcement and intervention for complaints should be swift and consistent conclusion to our knowledge this study is first study of indigenous mexican farmworker womens experiences of workplace sexual harassment and sexual assault it demonstrates that women are negatively affected by sexual harassment and assault even if it does not happen directly to them indigenous women and single women with children may be particularly vulnerable in these interviews women said repeatedly that they want and need to work this study and future studies will provide evidence to inform the creation of interventions and services to benefit indigenous women farmworkers but also the entire farmworker community as community partners reach out to involve all partners in the farmworker community including farm owners health service providers farmworker advocates and farmworkers themselves their continuing partnership will contribute to preventing future sexual harassment and assault

in order to examine the experiences of sexual harassment and sexual assault among indigenous and nonindigenous mexican immigrant farmworkers in oregons willamette valley a communityacademic participatory research partnership initiated a study which included focus groups conducted and analyzed by skilled practitioners and researchers the themes that emerged from the focus groups included direct and indirect effects of sexual harassment and sexual assault on women and risk factors associated with the farmworker workplace environment and the increased vulnerability of nonspanishspeaking indigenous women due to low social status poverty cultural and linguistic issues and isolation recommendations for prevention and improved services for vulnerable women will be discussed as well as limitations and future research directions

introduction basque is a low resourced language spoken by 284 and understood by 448 of the population of the basque country thanks to its official status it is a language with presence in the regional public administration education system and in some news media thus in eitb the basque public radio and television broadcaster it is possible to find radio and television channels in which all content is entirely broadcasted in basque furthermore there are other independent media such as berria argia and hamaikatb in which basque is the vehicular language still the presence of basque in traditional television and news media remains quite low particularly when compared with those available for spanish in this context the increasingly used social networks such as twitter are of particular importance for a low resourced language such as basque thus it is possible to find a strong and active community of basque speakers in twitter which generates for a low resourced language a large amount of textual content written on basque furthermore as users create both explicit and implicit relations and communities this data is useful to do social research using methods that may complement those traditionally used in sociology following this a promising and relatively new avenue of research in social and demographic analysis combines the study of social structures created in media such as twitter with the automatic analysis of texts via nlp for example previous work has focused on twitter to study the spread of rumours the detection of political stance or hate speech in this paper we will take into account both social and linguistic aspects in order to perform demographic analysis by processing a large amount of tweets in basque language the study of demographic characteristics and social relationships will be approached by applying machine learning and modern deeplearning nlp techniques combining social sciences with automatic text processing more specifically our main objective is to combine demographic inference and social analysis in order to detect young basque twitter users and to identify the communities that arise from their relationships or shared content by basque twitter users we refer to those that write at least 20 of their tweets in basque this social and demographic analysis will be entirely based on the automatically collected tweets using nlp to convert unstructured textual information into interpretable knowledge current work substantially improves and extends the preliminary experimental work presented in these improvements have led to a number of contributions first and taking as a starting point the heldugazte corpus containing 6m tweets in basque language we devise a whole new methodology to classify users by lifestage this new method generates a new dataset heldugazteage containing 80k tweets semiautomatically annotated at youngadult level second we explore the application of modern pretrained large multilingual and monolingual models in order to identify young and adult users third we perform a qualitative analysis comparing human performance vs life stage classifiers for classifying basque users into the young or adult categories four we use recently developed deep learning techniques for community detection achieving better detection and visualization of the communities as well as providing information of the relations among them we believe that the methodology presented in this paper might be of interest for other nlp tasks and other types of social and demographic studies finally we publicly distribute every resource to facilitate further research for low resourced languages such as basque1 the rest of the paper is structured as follows in the next section we describe related work in computational sociolinguistics and nlp in section 3 we present our method to build the heldugazteage annotated dataset to train classifiers for life stage detection section 4 presents systems used to train classifiers for life stage detection these classifiers are evaluated in section 5 and applied to perform social network analysis in section 6 we finish with some concluding remarks and future work context and related work social media offers the opportunity to express beliefs sentiments or opinions in a variety of formats including text image audio and video social media publications express conscious andor subconscious manifestations of our social emotional and rational condition previous work in sociolinguistics argues that our writing style can even be a reflection of demographic characteristics considering the fact that language is a social phenomenon and thanks to the evergrowing capacity in the nlp field to collect and process largescale amounts of texts computational sociolinguistics is becoming increasingly popular the widespread use of twitter has in fact benefited such approaches as it is possible now to mine large amounts of texts also for less resourced languages twitter is widely used in nlp for tasks such as mining opinions about specific products or topics detecting political stance and hate speech or for basic tasks such as pos tagging named entity recognition normalization and language identification nlp techniques specifically adapted for twitter have also been used to infer demographic characteristics such as gender age or location moreover relationships style shifting and community dynamics can also be inferred from language analysis of particular interest to us is the body of work performed with the objective of age or life stage detection for twitter users previous works usually generate their own manually annotated datasets covering languages such as dutch english or spanish for a user range between 300 and 3000 the best performing systems are those that model life stage classification as a binary or ternary task in relation to the study of the social relationships that are generated within the network closer to us are those studies that have aimed to identify communities of users based on their retweets among these one can find studies about political polarization political affiliation detection or even studies about identifying communities in movements for independence finally there are different research works investigating the use of low resourced languages within social networks an investigation about welsh speakers and twitter shows that speakers of this language are also active in social media additionally there is another work that extracts and analyzes more than 80k tweets in irish to do content sentiment and network analysis it is also interesting a study combining welsh irish and frisian to investigate the use of hashtags across 3000 different tweets all these works show the potentiality of twitter to provide text data even for low resourced languages giving the chance to find and study a huge variety of languages and cultures 3 heldugazteage a new dataset for life stage classification in this section we propose a new methodology to semiautomatically obtain labeled data to develop life stage classifiers the result is a new dataset for to train classifiers for life stage detection namely the heldugazteage corpus the first step to identify online communities of young basque speakers is collecting the data as a starting point we will use the basque corpus heldugazte which consists of 6m basque tweets from 8000 users collected in may 20182 in this collection the last 3200 tweets from each user were retrieved including personal tweets and retweets the heldugazte corpus will be used to semiautomatically generate a labeled subset of the corpus 80k tweets to train classifiers to detect youngadult users the obtained classifiers will then be applied to the rest of the heldugazte corpus to obtain a large number of tweets written by young users this data will be used to detect the communities between young users in order to obtain a youngadult classifier we need some labeled data for training and evaluation however labeling users tweets by life stage is a difficult task due to two main reasons users age hardly ever appear in the tweets metadata and manually annotating tweets by life stage is far from being trivial examples below illustrate the difficulty of manually labeling individual tweets by life stage and without any additional context zarauzko triatloian izena ematea lortu gabe motibazioa falta i have not managed to sign up for the zarautz triathlon i am unmotivated a zer nolako eguraldi kaxkarra ez al du gelditu behar edo what a bad weather shouldnt stop or what 5 mila euro bideo kamera eta telefono mugikor bat eroan dituzte lapurrek 5000 euros a video camera and a cell phone were taken away by the burglars in order to overcome this problem previous sociolinguistic work has argued that writing style could be associated to authors life stage assuming that young peoples style is more informal than that of adults based on these previous works fernandez de landa et al trained various classifiers to distinguish between formal and informal writing style in tweets every tweet for every user in the heldugazte corpus was automatically tagged projecting from formalinformal to youngadult classification depending on the concentration of formalinformal tweets in each users timeline the problem with this procedure was to objectively define a threshold for the proportion of formalinformal tweets required to classify a user as young or adult the proposed adhoc solution establishing that if 45 of the tweets were labelled informal then the timeline was to be classified as young was far from ideal figure 1 ranking users by proportion of formal and informal tweets in this paper we propose a new method to objectively and semiautomatically obtain the labeled data required to train youngadult classifiers the procedure is illustrated in figure 1 first we automatically tagged the 6m tweets in the heldugazte corpus using the formalinformal classifiers developed by fernandez de landa et al second we ranked users according to the proportion of informal tweets in their timeline the top users would contain mostly informal tweets whereas the users at the bottom of the rank would consist mostly of formal tweets third a manual inspection of 100 timelines established that it was feasible to manually annotate users at both ends of the ranking as youngadult in this step it was particularly helpful to perform the annotation at userlevel because a full timeline provides more contextual information to characterize a specific user fourth we took the 500 users at the top of the ranking to be young users and the 500 at the bottom to be adult as a result following this new method we obtain a set of 1000 users classified as adultyoung based on the initial formalinformal manual categorization of 1000 tweets provided by fernandez de landa et al the final step consisted of randomly sampling a number of tweets per user the idea was to vary the number of tweets and topics available per user providing a sample general enough to train robust youngadult classifiers with this objective in mind we picked 100 random tweets per user assigned to each of them the label attributed to the user as it is shown in here we present the two main systems used for life stage detection an offtheshelf system based on linear classification and clustering features and a deep learning approach based on learning contextual vectorbased word representations and the transformer architecture previous approaches address life stage detection as a supervised text classification task this means that classifiers will learn from annotated data that a given tweet is written by a young or an adult person an example of the dataset annotations used for training can be seen in table 2 the heldugazteage dataset developed in the previous section will therefore be used to train three different text classifiers ixa pipes multilingual bert and berteus label content adult taldeak mikel laboaren lanean oinarritu du bere hurrengo diskoa the band has based their next album on the work of mikel laboa adult gure herriko ateak zabalik dituzu the doors of our town are opened young buaa q follaa eun guztia eon zea ikasi ordez jolasateeenn jajaja how lucky you have been all day playing instead of studying hahaha young batzutan ze gutxi aguantatze zaituten sometimes i cant stand you table 2 examples taken from the heldugazteage dataset ixa pipes ixa pipes is a set of tools with a multilingual approach across nlp tasks this system has been successfully used in several sequence labelling tasks for various languages including named entity recognition and opinion target extraction the general objective of ixa pipes is to provide a general semisupervised approach that performs well across languages and tasks this approach consists of two different components in the first one a set of linguistically shallow features are extracted from the local context these features are based on orthographic and ngrams and characterbased information to capture multiword patterns and prefixes and suffixes of words which has proven useful to work with an agglutinative language such as basque the second semisupervised component injects external knowledge previously obtained from the unsupervised induction of clustering models over large amounts of texts this component provides several benefits first it generates denser document representations given that a document is represented with respect to the number of dimensions specified in the obtained clustering model second by training the clustering models on source data from different domains and text genres it is possible to inject domainspecific knowledge into the system finally ixa pipes includes the possibility of including features from three types of clustering models which helps to represent domainspecific information via complementary semantically induced knowledge more details can be found in for this particular work we train the ixa pipes document classifier using the same experimental setup used in transformer models as for many other nlp tasks current best performing systems for text classification are large pretrained language models which allow to build rich representations of text based on contextual word embeddings deep learning methods in nlp represent words as continuous vectors on a low dimensional space called word embeddings the first approaches generated static word embeddings namely they provided a unique vectorbased representation for a given word independently of the context in which the word occurs this means that polysemy cannot be represented thus if we consider the word bank static word embedding approaches will generate only one vector representation even though such word may have different senses namely financial institutionbench etc in order to address this problem contextual word embeddings were proposed the idea is to be able to generate word representations according to the context in which the word occurs currently there are many approaches to generate such contextual word representations but we will focus on those that have had a direct impact in text classification namely the models based on the transformer architecture and of which bert is perhaps the most popular example there are several multilingual versions of these models thus the multilingual version of bert was trained for 104 languages more recently xlmroberta distributes a multilingual model which contains 100 languages both include basque among the languages these multilingual models perform very well in tasks involving highresourced languages such as english or spanish but their performance drops when applied to lowresourced languages although this is still an open issue a number of reasons can be found in the literature first each language has to share the quota of substrings and parameters with the rest of the languages represented in the pretrained multilingual model as the quota of substrings partially depends on corpus size this means that larger languages such as english or spanish are better represented than lower resourced languages such as basque moreover multilingual models also seem to behave better for structurally similar languages berteus is a language model trained in basque language following berts architecture they show that training a monolingual basque bert model obtains much better results than the multilingual versions in this paper we will compare the performance of multilingual bert and berteus for life stage detection using the same hyperparameters as in agerri et al life stage detection in this section we will use the heldugazteage corpus to train the classifiers previously described the best classifier will then be applied to the whole heldugazte dataset in order to obtain a youngadult classification of the 8k basque tweet users contained in the corpus additionally an analysis of the results is performed to better understand the quality of the semiautomatically obtained annotations experimental results it should be noted that in contrast to our previous work the heldugazteage corpus allows us to directly classify users as youngadult without having to perform the formalinformal step we perform minimal preprocessing on the tweets we remove urls hashtags and usernames leaving labeltweet pairs such as the examples shown in table 2 this procedure has proven to be useful in previous text classification works with tweets table 3 reports the results obtained using the three systems described in section 4 the high scores show that our semiautomatic method to obtain youngadult training data produces good quality annotations furthermore the differences between the systems are not that large although berteus is consistently the best scoring model system accuracy in order to further test the robustness of our semiautomatic method described in section 3 we decided to manually annotate 200 randomly selected tweets two human annotators labeled the 200 tweets and we calculated an agreement between the annotators of 078 and a kappa score of 055 showing a moderate agreement between them furthermore the accuracy of the two annotators are 0795 and 0775 respectively when comparing these scores with the results reported in table 3 it is clear that manually annotating youngadult at tweet level is a very difficult task these results also show the effectiveness of our method to obtain the heldugazteage corpus in the rest of this paper we will use the berteus finetuned model to automatically annotate the whole heldugazte corpus it should be noted that the classifier works at tweet level this means that once every tweet is automatically annotated we still need to decide whether each of the user timelines corresponds to a young or adult user based on the number of individual tweets classified as youngadult labeling the large corpus once the tweet classifier is ready to use we apply the following strategy to automatically annotate the tweets in the heldugazte corpus first we assign a discrete young or adult label to each tweet we then obtain a single score by averaging the number of the youngadult classified tweets of each users timeline the last step is to decide whether a given timeline corresponds to a young or adult user based on the score obtained from the classification of the individual tweets in order to avoid establishing an adhoc value as a threshold we introduce a third class for classification in other words a new synthetic category underdetermined is created thus transforming a binary task into a ternary one based on the new ternary task two thresholds are used instead of one located at 60 and 40 of the number of tweets annotated as young in each timeline thus if the proportion of labels or the average probability is over 60 the user will be defined as a young user on the other hand if those values are lower than 40 the timeline will be considered to be from an adult user finally if the value is between 40 and 60 we will consider the timeline to be underdetermined meaning that we do not have enough evidence to decide the life stage of the user adding the underdetermined class has the benefit of avoiding to commit ourselves to classify difficult cases as youngadult we are also interested in comparing the distribution of youngadult users obtained using the described procedure with those that are obtained using our previous method as a reminder in our previous work each tweet is classified as formalinformal and then based on the number of informal tweets we decide whether the user is young or adult however for a fair comparison we will adapt it to use two thresholds and three classes as it has been described above adult underdetermined young previous system 5213 911 962 new system 4472 980 1635 table 4 shows the number of timelines classified as youngadult or underdetermined using our new and old methods it can be seen that the main difference corresponds to the quantity of young users obtained by each of the methods in the next subsection we further look into this issue comparison of methods in this section we look at those variations in the automatic annotations assigned by the old method with respect to the one presented in this paper table 5 shows the differences of classifying the timelines using the old with respect to the the new method after a superficial look to the variations it can be seen that 2179 of the labels were differently labeled from previous to new system a substantial difference besides one of the most significant variations is the increase in the amount of users labeled as young figure 2 two of the three most important variations marked with an asterisk refer to the transfer of timelines to the young class it is also important the transfer from adult to underdetermined taking a deeper look into these specific cases we manually inspected some randomly chosen timelines to see if these transfers are actually true positives or whether they are misclassifications the objective of this comparison was to study the transfer of classifications across categories when using the new classification method more specifically we analyzed a random sample of 10 of the cases for each variation below we can see example tweets from three different users with respect to user2 and user3 they show that our new method as opposed to the old one actually classifies correctly their timelines thus by looking at their tweets it seems that the users are indeed young based on the writing style but also because the tweets talk about exams an activity usually related to young people the case of user1 is more contentious as it seems too difficult to establish the life stage of the user based on those examples which is why the underdetermined classification does not seem misplaced • adult to underdetermined variation example user1 tweet 1a a zer nolako eguraldi kaxkarra ez al du gelditu behar edo what a bad weather shouldnt stop or what tweet 1b gu erakusteko prest etorri daitezela lasai eskuzabalik hartuko ditugu eta we are ready to show it we will wait for them with open arms • adult to young variation example user2 tweet 2a horrelakoekin gustua ta guzti hartzen zaio ikasteari with this you take pleasure in learning tweet 2b buenobueno ba ikasiko dut gehio jaja ta ikusikozu gaindituko dutt jaja weeeell weeeell ill learn more haha and youll see if i can pass the exam haha • underdetermined to young variation example user3 tweet 3a ze txupi txatxi no me da la nota awesome i dont get to pass tweet 3b ai naiz rayatzen pixkat asko con la mierda de la uni oh im going crazy a little bit with university shit figure 2 depicts the variations in the classification from the using the old method with respect to the new one the manual inspection performed would indicate that such variations are in fact correct in other words it would seem that the method introduced in sections 4 and 42 to develop classifiers to automatically annotate users in the heldugazte corpus as youngadultunderdetermined produce better results in this section we will study the relations that appear between basque young twitter users the starting point will be the retweets of messages written in basque by the 1635 users classified as young in the previous section we select the retweets because they are the type of interactions between users that can show correlations better than other interactions such as mentions specifically from the 418903 retweets of the 1635 young users we extracted 24837 nodes and 148304 edges or connections the nodes correspond to the users doing the retweets but also different users receiving them on the other hand the edges represent if a source user has retweeted one or more times another target user representing the connections in the graph once the retweets are gathered we proceed to transform the unstructured data into a readable graph first we created a giant graph using the data from each user to build the graph two features extracted from each retweet were used the retweeter and the user retweeted after extracting the data the visualization of the graph was created using the gephi program second we gave the network a spatial structure by using the forceatlas2 algorithm ordering the nodes according to the established relations this algorithm displays a spatialization process giving a readable shape to a network with the aim of transforming the network into a map this technique simulates a physical system in order to spatialize a network as a result of this process those nodes that are unrelated repulse each other while related ones will attract each other the algorithm can turn structural proximities into visual proximities allowing the analysis of this particular type of data based on interactions thus the relations can be displayed in a graph after creating the graph we focused on two different aspects first we identified the most important nodes of the network to establish which users are the most influential in a second step we uncovered the implicit communities of basque users splitting the huge graph into more readable subgroups that allowed us to infer the communities of young people basque influencers among young users the most retweeted users of the graph can reveal important characteristics of the investigated sample the most important nodes show which users are the leaders for our sample thus in table 6 we can see the top 15 most retweeted users based on two different classifications on the one hand there are those users with most overall retweets on the other hand we have the users that have been retweeted by different young users focusing on how many different users have retweeted these users these two rankings illustrate which users are actually the most influential between young basque twitter users by looking at the obtained rankings we can see that at the top there are accounts related to basque media berria argia naiz info topatu eus hamaikatb euskaltelebista and leakohitza and basque journalists larbelaitz axierl boligorria and ibroki we attribute this to the fact that those people perform important roles in the creation and distribution of basque language content in the web after a manual analysis of the obtained influencers it has to be said that only two of them are accounts related to young people ernaigazte and topatu eus are both accounts related to organizations formed by young people on the one hand ernaigazte is the account of the basque nationalist left youth organization named ernai on the other hand topatu eus is a digital media account related to young people very related to the basque nationalist left the lack of influencers among young users could be related to the characteristics of twitter which is mostly structured around to political issues basque speaking communities for young users once the main network graph was created we split it into subgroups to analyze how the subcommunities or subgroups inside each one are formed we divided each graph into subgroups using the node2vec algorithm which allows us to obtain consistent subgroups the node2vec user times retweeted berria 8671 argia 5646 ernaigazte 4553 topatu eus 4236 enekogara 3274 naiz info 3262 zurihidalgo 2568 askegunea 2561 realsociedadeus 2531 larbelaitz 2471 arnaldootegi 2188 ibroki 2031 leakohitza 1893 athletic eus 1818 euskaltelebista 1744 total rts done to users user users retweeted berria 998 argia 844 naiz info 710 larbelaitz 585 topatu eus 531 arnaldootegi 518 ernaigazte 478 enekogara 454 hamaikatb 442 jpermach 427 axierl 413 ielortza 407 maddaleniriarte 404 boligorria 398 gureeskudago 394 young users retweeted accounts table 6 most retweeted accounts by young users algorithm can freely explore network neighborhoods which is useful to discover homophilic communities unlike modularity based algorithms used in a previous analysis of basque communities node2vec gives the opportunity to choose the exact number of communities to be extracted besides this algorithm can be tuned in order to give more importance to homophilia or to structural equivalence thus figure 3 shows that node2vec generates clearly distinguishable subcommunities which in turn makes them more interpretable thereby facilitating the understanding of the existing relations between them after splitting the graph into four communities we had to infer the main characteristics of each subgroup for this process we focus again on the most important nodes which are the ones used to define the community itself each of the subgroups displays a common characteristic namely all of them have a direct relation with topics or issues related to the basque country those topics are different in each of the subgroups in the graph showing the characteristics or differences of each community thus it can be seen that basque language interactions are used to talk about various basque current affairs and politics also it can be seen that music and sports are also widely commented by young people in other words it seems that the main function of twitter interaction is to spread content about politics and social issues but with a clear focus on the basque community and language in the following we describe the main characteristics of each of the four subgroups contained in the graph • news in this community the nodes found at the top of the ranking are related to news media from the basque country specific basque journalists and also to other very active users that write about the most noteworthy news in basque • nationalist left the composition of this particular subgroup is characterized by nodes related in different ways with the nationalistindependentist basque left the nodes can refer to news media political and social organizations and politicians from the main parties in this political movement • sports in the sports subgroup the most important nodes are actually journalists and news media specifically specialized in the sports domain thus for this specific group the top accounts also refer to newspapers and television broadcasters other important nodes here are those related to sport teams such as football teams and basque ball clubs or their players which are mostly footballers from professional teams or even well known cyclists • music in the music subgroup appear in prominent places music bands or singers which sing in basque although other accounts related to music seem to be also very active figures 3a and3b show that young basque users generally interact with users related to social issues as well as with those related to leisure due to the new method applied for community detection we are able to map the communities in a more consistent way showing in a clear way where each community is located the position of each community on the graph and the closeness between communities show how related the topics are between them in this way we can see that communities related to social issues are next to each other while the same occurs with the leisurerelated communities the community related to politics is close to news and music illustrating both the relation with current news and the political stance of some basque music bands besides in three of the four communities media and journalists are referential proving again that media is important at disseminating basque content among young people in spite of the main topic of the community in this section we show that combining the community detection algorithm and the visualization of the spacial representation of the graph humans can easily interpret the meaning and characteristics of the displayed data thus any information based on user interactions could be displayed and interpreted using these techniques helping us to transform unstructured information into knowledge in this paper we have presented a new methodology to perform demographic analysis by processing a large amount of tweets in basque language we have applied machine learning and deep learning approaches to natural language processing to extract structured knowledge from unstructured data our experimental results have shown that our new method produces good quality labeled data for training youngadult classifiers this allows us to generates a new dataset of 80k tweets annotated at user level namely heldugazteage the analysis of the classifiers performance has shown that when compared with manual annotations at tweet level the annotations of our semiautomatically generated heldugazteage dataset benefit from taking into account userlevel information furthermore we have experimented with modern deep learning techniques for nlp and for the detection and visualization of communities in twitter the use of these technologies has allowed us to get more consistent and readable results than in our previous approach apart from a better understanding of communities and their interactions as a result of our new methodology we have seen that the the young basque users can be grouped in four main communities furthermore we have also seen that the most influential accounts among young users are related with basque media revealing the importance of this actor at disseminating content in basque among the youngest a general conclusion has been that basque is mostly used in twitter to speak about basquerelated topics being that news politics sport or music we believe that the methodology presented in this paper might be of interest for other nlp tasks and other types of social and demographic studies finally we publicly distribute every resource to facilitate further research for low resourced languages such as basque3

in this paper we take into account both social and linguistic aspects to perform demographic analysis by processing a large amount of tweets in basque language the study of demographic characteristics and social relationships are approached by applying machine learning and modern deeplearning natural language processing nlp techniques combining social sciences with automatic text processing more specifically our main objective is to combine demographic inference and social analysis in order to detect young basque twitter users and to identify the communities that arise from their relationships or shared content this social and demographic analysis will be entirely based on the automatically collected tweets using nlp to convert unstructured textual information into interpretable knowledge

background quality of life is an important measure for evaluating the health situation of individuals and populations and is strongly influenced by the constant environmental technological economic and labor relation changes in this sense qol is an important indicator of individual and collective health provided that it is measured based on its complex conceptual framework 1 2 3 since the establishment of the world health organization quality of life group the world health organization expanded the concept of qol adding to it the individuals understanding of their life condition in the context of cultural and social values in response to the expectations and concerns encountered in the development of their life plan 12 several factors interfere with qol these are related to the multidimensionality and subjectivity of its conceptual aspects the workers lifestyle can be a determining factor for health risk behavior clinical condition physical activity and selfrated health these elements in turn potentially affect qol 1245 in brazil the industry and commerce sector accounts for approximately 40 of the countrys formal jobs 6 therefore it is important to measure the qol levels of formal workers as the results could be used as occupational health indicators thus contributing to the understanding of health conditions the constructionimplementation of public policies and the planning of systematized actions for providing care 1 2 3 qol levels in workers are affected by their interaction with the labor market which requires high productivity but offers inadequate working conditions and low pay most of the time some workers still live with occupational and chronicdegenerative diseases which directly interfere with their qol and promote presenteeism at work 78 empirical studies on qol do not address formal workers most of the data available on the topic refer to specific groups such as women the elderly and people with chronic diseases thus no information about young and healthy workers which represents the majority of the workforce is available investigating this topic may contribute to reducing the knowledge gap regarding this groups qol levels and add to the theoretical and epidemiological framework of public policies on occupational health identifying the qol levels of workers and recognizing it as a potential indicator of occupational health may allow the development of health promotion actions which could make the work environment more compatible with an increasing market production without causing occupational pathologies in workers 3910 therefore thias study aimed to identify the factors associated with qol in young workers from a municipality in northeast brazil methods study design and population this was a crosssectional study conducted in brazil on users of the healthrise programa program targeting the reduction of premature death from chronic noncommunicable diseases such as diabetes and hypertensionin vitória da conquista aimed at improving users access to primary health services qualifying care implementing medical records and offering special tests to patients with chronic diseases 11 the municipality of vitória da conquista is located in northeastern brazil with an estimated population of 338000 inhabitants in 2019 and a territorial area exceeding 3700000 km 2 12 most of this population lives in urban areas which corresponds to approximately 87 12 the municipality is located in an important road junction that services the outflow of production between southeastern and northeastern brazil and has a servicebased economy with a predominance of the health education commerce and civil construction sectors data collection data were collected at industry social service a private nonprofit entity whose mission is to qualify the workforce and promote workers health 13 thus the participants were workers assisted by sesi the inclusion criteria for participants were workers aged 18 years or above living in the municipality and having attended sesi for periodic consultations with the occupational doctor the exclusion criteria were workers coming from other municipalities or those awaiting medical evaluation before dismissal data were collected between august 2017 and july 2018 we sought our study sample from the 3727 workers that scheduled consultations with an occupational physician during this period however 339 of them did not attend their consultations 833 awaited medical evaluation after being dismissed 516 were from other municipalities 25 were under 18 years old and 744 refused to participate in the study all of which were consequently excluded from the study further information about the sample can be found in the results section procedure data were collected by trained interviewers using a digital questionnaire built using the kobotoolbox platform on tablets the questionnaire was adapted from the brazilian national health survey 2013 14 and included information relevant to the outcomes of the project such as evaluating the selfcare of patients with chronic diseases evaluating users access to health services and measuring workers stress levels and qol additionally the objective measurements of weight and height were collected a properly calibrated seca 813 ® portable digital electronic scale was used for measuring weight with the participants barefoot and wearing light clothing to measure height a portable nutrivida ® stadiometer was used with the participants barefoot and in an upright position instruments and measurement variables qol was considered the outcome variable and was measured using the eurohisqol eightitem index an instrument created by who together with the whoqol group aimed at developing research instruments that produce health indicators through an economic approach and have a possible application in different countries to facilitate comparison between brazilian data and data from other countries 12 the eurohisqol eightitem index instrument was validated and translated into brazilian portuguese it consists of eight questions based on the four whoqolbref domains physical health psychological health social relationships and environment with each item rated on a fivepoint likerttype scale ranging from 1 to 5 the total qol score is obtained by adding the scores on all items and ranges from 8 to 40 with higher scores indicating higher qol 12 qol was treated as a continuous variable and categorized into tertiles demographic socioeconomic behavioral and clinical variables were considered explanatory variables the brazil economic classification criterion of the brazilian association of research companies which came into force from 2015 was used with an update of the class distribution in 2016 15 the demographic and socioeconomic variables of interest were gender age socioeconomic class marital status and work shift only two categories were considered for marital status living or not living with a partner work shift was also divided into two levels those working exclusively during daytime and other work shift modalities the behavioral variables considered in this study were diet smoking alcohol consumption and pa healthy eating was defined as the consumption of greens vegetables fruits and fruit juices with at least one portion of fruit or fruit juice and two servings of greens and vegetables at least five times a week 1416 workers who used tobacco in any quantity even sporadically were considered smokers risky alcohol consumption was described as consuming four or more doses of alcohol for women and five or more doses for men on the same occasion within the last 30 days 14 pa was assessed using the international physical activity questionnaire and participants who engaged in more than 150 min of pa per week were considered to be physically active 1718 the clinical variables included were selfrated health and nutritional status which was classified by body mass index and grouped into two categories nonobese workers and obese workers 19 20 21 22 statistical analysis the descriptive analysis of the study variables was initially performed continuous variables were represented by means and categorical variables were represented in simple frequencies and percentages the homogeneity of variance of means was evaluated by levenes test anova or brownforsythe tests were used to determine the differences between means and a tukeys hsd test was used to show the differences twoway anova was used to compare the mean qol in men and women taking into account socioeconomic and clinical characteristics cumulative odds ordinal logistic regression stepwise format with proportional odds was used to determine the effect of risky behaviors clinical conditions and demographic and socioeconomic determinants on qol levels a significance level of 20 was used in the model for the explanatory variables the proportional odds were evaluated by a total likelihood ratio test comparing the fitted models with models with variable localization parameters the adjustment quality deviation test indicated that the model had a good fit and significantly predicted the dependent variable logistic regression produced estimates which were calculated by points and intervals with a 95 confidence and a significance level of 5 statistical analyses were performed using ibm spss statistics software version 27 ethical considerations the research was approved by the research ethics committee of the federal university of bahiamultidisciplinary institute in healthanísio teixeira campus according to caee number 62259116000005556 all the participants signed an informed consent form results the mean age of the 1270 workers who participated in the study was 33 years and most of them were men of them 495 belonged to social class c and 622 were married or lived with a partner the predominant work shift was the daytime shift a total of 866 reported having good or very good health the prevalence of obesity was 148 while that of unhealthy eating was 56 tobacco use was reported by only 84 while risky alcohol consumption was reported by 287 a total of 623 of the workers engaged in pa daily the bivariate analysis of socioeconomic and clinical conditions showed a statistically significant difference in the qol between men and women men had a higher mean qol than women the groups with higher mean qol were the ≤29 years and ≥50 years age groups with qol scores of 310 and 312 respectively followed by social classes a and b with a score of 312 and workers who reported very good health with a score of 331 the bivariate analysis of qol including risky behavior habits and lifestyle showed statistically significant differences with higher mean qol for individuals classified as nonobese nonsmoker and physically active however individuals who practiced risky drinking had a higher mean qol level than those who did not the comparison between the qol in men and women using twoway anova showed statistically significant differences for all demographic socioeconomic behavioral and clinical variables the ordinal logistic regression analysis showed that qol was likely to be 30 higher in individuals who were physically active and even after the odds ratio was adjusted for gender age group marital status socioeconomic class selfrated health nutritional status and risky alcohol consumption it remained stable and statistically significant for active individuals males had a higher odds ratio value for qol than females in all logistic regression models it is worth noting that after adjusting the model by age group marital status and socioeconomic class men were twice as likely to have a higher qol as women were workers who reported having very good or good health were approximately six and seven times more likely to have a higher qol respectively when compared to workers who reported having regular poor or very poor health model or odds ratio ci confidence interval these criteria evaluate individuals socioeconomic level through a household assessment scores range from 0 to 100 points with higher scores representing a higher economic stratum a b1 b2 c1 c2 and de discussion the main factors associated with qol in young workers in the present study were the male gender and regular pa practice even in the model adjusted for sociodemographic economic behavioral and clinical variables the stable qol level in physically active individuals even in the analysis model reinforces the positive association of pa with all qol domains the studied population of formal workers comprises young individuals predominantly males which is similar to other studies conducted in brazil since 56 of formal jobs are occupied by men 23 although there is a movement in government and nongovernmental institutions in the contemporary world for valuing and inserting women in the labor market these actions cannot guarantee gender equality in the productive sector most workers in the present sample were married practiced pa and reported having good or very good health moreover some studies indicate a positive relationship between pa and selfrated health this association may be due to the benefits generated by the practice of pa such as reduced incidence of diseases improved selfesteem and cognitive ability and promotion of social contact with people with healthy habits which may favor a better selfrating of health conditions which is a good health indicator for the population 2425 selfrated health has good reliability and validity not only as a predictor of morbidity and mortality but also for identifying the health needs of the formal worker population and more objectively for stratifying their clinical health conditions and behavioral attitudes 2526 most workers who reported having good or very good health also reported higher qol levels as identified in a brazilian populationbased study 26 in which selfrated health was 742 a percentage that reduces as the number of morbidities increases leading to worse selfrated health and reduced q o l the study showed better qol levels among workers who practiced risky drinking this result may be partially explained by the fact that the workers in this study were mostly young another explanation could be that as alcohol consumption is often associated with moments of leisure and partying it may subjectively be perceived as spending quality time 2527 gender is an important variable when we consider the historically consolidated differences between men and women and the same was found in the results of this study men had a higher quality of life and occupied more job positions than women did several studies on the role of gender in health present possible causes for these differences including double working hours for women number of children and the difficulty of entering the labor market faced by women 1023 in this sense the power relations established by a gender bias have historically built the social division of labor based on biological aspects associated with sexist social stereotypes and cultural norms of appreciation of men consequently limiting women to unpaid activities and jobs considered to be of little administrative and economic relevance this trend continues today as can be seen in the income gap by gender such that in 2019 brazilian women had a mean income 1163 lower than that of men 6 2829 the inclusion of women in precarious job positions with low pay has a negative impact on qol as income is one of the determinants of lifestyle access to goods and services and consequently health condition which is influenced by working life 2830 physically active individuals showed higher qol levels than those who were inactive we constructed a model in which the main variables of the database were used to better understand their relationship with the outcome of the study the main exposure variable in the model was pa as the available literature shows that there is a relationship between pa and qol level the model derived from ordinal logistic regression showed a certain stability of qol levels in physically active individuals 53132 this is because the benefits of pa go beyond the improvement of the clinical and biological condition since it promotes social interaction the establishment of bonds of friendship and emotional balance which are subjective and integral elements of the multidimensional aspect of the qol construct 32 our findings support that pa is a variable that directly and indirectly positively influences all domains of qol 1 the results of studies show that pa induces behavioral change which is fundamental for disease control and prevention thus the incorporation of pa in daily life becomes an important therapeutic alternative capable of improving general health conditions which necessarily results in better qol levels for workers 3132 most workers were considered active this may be due to the benefits of pa practice the desire for a better body image and the availability of public equipment moreover the population mostly comprised young people 33 however a significant proportion of workers were inactive this may be a reflection of technological evolution that is providing comfort increased productivity reduction of time requirements and work and at the same time less physical effort no statistically significant differences in qol were found in terms of age and marital status in this study although age is an important factor in the labor market it was not present in the regression and was associated with increased qol levels these results differ from those found in the literature 10 however when age is analyzed separately workers over 50 years of age had the highest qol means not agreeing with the findings of other studies 910 this contrast may be due to the greater financial resources and professional stability of these workers 34 the higher socioeconomic classes had higher incomes and consequently greater purchasing power of goods and services stability in work relationships and more job satisfaction which are determining factors for physical and mental health essential elements for qol 152635 their economic and social position seems to be a determining factor of qol levels which is consistent with the results of our study workers of higher socioeconomic classes had better qol in all proposed models 2635 selfrated health is influenced by subjective and objective criteria and according to previous studies it is a good predictor of mortality being a reflection of biological socioeconomic and behavioral aspects 36 we found that individuals who reported having better health had higher qol levels nutritional status and alcohol consumption in turn were not associated with qol since the results did not show statistical significance 25 the findings of this study should be interpreted considering some methodological limitations first the presence of acute pathologies was not assessed when data were collected which may have influenced qol levels second in terms of the study design as crosssectional studies are limited to identifying associations and causal relationships cannot be established reverse causality can occur 37 for example although lower levels of qol were associated with obesity it can be argued that the problems caused by overweight obstruct qol the results of this study support the use of qol as an epidemiological indicator for the planning of healthrelated arrangements for workers because qol is an indicator of health conditions it can be adopted into all levels of the healthcare system especially primary care which is usually a workers first point of contact with the health system to identify general health needs and diagnose possible occupational diseases conclusions most of the participant workers engaged in regular pa and demographic socioeconomic clinical and some behavioral factors had little influence on qol levels the results of this study may contribute to guiding the implementation of public policies that systematically promote pa in the daily lives of workers it also highlights the need for further studies to investigate factors associated with qol in women to confirm and possibly deepen the understanding of the present results funding the healthrise vitória da conquista study was funded by the medtronic foundation through the healthrise program a global initiative led by the abt associates and institute for health metrics and evaluation designed to provide access to chronic illness care for individuals in underserved communities this study also was financed in part by the coordenação de aperfeiçoamento de pessoal de nível superiorbrazil finance code 001 medtronic foundation and capes had no role in the study design collection analysis or interpretation of the data writing the manuscript or the decision to submit the paper for publication institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by the ethics committee of multidisciplinary health institute federal university of bahia informed consent statement informed consent was obtained from all subjects involved in the study conflicts of

background this study aimed to identify the factors associated with the quality of life of young workers of a social work of industry unit methods this was a crosssectional study conducted on 1270 workers data were collected using a digital questionnaire built on the kobotoolbox platform that included the eurohisqol eightitem index to assess quality of life demographic socioeconomic behavioral and clinical variables were considered explanatory the associations were analyzed using the ordinal logistic regression model at a 5 significance level results men and women had a mean quality of life of 311 and 294 respectively workers that rated their health as very good had an odds ratio of 74 95 confidence interval ci 5171081 and those who rated it as good had an odds ratio of 29 95 ci 231377 both these groups of workers were more likely to have higher levels of quality of life as compared to workers with regular poor or very poor selfrated health physically active individuals were 30 more likely to have higher levels of quality of life odds ratio 13 95 ci 108165 after adjusting the model by gender age group marital status socioeconomic class selfrated health nutritional status and risky alcohol consumption the odds ratio of active individuals remained stable odds ratio 13 95 ci 105166 conclusions in the present study selfrated health physical activity and gender were associated with young workers quality of life

introduction since december 2019 covid19 has been affecting societies and countries across the globe posing important questions for individual and social lives amidst a hygienic crisis with multifaceted implications while the virus was rapidly spreading around the world conspiracy theories and other forms of fake news were finding a fertile ground to spread too from the very beginning of the pandemic the director general of the world health organization claimed that beyond the battle of the virus itself who is also battling the spread of conspiracy theories regarding the virus and any misinformation that undermines the importance of urgent and necessary measures to tackle the infection rates 1 indeed several explanations of the origin of the virus were circulated during the beginning of the pandemic based on conspiracies such as that covid19 had been intentionally engineered as a political mode of controlling the masses or as a hoax which had been spread out worldwide by 5g networks these conspiracy theories led in their turn to further hoaxes creating vaccination hesitancy and denial threatening to become an immense public health problem 2 moral identity and moralityascooperation as it was previously mentioned morality in the era of the pandemic has been prominent and is worth of further empirical investigation in our multicountry study we conceptualized morality as an individual trait as well as a cooperative grouprelevant variable to begin with moral identity reflecting the individualized conceptualization of morality refers to the subjective importance of morality to someones personal identity typically represented as a traitbased difference between people or as a trait in the form of selfschema 3 moral identity is composed by a private having component and a public doing component internalization concerns the degree of centrality of moral traits for someones selfconcept while symbolization has more to do with the degree of reflection of these moral traits in public action and choices taking place in certain social settings 4 from a motivational perspective internalization relates to seeking for maintaining selfconsistency between identity and behavior on the other hand symbolization is motivated by goals of selfpresentation and recognition of the self in terms of a social entity that seeks for selfaffirming feedback from other people 5 to date research mainly focuses on the internalization aspect calling for more empirical attention to the symbolizationdoingaspect of moral identity 56 concluding symbolization and internalization act as synergetic in peoples moral reasoning and decision making additionally colby and damon 7 suggested that what differentiates moral people from other people is the extent to which they perceive their own sense of morality and personal goals as united extending this argument frimer and walker 8 proposed a reconciliation model which relies on moral identity and describes moral identity as entailing agencyrelated motives and communionrelated motives such motives are supposed to act as synergetic and not as competing and eventually the integration of personal and communion moral goals provide a powerful source of commitment to action moralityascooperation in this context is exemplified in communitybased and societal challenges where moral actions are needed moralityascooperation indeed identifies problems and societal challenges which can be solved via exhibiting cooperative behavior such as reciprocation or help towards the group 9 in light of mutualism as a prerequisite for moralityascooperation behaviors 10 there are situations which beg for cooperative behaviors and where individuals benefit each other by jointly and cooperatively working with others coordinating to achieve a mutual advantageous outcome requests joint coalitions and efforts to compete with threats and uncertainties 11 conspiracy theories and moral concerns during the pandemic adherence to health protective behaviors and compliance with public health policies has become a morally expected issue with relevant moral concerns when public health protection rules are violated 12 prioritizing public health and responding to public health risks also raised multiple moral dilemmas that have become the subject of extensive debates 13 to this end we aimed to consider moralityrelevant variables in empirical investigation of the topical debate on conspiracy theories that have flourished during the pandemic and the degree to which morality variables mediate the relationship between endorsement of covid19 conspiracy theories and adherence to public health behaviors and support for equivalent policies conspiracy theories share a common theme in the way that they rely on negative and traumatic events conceptualized and explained as intentional and plotted plans from powerful elites against populations 14 these hidden plans often entail a morality component indeed leone et al 15 posit that conspiracy theories entail a moral evaluation component on the grounds that traumatic and frightful events originate from malevolent elites 16 and thus trigger a moral reasoning relevant to the actual understanding of conspiracy theories 17 farinelli 18 has described conspiracy theories as morality tales based on archetypal narratives about right versus wrong good versus evil this conceptualization of conspiracy theories can reflect the degree to which people who are attentive to morality issues may also believe in conspiracy theories which in turn appeal to peoples moral perceptions values and judgements moral concerns may be relevant to peoples individual and also collective wellbeing referring to individual and groupfoundations respectively 19 moral foundations concerning peoples group membership relate more strongly with endorsement of conspiracy beliefs than moral foundations concerning peoples individual moral traits and judgements 15 this claim lies on the nature of conspiracy beliefs per se as a reflection of an usversusthem mentality this mentality is often anchored in events against nations religious and other large groups as victims of such conspiracy theories 20 that are supposed to attack the populations leone et al 15 have suggested that the group perspective of conspiracy theories activates a group identity perspective when people think in terms of their binding to the group and not in terms of individual binding however following the aforementioned conceptualizations of moral identity and moralityascooperation especially in light of the reconciliation model as dimensions that can complement each other we hypothesize that there will be a significant positive association between both moralityascooperation and moral identity with conspiracy beliefs about covid19 the threats that are entailed in conspiracy theories are supposed to trigger a defensive way of life on the part of the people reflected in their moral principles of selfresponsibility and cooperation to overcome the impact of such threats this explains the expected positive direction of the expected association morality beliefs and conspiracy theories and health protective behaviors while several conspiracybased explanations of various events can fascinate people across time and be harmless 21 most conspiracy theories relevant to public health crises can be dangerous and harmful for individual and societal wellbeing and resilience 2223 these types of conspiracy theories include misinformation and disinformation related to covid19 and cast doubt on the existence of the virus per se in turn making people who endorse such conspiracy theories less likely to comply with public health measures 24 concerning moral foundations health choices and practices of protection of public health during the pandemic exemplify a choice of individuals to depend on their moral attitude to protect themselves and others containing pandemicrelated behaviors as actions that people need to take to tackle the spread of the virus morality is one key factor that plays an important role in determining the extent to which people will engage or not in such actions indeed individuals are supposed to be motivated to take actions depending on their willingness and intention to defend and protect sacred values such as their quality of life and health which in turn are threatened 25 people who endorse conspiracy theories rarely make healthrelated choices recommended by authorities pummerer et al 26 confirm findings according to which believing in conspiracy theories decreases governmental support and adoption of healthrelated containing behaviors such as physical distancing uscinski and parent 27 have showed that people high in conspiracy beliefs were less likely to engage in cooperative and altruistic behaviors or donation practices more recent findings come from a study by imhoff and lamberty 28 on conspiracy worldviews of covid19 and engagement with pandemic preventive and hygienic behaviors in this study conspiracy theories that described the covid19 pandemic in terms of a hoax were more strongly associated with reduced containment pandemicrelated behavior this finding was observed in the united kingdom and the united states further it has been suggested that when morality is central to peoples selfconcept then moral judgements of actions such as intention to adopt hygienic measures are translated into actual behavior 29 here scholars have shown that moral judgement and empathy for significant others is a key predictor of engagement with preventive pandemicrelated behaviors additionally pagliaro et al 30 have evidenced that discretional covid19 related behaviors are exhibited when they are prescribed by their very moral essence to foster the collective wellbeing and welfare of the community amidst the pandemic crisis we thus hypothesize that conspiracy beliefs will be negatively associated with pandemicrelated behaviors and policy support but this association will be positively mediated by moral identity and moralityascooperation overall with our study we aim to show how both political and nonpolitical underpinnings of conspiracy theories about covid19 can lead to public health containment behaviors and support of measures the contribution of our study lies on identifying the associations between conspiracy beliefs and healthrelated behaviors and policy support via two levels of morality individual and groupbased morality examining how such associations occur across 67 countries that differ in the way they implemented measures and contained the spread of the virus up until now very few studies take both the individual and group dimension of morality at the same into account 1531 rationale of the study in the present study we used moralityascooperation to measure the cooperative component of morality that ties individuals to their living community additionally we used a traitbased measure of moral identity 32 to discover the traits that compose peoples unique moral identity as part of individuals selfconcept rather than their cooperation with community group members moral identity is conceptualized as an individual traitbased tendency to consider morality as central to individual selfconcept and sense of selfconsistency on moral action and personal identity 5 formation of moral identity is thus linked with individual characteristics and contexts for moral actions 33 when individuals integrate moralityrelevant values into their selfconcept then a moral selfidentity arises 34 on the other hand moralityascooperation conceptualizes morality in terms of a groupfocused behavior and cultural solutions to issues of cooperation and conflict that may occur in peoples social life moralityascooperation is based on interactions between groups and people characterized by mutual coordination social exchanges or division and disputes 935 moralityascooperation mechanism motivates people towards altruistic and cooperative behaviors as well as opportunities to evaluate behaviors of others 36 to the extent that moral identity can be conceptualized as a foundation for comprehending moral agency in groups and organizations 37 we suggest that moral identity and moralityascooperation complement each other moral identity by definition entails an interactive cooperative component too since individuals with moral identity develop a sense of personal responsibility considering themselves responsible for their actions in particular contexts therefore they act either proactively or reactively and always in congruence between their judgement of the context and their actions for the benefit of themselves and others who are present in a situation at hand 38 materials and methods measures we used three measures of public health support 31 we used a spatial limiting distancing 5item scale to measure peoples maintenance of spatial distance and reduction of physical contact with items such as during the days of the coronavirus pandemic i have been staying at home as much as practically possible furthermore we used a physical hygiene 5item scale to measure peoples adoption of healthrelated behaviors and improvement of their physical hygiene with items such as during the days of the coronavirus pandemic i have been washing my hands longer than usual finally we used a policy support 5item scale to measure peoples support towards implementation of healthprotective policies and measure as responses to the pandemic with items such as during the days of the coronavirus pandemic i have been in favor of closing all schools and universities we used an 11point slider scale with three labels 0 strongly disagree 50 neither agree nor disagree 100 strongly agree these labels were recoded to a scale ranged from 0 to 10 additionally we used a 4item covid19 conspiracy beliefs scale to measure peoples endorsement of conspiracy theories about the origin and the causes of the pandemic with items such as the coronavirus is a bioweapon engineered by scientists as it was mentioned in the introduction in this scale we included not only politicalrelated items but also items relevant to the scientific community interest social groups not necessarily political as well as global economic issues a scale from 0 to 10 was used engaging government science interest social groups global institutions and an explanation of the virus as a hoax in measurement of conspiracy beliefs helped us avoid effects of political attitudes and ideological preferences on the associations we examine lastly we measured morality using two scales first we used a 7item moralityascooperation scale 9 to measure different cooperative moral behaviors such as helping groups participants were instructed to think when they decide whether something is right or wrong to rate the extent to which a number of considerations is relevant to their thinking example consideration was whether or not someone worked to unite a community a scale from 0 to 10 was used next we used a 10item moral identity scale 32 to measure peoples selfidentification based on moral prosocial attributes this scale consisted of two subscales moral identity symbolization and moral identity internalization participants first read 9 characteristics that might describe a person who could be themselves or it could be someone else next participants had to visualize in their mind the kind of person who has these characteristics participants were asked to imagine how that person would think feel and act when they had a clear image of what this person would be like participants were asked to rate statements such as i am actively involved in activities that communicate to others that i have these characteristics and being someone who has these characteristics is an important part of who i am a scale from 0 to 10 was used recent research which has also used this data and originated from the same international collaboration project have used advanced machinelearning algorithms established measurement equivalence of the moral identity internalization and symbolization subscales across the 67 countries included in the data set 39 the original paper of van bavel et al 31 reported a twofactor model with acceptable internal consistency this twofactor structure was confirmed in our subsequent machinelearning analysis 39 after correlating residuals of items 8 and 9 and 4 and 7 covariates in all analyses we controlled for participants age gender employment status and living area participants levels of national identification measured with two items participants political ideology measured in one item where participants had to rate their political views in a scale from 0 to 10 where 0 indicated very leftleaning views and 10 indicated very rightleaning views the full list of scales along with the dataset in spss and a csv form can be found here results we initially performed a principal components analysis with varimax rotation on the four items measuring belief in conspiracy theories in order to check whether all items loaded on the same factor the results of this analysis suggested that all items were captured by one dimension in 9 out of 13 estimation algorithms hence allowing us to aggregate the measure of belief in conspiracy theories into one variable used in the subsequent modelling summary statistics of all variables included in the analysis are shown in table 1 next we fitted two linear mixed effects models 40 to predict our three dependent variables of spatial limiting distancing physical hygiene and policy support specifically in model 1 we predicted our measure of spatial limiting distancing by belief in conspiracy theories moral identity moral identity and moralascooperation with country as a random effect in model 2 we predicted our measure of physical hygiene by belief in conspiracy theories moral identity moral identity and moralascooperation again with country as a random effect finally in model 3 we predicted our measure of policy support by belief in conspiracy theories moral identity moral identity and moralityascooperation with country as a random effect as it was previously done for all models all standardized parameters were obtained by fitting the model on a standardized version of the dataset and 95 confidence intervals and pvalues were computed using the wald approximation results are reported in table 2 for model 1 multilevel modelling showed that spatial limiting distancing had a significant negative association with belief in conspiracy theories while having significant positive associations with moral identity moral identity and moralityascooperation the intercept model was found to be at 597 6011 p 001 the random effects intraclass correlation coefficient for the model indicated that most of the variance in the model was explained by the fixed variables while 12 of the variance could be explained by the randomeffect of country indicating moderate differences between the 67 countries in the data in a similar vein for model 2 multilevel modelling showed that abidance to physical hygiene had a significant negative association with belief in conspiracy theories while having significant positive associations with moral identity moral identity and moralityascooperation the intercept for the model was found to be at 613 6197 p 001 the random effects intraclass correlation coefficient for the model indicated that most of the variance in the model was explained by the fixed variables while 12 of the variance could be explained by the randomeffect of country indicating moderate differences between the 67 countries in the data for model 3 results showed that policy support aimed to combat the spread of covid19 had a significant negative association with belief in conspiracy theories and significant building on the results obtained in the linear mixed effects models we subsequently fitted three multilevel mediation models in order to test if moral identity and moralityascooperation mediated the negative relationship between belief in conspiracy theories and spatial limiting distancing physical hygiene or policy support respectively the results of these three models are reported in tables 3 4 and5 3 below next for multilevel mediation model 2 the model with physical hygiene as a dependent variable was significantly different from a baseline model 2792180 p 001 and gfi agfi and rfi suggested a satisfactory fit as in the linear mixed effects model the results suggest that belief in conspiracy theories is negatively 4 below finally for multilevel mediation model 3 the model with policy support as a dependent variable was significantly different from a baseline model 2793614 p 001 and gfi agfi and rfi suggested a satisfactory fit as with 5 below discussion the aim of this paper was to investigate how beliefs in conspiracy theories led to adoption of healthrelated behaviors and support of public health policies how these associations were mediated by moral identity and moralityascooperation our findings showed that beliefs in conspiracy theories reduced policy support of governmental measures as well as the abidance to healthrelated behaviors related to the pandemic importantly this relationship was mediated by moral identity and moralityascooperation while evidence suggests that conspiracy theories exemplify a kind of calling cards that signal the generation of collective action and other political actions 4142 in the era of covid19 it has been shown that collectively adopting healthrelated behaviors as a form of action as well as policy support toward the government measures is reduced when people endorse conspiracy theories about covid19 2628 furthermore our results confirmed the expected positive association between beliefs in conspiracy theories and moral identity and moralityascooperation 1520 mediation of moral identity and moralityascooperation in the relationship between beliefs in conspiracy theories and containment of healthrelated behaviors adds to current findings which have mainly focused on endorsement of moral principles of care and fairness that increase in turn peoples inclination to trust the science and government demonstrating higher policy support and adoption of prescribed healthrelated behaviors 30 specifically we have built on and expanded these findings by simultaneously testing moral identity as an individual trait and moralityascooperation as a variable related to collective life identifying potential similarities or differences in their effects on the adoption of healthrelated behaviors and policy support although the theory suggested that moralityascooperation would have a stronger effect than moral identity 15 we found that both moral identity and moralityas cooperation both significantly mediated the relationship between beliefs in conspiracy theories and the dependent variables peoples moral judgements constitute key antecedents of the adoption of containment behaviors and compliance with and support of political decisions to tackle the spread of the virus but when beliefs in conspiracy theories are high it is reflected in peoples distrust toward science and government exhibiting low adoption of relevant preventive hygienic behaviors 43 conspiracy explanations of the virus can potentially raise a collective action dilemma while cooperation between people and their moral foundations could potentially be increased amidst the pandemic the dilemmatic nature of the underpinnings of the viruswhether the virus is a hoax or it is a factseems to determine peoples actual hygienic behaviors and their moral judgements toward each other and themselves evaluating their position in this context similar dilemmas for collective action have been identified in other cases such as the antibiotic resistance 44 our study emphasizes the importance of individual and group moral foundations that can inhibit the effect of believing in conspiracy theories on exhibiting healthrelated behaviors and policy support for healthprotective measures the indirect association of beliefs in conspiracy theories with individual and groupbased moral foundations and policy support as well as containment healthrelated behaviors open novel interpretations of conspiracy beliefs as perceptions of facts which are morally infused policymaking programs that aim to reduce the consistently negative impact of conspiracy beliefs on societal factors 45 such as adopting healthrelated behaviors and complying with policy measures could take into account that beliefs in conspiracy explanations of the origin and nature of the virus do not simply constitute antecedents of cognitive biases or failures nor maladaptive behaviors based on personality traits instead conspiracy beliefs as well as adoption of and support of policy measures reveal a deeper moral stance regarding what is right andor wrong and who is to blame for the situation beyond the contribution of our study we should acknowledge some limitations of our study that could offer a fruitful avenue for future research first it is worth mentioning that while some of our effects were not very large they might still have a big impact 46 specifically as abelson 47 has noted seemingly smaller effect sizes can still matter in the long or shorter run they can have the potential when they are cumulated through longitudinal observations or observations across multiple countries or settings to have important implications for psychological research they can do so by offering explanations of life outcomes such as peoples public health institutional trust and compliance overall life quality and resilience against misinformation second the study was correlational thus it prevented us from inferring causations future research can inform existing findings by setting up experimental designs and testing the effects of moral traits on different forms of conspiracy theories and support for public health and other similar policies furthermore speaking of a period when conspiracy theories have become widely attractive an interesting avenue for future research could be whether people would be also inclined to endorse conspiracy theories about situations unrelated to covid19 events for example people who adopt a specific conspiracy explanation about covid19 as a hoax may tend to describe other events in terms of conspiracies and hoaxes too in a context of a general conspiracy mentality ie a tendency to broadly believe in conspiracy theories 48 because other events unrelated to covid19 beg for collective actions and adoption of prescribed behaviors too with moral underpinnings it is of interest to identify similar relations between conspiracy beliefs moral foundations and exhibition of actual prescribed behaviors if we accept existing claims 49 suggesting a generalization of conspiracy beliefs about one specific event to other unrelated events one could examine whether the respective effects of believing in conspiracy beliefs are also generalized to explain other events as well policymaking impact of our research practitioners and policy makers can benefit from our research by acquiring information about peoples moral foundations that can mediate their inclination to endorse conspiracy beliefs with a subsequent effect on adopting necessary healthrelated behaviors to reduce the spread of the virus in addition to this national leaders can obtain useful information by this study in order to get an overview of how they can effectively formulate and tailor political messages to appeal to peoples moral principles once people perceive political messages and decisions as moral ones then they would be more likely to willingly adopt containing healthrelated behaviors and reject any conspiracy theories that explain the origin and spread of the virus indeed peoples individual and collective healthrelated choices are put under moral constraints and raise important moral questions 50 potentially depending on what moral foundations politicians appeal to and whether they achieve to make people reject the conspiracy explanations of the origin and spread of the virus tackling conspiracy informationknown also with the popular term infodemicduring the covid19 pandemic constitutes another one important task for governments and politicians from a political communication perspective conspiracy theories about covid19 often debunk political messages distort public perception of the virus and eventually weaken the credibility of the source of such political information and guidelines 51 conspiracy theories about the pandemic have also reduced the perceived effectiveness of political messages and recommendations of health containment behaviors 52 thus perceived morality constitutes an important dimension for policymakers to take into account so that to reduce any distortion of information about the pandemic enhancing public wellbeing and encouraging peoples engagement with health recommendations 53 by considering the mediating role of moralityeither in an individual or a group cooperative levelin the association between beliefs in conspiracy theories about covid19 and the actual engagement with health containment behaviors and policy support politicians can tailor their political messages to communicate strategically structured narratives advancing public health appealing to individual and collective welfare ensuring at the same time the communication of comprehensive and accessible health information overall the covid19 pandemic constitutes a global challenge for governments and countries as well as for the people whose lives have been significantly affected in a digital era when fake news conspiracy theories and rumors circulate and spread impressively fast the pandemic features an additional challenge the identification of the actual effects of such conspiracies on important dimensions such as peoples moral judgements and behavioral change factors which are crucial to determine the spread of the virus and the future of public health appendix a symbolization and internalization items of the moral identity scale symbolization items • i often wear clothes that identify me as having these characteristics • the types of things i do in my spare time clearly identify me as having these characteristics • the kinds of books and magazines that i read identify me as having these characteristics • the fact that i have these characteristics is communicated to others by my membership in certain organizations • i am actively involved in activities that communicate to others that i have these characteristics internalization items • it would make me feel good to be a person who has these characteristics • being someone who has these characteristics is an important part of who i am • i would be ashamed to be a person who had these characteristics • having these characteristics is not really important to me • i strongly desire to have these characteristics the data can be found at the webpage of the international project data curation theofilos gkinopoulos formal analysis theofilos gkinopoulos christian truelsen elbaek methodology theofilos gkinopoulos supervision theofilos gkinopoulos writing original draft theofilos gkinopoulos writing review editing theofilos gkinopoulos christian truelsen elbaek panagiotis mitkidis

believing in conspiracy theories is a major problem especially in the face of a pandemic as these constitute a significant obstacle to public health policies like the use of masks and vaccination indeed during the covid19 pandemic several ungrounded explanations regarding the origin of the virus or the effects of vaccinations have been rising leading to vaccination hesitancy or refusal which poses as a threat to public health recent studies have shown that in the core of conspiracy theories lies a moral evaluation component one that triggers a moral reasoning which reinforces the conspiracy itself to gain a better understanding of how conspiracy beliefs about covid19 affect public health containment behaviors and policy support via moralityrelevant variables we analysed comprehensive data from the international collaboration on the social moral psychology icsmp of covid19 consisting of 49965 participants across 67 countries we particularly explored the mediating role of two levels of morality individual and groupbased morality results show that believing in conspiracy theories reduces adoption of containment healthrelated behaviors and policy support of public health measures but moral identity and moralityascooperation significantly mediate this relationship this means that beliefs in conspiracy theories do not simply constitute antecedents of cognitive biases or failures nor maladaptive behaviors based on personality traits but are morally infused and should be dealt as such based on our findings we further discuss the psychological moral and political implications of endorsement of conspiracy theories in the era of the pandemic

using a comprehensive proven tool like the equity matrix proposed by dr shainoor ismail and colleagues is critical to avoid exacerbating inequities with the inequitable allocation of sarscov2 vaccines without such a roadmap to illuminate the diverse spectrum and sources of inequities to direct ethically just interventions our passage out of this pandemic will inevitably be slow and bumpy navigating inequities a roadmap out of the pandemic the covid19 pandemic has necessitated physical gaps between individuals with distancing and exposed unjust gaps of disparities between populations without a thoughtful roadmap for the equitable allocation of vaccines this pandemic will lead to the exacerbation of inequities between and within countries like sarscov2 the affliction of the social gradientwhere those at lower socioeconomic positions have inferior levels of healthinfects all countries regardless of level of wealth 1 the sarscov2 virus is novel but disparities are not it is no longer sufficient to don a single vision equity lens to examine some disparities some of the time a comprehensive investigation of all health inequities and the complex reasons for these inequities is urgently needed for the implementation of fair restorative interventions here we present the first validated successfully used equity framework applied to covid19 unlike anything in the literature to date this framework illuminates the spectrum of health inequities navigates their sources and intersections and helps avoid deepening disparities through ethically just policies such a roadmap is critical to steer global leadership towards the mitigation summary box ► the covid19 pandemic has magnified inequities and threatens to exacerbate them with the inequitable allocation of scarce resources like vaccines ► using a single vision equity lens to consider some inequities some of the time without understanding their sources and intersectionality leads to policies and programmes that blindly deepen disparities and further stigmatise and discriminate ► diverse interventions that are inclusive and respectful of all populations will be paramount to stop transmission of this virus and inequities ► we present the first validated equity tool applied to covid19 that provides evidence and guides research on the full spectrum of health inequities analyses their sources and interactions and directs diverse and ethically just interventions appropriate for pluralistic societies ► this equity matrix fills a gap in discussions on managing the covid19 pandemic and is urgently needed to steer global leadership away from deepening disparities and towards equitable programmes and policies on february 16 2024 ► differential disease severity has been shown to have large independent associations with chronic medical conditions and obesity 10 ► differential disease severity has been shown to have moderate independent associations with obesity and haematological malignancy 10 ► no clear evidence of an independent association of differential disease severity in pregnancy currently exists 10 however the possibility has been suggested in some studies ► 49 of data collection processes in their communities ► consider these populations as key groups for vaccination ► facilitate rides to immunisation clinics or home visits for those who are immobile to improve access to vaccine and testing for infection ► offer vaccination at healthcare visits for preexisting conditions ► enable ipc measures † to reduce exposure place of residence ► differential exposures in institutions exist with evidence of a high number of outbreaks in longterm care facilities hospitals prisons shelters 50 ► outbreaks involving large numbers of reported cases have occurred in rural and remote communities 50 ► differential disease severity has been shown to have large independent associations with homelessness 10 ► homeless populations and those living in sheltersgroup homes or in overcrowded neighbourhoods or homes as well as rural remote and indigenous communities have differential exposure and challenges with physical distancing and other ipc measures † as well as potentially decreased access to healthcare ► indigenous communities have been disproportionately impacted in previous pandemics 4 multiple possible intersections such as preexisting condition ses educationliteracy level social capital racialisation ► include these populations in clinical trials of interventions ► consider these populations as key groups for vaccination ► consider standing orders in institutions and mobile clinics in hardly reached populations to improve access to immunisation ► enable ipc measures † to reduce exposure ► consider vaccinating all eligible individuals in remote areas facilitated by community membersleadersadvocates for efficient effective use of resources ► support programmes and policies aimed to assist and empower systemically marginalised populations and improve access to healthcare racialisation ► differential disease severity has been shown to have large independent associations with some racialised populations 10 evidence of higher rates of covid19 and differential disease severity in ethnoculturally diverse neighbourhoods exists 17 18 19 ► racialised populations have differential access to healthcare and may experience stigmatisation and discrimination lower vaccination rates have been observed in immigrant children and seniors for other vaccinepreventable diseases 41 visible minorities and indigenous canadians appear to be less willing than nonvisible minorities to get an effective recommended sarscov2 vaccine 42 ► immigrantrefugee populations or migrant workers may have differential exposure due to international travel ► racialised populations are disproportionately represented in precarious jobs and workplace settings such as in the food or healthcare sectors and often reside in multigenerational living spaces leading to differential exposure and transmission within communities multiple possible intersections such as ses place of residence occupation preexisting conditions social capital educationliteracy level ► include populations from diverse racial ethnic and cultural backgrounds in clinical trials ► address racialised barriers to accessing healthcare and support policies that target systemic racism and protect the rights of racialised groups ► consider these populations as key groups for vaccination ► offer alternate immunisation settings such as mobile worksite or afterhours immunisation clinics and testing ► enable improved ipc measures † to reduce exposure gender identitysex ► differential disease severity has been shown to have a large independent association with male sex 10 that may be linked to immunological sex differences or gendered differences in behaviours such as differential access to healthcare before progression of disease ► gendered differences in caregiver roles genderbased violence and socioeconomic instability may result in differential direct and indirect impacts of the pandemic multiple possible intersections such as occupation preexisting conditions ses social capital risk behaviours ► consider gendersexinclusive vaccination policies ► address gendered barriers to accessing healthcare and vaccination programmes ► support sex and genderbased analyses ► support programmes and policies aimed to assist and empower systemically marginalised populations and improve access to healthcare ► enable improved ipc measures † to reduce exposure ► support programmes and policies aimed to assist and empower systemically marginalised populations and improve access to healthcare educationliteracy level ► those with lower education or literacy levels potentially have decreased access to healthcare lower levels of education have been associated with lower vaccination rates in all age groups for various vpds 44 45 ► those with lower education or literacy levels are less likely to be able to work from home potentially leading to differential exposure ► international students may have differential exposure if they travel internationally and differential access to healthcare if not insured multiple possible intersections such as place of residence occupation preexisting conditions smoking ses racialisation ► offer alternate immunisation and testing settings to improve access ► provide educational materials at appropriate literacy levels ► have translators available in clinics ► enlist multilingual familycommunity members to assist in communication socioeconomic status ► differential disease severity has been shown to have large independent associations with low socioeconomic status 10 ► populations with lower income status and inability to pay for ipc resources higher risk occupations with limited ipc measures † job insecurity and inability to work from home have differential exposure ► lack of healthcare insurance or inability to pay for healthcare interventions may result in differential access vaccination rates tend to be lower in lower socioeconomic groups for various vpds even if vaccines are publicly funded 43 bmj global health of the unfair burden of this pandemic on marginalised populations who systemically experience greater obstacles to health equity matrix a validated tool to help fix complex issues the equity matrix is the first peerreviewed published tool that comprehensively outlines how to methodologically assess and respond to critical equity issues in a timely practical way it is part of a broader framework that also integrates ethics feasibility and acceptability to ensure appropriate implementation of public health recommendations 2 the resources and time taken to develop this overall framework through 5 years of environmental scans stakeholder consultations surveys and literature reviews have reduced the resources and time taken to implement it the evidenceinformed equity tool supporting the overall framework has been validated for its utility and comprehensiveness and successfully used for vaccines in recent years traditionally most vaccine guidelines rigorously assess clinical factors such as efficacy and safety while equity is increasingly considered conceptually it is not explored systematically or transparently the equity matrix has been fundamental in guidance on covid19 immunisation by canadas national immunization technical advisory group the national advisory committee on immunization 3 4 and may be valuable to other nitags and organisations around the world hastening to develop recommendations on covid19 health products based on principles of equitable access and fair allocation 5 6 7 application of this matrix for the development of recommendations on the use of interventions such as sarscov2 vaccines will be critical to reduce rather than exacerbate inequities the pursuit of health equity has become a worldwide public health objective 1 the equity matrix though initially developed for vaccine guidance can be applied across a broad spectrum of policy and programme interventions to pursue this objective while complex in nature health inequities share common features they are systematic avoidable and unfair 8 they arise because of the circumstances in which people grow live work age and the systems put in place to deal with illness 1 they can be modified through altering institutions policies and practices that cause inequitable distribution of power and resources 9 the equity matrix provides a ► no large increased risk in hospitalisation in current or former smokers has been observed to date with limited data for associations with substance use disorders 10 however data continues to evolve ► these populations may have differential access to healthcare ► indirect impacts of the pandemic could lead to increased substance use with increased substancerelated deaths and harms multiple possible intersections such as ses social capital place of residence preexisting conditions educationliteracy level ► include these populations in clinical trials following reb guidelines and ocap principles 49 bmj global health roadmap to navigate health inequities with interventions that uphold the ethical principle of justice with the socially just distribution of limited resources it can be applied within and between countries and regions so that scarce initial supplies of sarscov2 vaccines are effectively distributed globally based on a gradient of risk rather than a gradient of wealth it is also an inclusive tool to direct surveillance and research and unveil epidemiological uncertainties and evidence of yet undiscovered inequities of novel diseases like covid19 table 1 reflects the equity matrix we populated with emerging evidence for covid19 in consultation with other experts and stakeholders it was used to inform guidance for the efficient effective and equitable allocation of sarscov2 vaccines in the context of limited initial supplies in canada 4 as well as research priorities for clinical trials 3 the table incorporates results of a rapid review of risk factors for severe outcomes in organisation for economic cooperation and development member countries 10 technical experts and policymakers in consultation with stakeholders across sectors can populate the equity matrix with evidence relevant to the country or countries for which policies are being made the completed tool can be adapted over time to succinctly and comprehensively summarise uptodate evidence and guide research and surveillance where evidence is lacking the first column summarises biological and social factors that may contribute to health inequity this allows the identification of groups at high risk for whom reduced access to a public health intervention may further exacerbate the inequity for each group identified the sources of the inequity are explored to aid in the process of reviewing interventions that could address the inequity and improve access while experts acknowledge that inequities must be taken into account when considering government interventions there is no scientific consensus on how to effectively take action to reduce these inequities 11 evidence on interventions aimed at individual determinants of health and on the impact of intersectoral action on health equity is limited 12 13 this should not be interpreted as a lack of effect but rather insufficient rigour in evaluations of these interventions 13 a systematic review conducted to inform the equity matrix found limited evidence on the effects of interventions on hospitalisation for or mortality from vaccinepreventable diseases and the evidence from these trials was uncertain 14 randomised trials of immunisation aimed at improving health equity is unethical and measuring the outcome of health inequities related to many vaccinepreventable diseases requires longterm followup wellconducted scientifically rigorous ethical studies of interventions evaluating the impacts on health equity would be valuable to populate this tool however a paucity of such evidence should not preclude the implementation of ethically just interventions therefore the third column of table 1 was completed with stakeholder and expert input on interventions that could address inequities the equity matrix supports the inclusion of multisectoral interventions for structural systemic changes needed to address inequities however given the urgent need for equitable health policies in this pandemic table 1 focuses on shortterm actions within the health sector with examples for immunisation specifically the information summarised in this matrix is critical to ensure equity issues are appropriately addressed and integrated into expert health guidance including recommendations on the optimal use of sarscov2 vaccines illuminating the spectrum of health inequities evidence linking severe covid19 disease to biological risk factors such as advanced age and preexisting conditions is wellestablished 15 16 evidence continues to emerge separately about the links between covid19 and factors such as ethnoracial background 17 18 19 the equity matrix comprehensively illuminates an array of overlapping factors that compound health inequity the spectrum of factors included in the first column of this matrix was adapted from the progressplus model of health determinants and outcomes 20 we expanded the categories captured in progressplus and added important health equity factors that were not explicitly included in the existing model such as having preexisting conditions racialisation age and behaviours such as drug or alcohol use and smoking the categorical inclusion of these factors ensures that they are unequivocally considered these additional factors are all critically relevant to covid19 epidemiology and infectious diseases in general and were among the most commonly investigated factors in a systematic review on health inequities related to vaccination 14 the resulting p 2 rogress and other factors framework was used to guide a rapid review on covid19 which included studies using multivariate analyses to adjust for potential confounders 10 using this framework the review illuminated independent biological risk factors and independent social risk factors where evidence exists as well as potential risk factors for severe outcomes of covid19 where evidence is sparse disregarding potential inequities due to the absence of disaggregated data such as in migrant workers differentially exposed to sarscov2 could undermine an effective pandemic response using the equity matrix to recognise that inequities may exist where evidence does not exist is important for ethically just interventions where people are treated with equal concern and respect bmj global health navigating the sources and intersections of health inequities public policies should unravel inequities to avoid perpetuating them the second column of the equity matrix outlines reasons why an inequity may exist including differential access to healthcare or as outlined in the quinn and kumar framework 21 pathways through which various factors can influence the differential exposure susceptibility severity and consequences of infectious diseases the matrix also illustrates how different factors converge to produce inequities for example inequities due to socioeconomic status intersect across multiple factors populations living in deprived areas as well as visible minorities and immigrant populations seem to be disproportionately affected by covid19 with differential severity in the usa 17 england 18 and parts of canada where data exists 19 the rapid review of evidence summarised in table 1 found that low income and ethnoracial background were important independent risk factors for severe outcomes of covid19 10 this review also found that diabetes is an important independent risk factor for severe outcomes of covid19 the association between low income ethnoracial background and risk of type 2 diabetes is wellestablished in many countries 22 23 24 though found to be independently associated with increased risk of severe covid19 the intersection between these factors is important to acknowledge the negative association between racism and physical health mental health and health risk behaviours is wellestablished 25 even in countries with universal healthcare policies evidence on differential access to quality healthcare among racialised populations exists 25 such intersections are especially important to note because the direct effects of genetic or biological host factors on disproportionately higher rates of severe covid19 in racialised groups remain unknown and research into the contribution of policy healthcare system and societylevel determinants to the roots of such inequities is needed 26 male sex has been found to be an independent risk factor for severe outcomes of covid19 10 even though cases of covid19 appear to be equally distributed between the sexes worldwide 27 biological or immunological differences may contribute to this inequity 28 but gendered differences in occupations and behaviours such as differential access to healthcare before progression of disease may also explain observed differences while direct evidence on differences in severe outcomes due to male sex exists indirect and direct impacts of the pandemic due to gendered differences in caregiver roles genderbased violence and socioeconomic instability cannot be ignored disproportionate rates of infections with devastating consequences have occurred in previous epidemics among indigenous canadians 29 and are being observed in the current covid19 pandemic among indigenous peoples in other countries 30 31 differential disease exposure and severity in these populations are not only linked to differential access to quality healthcare but also systemic racism in society and the healthcare system inequities in the social determinants of health such as adequate housing 32 and an underlying history of colonialism 33 similarly migrant and ethnic minority populations have been disproportionately affected by infectious diseases and epidemics in the midst of economic crises in the past due to lack of access to healthcare and poor living conditions 34 in the current pandemic these populations are also subject to differential exposure to sarscov2 due to disproportionate representation and precarious occupations in sectors such as food and healthcare deemed essential and not subject to lockdowns 35 reduced access to paid time off and personal protective equipment or other infection prevention and control measures in congregate living and work settings perpetuates transmission of infection within communities recognising the intersectionality of the social determinants of health in predisposing systemically marginalised populations to inequitable health outcomes is critical to changing the course of this pandemic a focus solely on biological explanations of disease is narrow and has been damaging to science and people labelling populations as vulnerable without understanding the reasons for the increased risk in outcomes causes further stigmatisation and discrimination the equity matrix allows for holistic reflections on biological and social inequities and their origins and intersections rather than fragmented assessments that could perpetuate harmful misunderstandings injustices and ineffective public health solutions identifying how to close rather than widen the gap of health inequities applying an equity lens to bring inequities into focus without a vision to alleviate them is shortsighted in order to be effective public health actions in a pluralistic society cannot ignore diversity in disparities therefore the equity matrix includes a third column identifying practical interventions to reduce varied inequities in the face of limited interventional resources such as vaccines and costprohibitive populationlevel programmes or product characteristics where vaccine effectiveness cannot support herd immunity populationbased risk assessments must extend beyond traditional biological risk factors to be successful and fair in immunisation strategies where some groups may get vaccine earlier than others to reduce morbidity and mortality of covid19 and minimise disruption to society healthcare systems and the economy specific strategies to increase access to interventions and respectfully engage systemically marginalised populations will be required as summarised in table 1 pluralism is a prerequisite for success and respect for the diversity of communities and traditions is the key to open doors rather than a reason to put up walls this has been evident in the success of indigenous communities in canada who through public health interventions should navigate inequities in order to reduce them through inclusion rather than exacerbate them with policies of neglect for example real efforts should be made to include populations from a variety of socioeconomic gendered and racialised backgrounds in clinical trials unfortunately an examination of a subset of published studies investigating the effects of covid19 treatment found that a third of the studies did not report ethnoracial data and black patients were underrepresented in all studies relative to the burden of disease among black communities in which the studies took place 37 such exclusions in vaccine clinical trials contribute to distrust and vaccine hesitancy 38 while there is a race to develop sarscov2 vaccines public surveys indicate that there may not be a race to get one 39 40 41 42 vaccine hesitancy has been deemed one of the top ten global heath threats by the who in 2019 43 and could limit the success of a covid19 immunisation programme in canada an examination of acceptability of sarscov2 vaccines and coverage rates of existing vaccines reveals additional issues contributing to inequities in groups already at high risk of severe covid19 visible minorities and indigenous canadians appear to be less willing than nonvisible minorities to get a sarscov2 vaccine that is effective and recommended 42 though significant differences in willingness to get a sarscov2 vaccine have not been observed by sex or socioeconomic status in canada 41 42 vaccination coverage rates in general have tended to be lower among men and those in lower socioeconomic groups 44 45 suggesting issues related to decreased access to vaccines even among healthcare workers who tend to have higher vaccine coverage rates uptake varies by ethnicity 46 studies have demonstrated protection against infection with the appropriate use of ppe in healthcare workers 47 48 unfortunately differential access to and training in the use of ppe and other ipc measures intensifies inequities key reasons for vaccine hesitancy include complacency inconvenience in accessing vaccines and lack of confidence 43 population differences in access to and trust in vaccines and healthcare as well as intent to get a safe effective sarscov2 vaccine should influence the direction of effective interventions as outlined in the equity matrix for example offering publicly funded vaccines in key highrisk groups ensuring vaccines are safe and effective in all highrisk groups and providing mobile immunisation clinics with recall and reminder systems could increase access to vaccines for many populations engaging social influencers and leaders of cultural and faithbased groups with communitydriven efforts for coordinated public health approaches and immunisation programme planning and providing culturally sensitive educational materials in appropriate languages literacy levels and media channels could combat misinformation and mistrust about vaccination in general and sarscov2 vaccines specifically receiving a recommendation from a healthcare provider is linked to increased acceptance for vaccination in general 2 and trust in doctors is a key factor in willingness to get a sarscov2 vaccine 41 empowering healthcare providers and the public with transparent evidenceinformed recommendations based on systematic analyses of critical equity issues in addition to factors such as the safety and efficacy of interventions is vital diverse strategies will be required for diverse inequities conclusions navigating health inequities using this roadmap can assist in the development of evidenceinformed pluralistic socially just effective policies that respect diversity rather than deepen disparities our systematic framework examining the spectrum of inequities and their sources enables policy makers around the world to direct public policies toward interventions and programmes that will reduce avoidable unjust unnecessary inequities in this pandemic and beyond the equity matrix also provides an inclusive tool to direct surveillance and research in order to unveil epidemiological uncertainties of novel diseases like covid19 data disaggregation by variables such as racialised groups is critical to avoid assumptions or the exclusion of populations from the covid19 response without seeing these data we turn a blind eye to inequities while our matrix for covid19 may be limited by evidence available and will require input and experience of experts and stakeholders its utility is enhanced as it draws on evidence and experience from other vaccinepreventable diseases the equity matrix provides a comprehensive map identifying where additional research and surveillance into inequities their intersections and evaluation of interventions to address inequities is required in a journey where the desired destination is clear but the path to success is less certain a roadmap to navigate the unknowns and illuminate inequities that exist along the way has been absent and is urgently needed our application of the equity matrix to covid19 sheds light on the evergrowing spectrum of inequities magnified by this pandemic and leverages previous successes of its use to develop effective comprehensive and timely guidance on track with the race for covid19 interventions we urge policy makers in countries across the social gradient to use a tool like the equity matrix as a compass to direct ethically just policies towards interventions and programmes that will reduce disparities policies and research that ignore inequities including their sources and intersections will perpetuate them and inevitably slow our passage out of this pandemic and into a more equitable and just future data availability statement there are no data in this work

the covid19 pandemic has exposed social inequities that rival biological inequities in disease exposure and severity merely identifying some inequities without understanding all of them can lead to harmful misrepresentations and deepening disparities applying an equity lens to bring inequities into focus without a vision to extinguish them is shortsighted interventions to address inequities should be as diverse as the pluralistic populations experiencing them we present the first validated equity framework applied to covid19 that sheds light on the full spectrum of health inequities navigates their sources and intersections and directs ethically just interventions the equity matrix also provides a comprehensive map to guide surveillance and research in order to unveil epidemiological uncertainties of novel diseases like covid19 recognising that inequities may exist where evidence is currently insufficient successfully applied to vaccines in recent years this tool has resulted in the development of clear timely and transparent guidance with positive stakeholder feedback on its comprehensiveness relevance and appropriateness informed by evidence and experience from other vaccinepreventable diseases this equity matrix could be valuable to countries across the social gradient to slow the spread of sarscov2 by abating the spread of inequities in the race to sarscov2 vaccines this urgently needed roadmap can effectively and efficiently steer global leadership towards equitable allocation with diverse strategies for diverse inequities such a roadmap has been absent from discussions on managing the covid19 pandemic and is critical for our passage out of it

introduction hierarchy is a central organizing principle of complex systems manifesting itself in various forms in biological social and technological systems 1 therefore to understand complex systems it is crucial to quantitatively describe hierarchies 2 3 4 5 and to identify their origins and benefits 67 among the various forms of hierarchy here we are concerned with social hierarchies emerging through competition including dominance and status hierarchies or socioeconomic stratification 89 ultimately such hierarchy represents a ranking of individuals based on social consensus a high ranking individual is expected to win a conflict against a low ranking one this type of organization is present in societies ranging from insects to primates and humans 3 10 11 12 and has been linked to resource allocation individual health collective decisions and social stability 7 13 14 15 the prevalence of social hierarchies motivated a long history of theoretical research in statistical physics and mathematical biology 6 16 17 18 19 the unifying theme in explaining the emergence of hierarchies is positive reinforcement of differences known as the winner effect initially equally ranked individuals repeatedly participate in pairwise competitions and after an individual wins the probability that they win later competitions increases conditions for hierarchies to emerge under this mechanism and their structure has been thoroughly investigated 911 18 19 20 yet from experiments focusing on animal groups we known that in addition to social reinforcement intrinsic attributes also play a critical role in hierarchy formation 911 the relative strength of the two effects depends on context however it was observed that they both affect hierarchies ranging from species with relatively simple social interactions such as cichlid fish 21 to species that form highly complex societies such as primates 1322 despite the clear indication from experiments that both talent and reinforcement matter we are lacking general theoretical understanding of their synergistic impact 2324 here we develop a rigorous model incorporating both and show that this captures a much richer landscape for pairwise interactions we show a tradeoff between relationship stability and having more talented individuals be the highranked leaders we then extend the model to open populations where individuals enter and leave the group and we characterize both the global and the local structure of hierarchies another pressing issue is to understand the response of hierarchical structure to perturbation eg the effect of removing an individual in particular animal behavior experts must often make strategic decisions to remove individuals from captive societies due to health issues or in attempt to promote social stability which sometimes lead to unanticipated reorganization of hierarchy and even societal collapse 1425 we show herein that if either talent or social reinforcement dominate hierarchy formation the associated models predict smooth response and no rearrangement it is only if their effects are equally important that removal of an individual can lead to a nontrivial series of rank reversals model our starting point is a classic model by bonabeau et al that considers only social reinforcement 6 it describes a group with n members where the rank of each member is determined by its ability to defeat others in pairwise competitions this ability is quantified by a score x i where the subscript indexes the individuals the scores are initially identical ≡ 0 and they change through two discretetime processes first through positive feedback in each time step participants are randomly paired to compete with each other and the winner increases its score by δ individual i wins against j with probability q ij 1 1 exp β x j where β is an inverse temperaturelike parameter for large β the outcome of the fight is deterministic for β 0 both parties have equal chance to win the second process is forgetting the effect of a fight wears off exponentially ie x i is reduced by µx i in each time step describing the full process with the deterministic equation x i x i δ n 1 j i q ij it was shown that depending on the relative strength of reinforcement and decay the model supports either egalitarian or hierarchical steady state solutions 626 to introduce intrinsic attributes we offset the score of each participant in eq by base abilities b i and b j q ij 1 1 exp β b i x j b j parameter b quantifies talents that are independent of social processes yet are relevant to conflict outcomes such as strength or intelligence this modification although formally simple requires new mathematical description and leads to series of nontrivial behaviors and unanticipated emergent properties two individuals to understand the consequences of intrinsic differences it is insightful to first investigate a population of n 2 the deterministic equation describing the steady state is 0 µ∆x δ 2 1 exp β 1 where ∆x x 1 x 2 and ∆b b 1 b 2 ≥ 0 introducing dimensionless quantities ∆x β∆x ∆ b β∆b and µ leads to 0 ∆x 2 1 exp ∆x ∆ b 1 meaning that the steady state is determined by the talent difference and a single parameter measuring the relative strength of decay to social reinforcement 27 supporting the opposite order which is unfair meaning that the less talented outrank the more talented in other words social reinforcement can outpace intrinsic abilities we call the ∆x 0 solution fair and the ∆x 0 one unfair since highranked individuals tend to have better access to resources more impact on collective decisions and higher chance to foster offspring figure 1c shows the dependence of c on ∆ b in general no closedform solution is available limiting cases however can be worked out analytically for small differences we find to answer this question we quantify the stability of a dominantsubordinate relationship with q the probability that the dominant wins a conflict q ≈ 12 indicates an unstable relationship and q ≈ 1 a welldefined relationship stable relationships reduce overall aggression and are positively associated with individual health 15 figure 1b shows that strong social reinforcement increases q revealing a fundamental tradeoff between stability and fairness stable relationships require strong social reinforcement however strong reinforcement allows for unfair hierarchical states similar tradeoff was experimentally observed in rankings of products in a marketplace competing for the attention of consumers strong social reinforcement led to less accuracy in selecting the highest quality product and to larger differences in market share 28 open populations so far we focused on the relationship of two individuals now we turn our attention to larger changing populations we study groups of n individuals where the talent of each individual is drawn randomly from a distribution p we initially allow the population to reach a stable ranking then in each step we remove a random individual and add a new member i to the bottom of the society ie x i 0 and again allow the population to reach a stable ranking for simplicity we restrict our investigation to the β → ∞ limit in which case q ij becomes a step function this allows us to explicitly formulate the condition for two consecutively ordered individuals to reverse ranks during the evolution of the hierarchy 29 eq is satisfied we reverse their order we repeat this until no more pairs are reversed b b ∆x ≡ δ µ in the supplemental material we derive various properties of the hierarchy through exact combinatorics and meanfieldlike approximations 29 the talent b of an individual represents an intrinsic ability or a combination of abilities that influence the outcome of a fight in our analysis we derive a number of properties of social hierarchies for general continuous talent distribution p including heavytailed distributions whenever specific p is necessary for calculations or simulations we focus on the standard normal distribution indeed body size intelligence and other relevant abilities are often normally distributed we now systematically investigate the structure of the emergent hierarchy as a function of ∆x the additional talent difference needed to overcome rank difference we measure correlation between rank and talent and between rank and experience using kendalls tau coefficient where experience is the amount of time an individual has spent in the population for example τ tal 1 indicates talent completely determines rank and τ tal 0 indicates no correlation analytical calculations and simulations show that for large ∆x rank is dominated by experience meaning that the only way to advance in the hierarchy is if a higher ranking individual is removed and for small ∆x rank is dominated by talent these two limiting cases are separated by a regime where both talent and experience matter theory predicts that the crossover point where τ tal τ exp 12 is ∆x c ≈ 036 for n 100 experimental measurement of τ tal is challenging since it requires exact identification of the relevant talents determining τ exp however is straight forward indeed tung et al established small captive groups of macaques by introducing animals onebyone into an enclosure and found that the spearmans correlation between rank and experience is ρ exp 061 demonstrating that some real systems are in fact near the crossover point 13 in addition to global correlations we also quantify local orderedness by calculating τ tal the talentrank correlation averaged over a sliding window of length w counterintuitively fig 2a shows that in the crossover regime τ tal is negative meaning that locally rank and talent are anticorrelated figure 2b provides an additional aspect of this paradox situation the expected talent b of an individual ranked kth at a random time step monotonically increases with rank yet the probability that the th individual the one immediately outranking the kth is less talented than the kth is greater than 12 to understand the mechanism producing the local anticorrelation first consider two consecutive individuals forming an ordered pair with respect to talent i individual passing the kth will necessarily pass the th too therefore an unordered pair will remain unordered until one of the pair is removed this asymmetry in creating ordered and unordered pairs is responsible for the local anticorrelation finally we also investigate the effect of removing an individual we find that in the talent or experience dominated limiting cases the systems response is trivial and no reorganization happens however figure 3 shows that p rr the probability that removal of an individual induces rank reversals is nonzero in the crossover regime for n 100 understanding the response of hierarchies to external perturbation is an important issue particularly removal of animals from primate groups can sometimes lead to large shifts in hierarchy and instabilities endangering the group 1425 here we demonstrated that traditional models of hierarchy formation those only considering either intrinsic abilities or social feedback predict trivial response to removal and that both effects have to be present simultaneously to observe rank reversals rr for large ∆x and are independent of n for small ∆x ie τ tal τ rr the location of their extreme value is at the crossover of these two regimes and in case of normal talent distribution scales as ∼ 16 n 13 we find universal bounds τ tal ≥ 2 ln 2 1 p rr ≤ 0294 for any continuous unbounded talent distribution and these bounds are reached in the large population limit for global talent correlation on the other hand we find that or if individuals do not randomly select opponents but selectively compete with similarly ranked ones the properties we observed for finite hierarchies may become more pronounced in the large population limit for example if n ∆x → ∞ but √ n ∆x → 0 global correlation τ tal converges to one while local correlation approaches its theoretical minimum in table i we provide detailed enumeration of possible behavior in the large population limit assuming ∆xn α c where c 0 is constant τ tal → 1 if √ n ∆x → 0 and τ tal → 0 if √ n ∆x → ∞ discussion we studied the synergistic effect of talent and social reinforcement on the structure of competitive social hierarchies and we identified behaviors that cannot be observed if either effect dominates although we derived our model assuming pairwise conflicts and a winner effect we believe that the results can be interpreted more generally the mechanism behind both local talentrank anticorrelation and removalinduced rank reversals is that to pass someone in rank it is not enough to be more talented but the talent difference has to be sufficient to compensate for the advantage of being higher ranked a in the limit of n → ∞ τ tal τ exp τ tal p rr n diff n 1 α 1 0 1 0 0 α 1 1 0 τ tal p finally our results prompt many research questions both experimental and theoretical for example local anticorrelation and removalinduced rank reversals are predictions that are testable through experiments future theoretical work may investigate sources of complexity not captured by our model for example the role of aging or slow deterioration of talent or nonlinear hierarchies where social tiers are occupied by multiple individuals

hierarchy of social organization is a ubiquitous property of animal and human groups linked to resource allocation collective decisions individual health and even to social instability experimental evidence shows that both intrinsic abilities of individuals and social reinforcement processes impact hierarchies existing mathematical models however focus on the latter here we develop a rigorous model that incorporates both features and explore their synergistic effect on stability and the structure of hierarchy for pairwise interactions we show that there is a tradeoff between relationship stability and having the most talented individuals in the highest ranks extending this to open societies where individuals enter and leave the population we show that important societal effects arise from the interaction between talent and social processes i despite positive global correlation between talent and rank paradoxically local correlation is negative and ii the removal of an individual can induce a series of rank reversals we show that the mechanism underlying the latter is the removal of an older individual of limited talent who nonetheless was able to suppress the rise of younger more talented individuals

introduction nowadays the issue of masculinity is the subject of various social debates as well as of interest and discussions among representatives of various scientific disciplines especially the cultural studies popular today the situation is different when we refer to past epochs when these topics were rarely addressed and even when they were addressed the category of masculinity was generally not used explicitly how this state of affairs was possible in a maledominated world is interestingly explained in the introduction to the encyclopaedia dedicated to men and masculinities coedited by michael kimmel and amy aronson where it is pointed out that there are libraries filled with volumes about men and university course catalogues are overflowing with courses about men but rarely are these volumes or these courses about men as men that is rarely are they also about gender instead they are called history or literature or political science its probably fair to say that if the course doesnt have the word women in the title its more than likely about men except that its rare for masculinity to be discussed at all 1 thanks to raewyn connell in contemporary studies on men masculinity is increasingly referred to in the plural form based on her research r connell argues that there are different masculinities existing simultaneously in every culture and epoch with one that is dominant and can be called hegemonic 2 this type of masculinity is also the subject of this research however since the understanding of hegemonic masculinity according to r connell 3 based on power relations only partly corresponds to the specificity of my research below i will not only use the abovementioned category but also the notion of traditionally understood masculinity in my opinion this concept better reflects the cultural background of the constructing of the dominant model of the ideal man in the area i have analysed starting from the perspective of social constructionism 4 this article focusses on the cultural conditions of structuring traditionally understood masculinity in the mid19 th century on the example of the polish community of west prussia at this point especially for the nonpolish reader it is worth to devote at least a few sentences to the introduction of west prussia the region in question was part of the polish state in the second half of the 18 th centu1 introduction in men and masculinities a social cultural and historical encyclopedia vol 1 aj by m kimmel a aronson santa barbara denver oxford 2004 xv see k kłosiński dekonstrukcja męskości deconstruction of masculinity teksty drugie 2015 2 p 13 2 rw connell a whole new world remaking masculinity in the context of the environmental movement gender and society 1990 4 p 454 3 rw connell jw messerschmidt hegemonic masculinity rethinking the concept gender and society 2005 6 s 832 ł skoczylas hegemoniczna męskość i dydwidenda patriarchatu o społecznej teorii płci kulturowej raewyn connell hegemonic masculinity and the dividend of patriarchy on raewyn connells social theory of cultural gender refleksje reflections 2011 4 p 1214 4 the understanding of social constructionism was adopted after p berger and t luckmann among other things these authors point out that reality is socially defined but the definitions are always embodied that is concrete individuals and groups of individuals serve as definers of reality to understand the state of the socially constructed universe at any given time or its change over time one must understand the social organization that permits the definers to do their defining pl berger t luckmann the social construction of reality a treatise in the sociology of knowledge penguin books london 1991 p 134 ry then as a result of the partitions of poland from 1772 it became an integral part of prussia at different times west prussia formed a separate province with a capital in gdańsk in 1920 the treaty of versailles returned most of the region to poland and the free city of danzig was established on the territory of danzig itself and the surrounding area since 1945 the entire area is located within the borders of poland and is now known as the vistula pomerania since i have highlighted the polish community as the subject of my research it is also worth noting the nationality relations that existed in the area under study according to various estimates in the second half of the 19 th century and the beginning of the 20 th century the population of west prussia was dominated by speakers of german the polish community was a minority the third national group was a small jewish population 5 it is worth noting that due to the multicultural character of west prussia the nationality choices of its individual inhabitants were not always unambiguous even in the first half of the 19 th century identity was determined more by religion than nationality ie catholicism was clearly dominant among the polish population and protestantism among the german population 6 7 as a result the views represented by the polish community were influenced more by the polish catholic clergy and representatives of the polish national movement than by the prussian administration that was associated with protestantism my decision to limit the analysis to the polish population was therefore guided both by the cultural and religious differences between germans and jews and by the influence exerted on the community under study by the polish intelligentsia warszawa 1909 p 553 j borzyszkowski inteligencja polska w prusach zachodnich 18481920 polish intelligentsia in west prussia 18481920 gdańsk 1986 p 18 m wojciechowski stosunki narodowościowe w prusach zachodnich w początkach xx wieku ethnic relations in west prussia at the beginning of the 20 th century in regiony pograniczne europy środkowowschodniej w xvixx wieku społeczeństwo gospodarka polityka border regions of central and eastern europe in the 16 th 20 th century society economy politics eds m wojciechowski r schattkowsky toruń 1996 p 7273 6 cf k wajda świadomość narodowa chłopów polskich na ziemiach pod panowaniem pruskim przesłanki integracji narodowej chłopów i jej przebieg national awareness of the polish peasantry under prussian rule the prerequisites for national integration of the peasantry and its process acta universitatis nicolai copernici historia 1997 322 p 141 paweł śpica methods and source basis of research conducting research on the issue of masculinity in relation to the 19 th century poses a certain challenge when we consider that this category was not at the centre of attention of the polish society at the time and also when the researchers area of interest is limited to a relatively small region perceived on a macrohistorical scale as peripheral this is the case with the aim of the present research ie investigating cultural factors constructing the traditionally understood masculinity in the polish community in west prussia in the middle of the 19 th century the realisation of this objective was only possible thanks to a contextual analysis of the polish journalistic writing of the studied region published in the period in question in the polish environment of west prussia the position of men in social life and even more so the subject of masculinity closer to our current considerations was not the subject of wider analysis in the area studied the functions and upbringing of women were given far more prominence as a result of the special role which was attributed to the mother in the process of maintaining and developing polish culture at a time when poland was deprived of its own statehood and because of the emerging process of womens emancipation in europe for the 19 th century society of west prussia however the roles and position of men in the family and society were so obvious unambiguous and unquestionable that they were barely discussed yet due to the fact that the publicists of the time often condemned the vices and shortcomings of the polish population we are in possession of source material on the expectations placed not only on women but also on men which allows us to formulate conclusions on the image of the model man of the period in question the research results presented in this article have been developed based on the method of critical analysis of sources characteristic for historicaleducational research in this particular case the polish journals of west prussia from the midnineteenth century were analysed all polish newspapers published in the region at that time were selected to carry it out however their journalists very rarely wrote about men as men therefore this publication uses only those press titles that directly and indirectly refer to the role of men in the family and society therefore the conducted research covered the following newspapers from the midnineteenth century biedaczek katolik dyecezyi chełmnińskiej nadwiślanin and gospodarz in addition to the abovementioned press the journal pielgrzym published since 1869 was also used due to the references to the analysed issues clearly appearing in this newspaper cultural factors conditioning the construction of male identity in the light of an analysis of the polish west prussian journalism publications preserved publications allow for the identification of several fundamental factors constructing male identity in the mid19 th century west prussia to which i would like to devote particular attention in this article ie the dominant narrative on the role of the male in the family the place of the male in social structure the role of insurrectionary and organic work ethoses the influence of professed faith and views proclaimed by catholic moralists on the role of men in the family and society as well as beliefs resulting from these views on male sexuality in addition to these factors it is also worth mentioning the cultural transmission of attitudes and behaviour patterns quite often based on traditional customs and habits originating in the nobility and folk culture as well as the importance of individual family relationships all the abovementioned determinants apart from the last two which are more or less correlated with each other constituted the hegemonic ideal of masculinity of poles in the studied region at that time at the same time some of these factors shaped different types of identity dominant narrative on the male role in the family in the 19 th century polish journalism of west prussia we are confronted with a uniform picture of the role of men in the family and society resulting from the discourse of gender polarization dominant in the region in question this discourse apparently delineated the basic characteristics of masculinity it was usually promoted by anonymous authors of articles published in the most influential opinionforming polish periodicals published in west prussia8 the nature of the views presented by the aforementioned authors was generally imitative as the idea of gender polarisation appears in the views of many philosophers including jeanjacques rousseau immanuel kant johann gottlieb fichte wilhelm von humboldt or joachim heinrich campe this idea was based on the belief that there are natural differences between men and women who complement each other but they are determined to perform different social roles 9 the concept of gender polarisation was therefore strictly essentialist in the traditional view the tasks of a man as a husband and father primarily included looking after the familys material wellbeing providing it with a sense of security and representing it externally 10 translating these tasks into the language of modern family pedagogy it can be said that the man was required to perform above all the economic protective and representative functions as the undisputed head of the family he also acted as the main decisionmaker analysing various press articles from the area of west prussia we can confidently conclude that in the studied area men were mainly expected paweł śpica to be hard working thrifty frugal sober and honest 11 these expectations were a consequence of the difficult economic situation of many polish families in the 19 th century the cultural image of the man of west prussia did not differ much from the model presented both in other polish lands and in the other provinces of the prussian state this state of affairs can be explained by the patriarchal narrative which prevailed throughout europe and the provincial character of the region in question which in the 19 th century was by no means original in terms of the development of original views on social life nevertheless the dominating discourse of masculinity in west prussia also had its specific foundations this is because the concept of gender polarisation played an important role in the process of maintenance and development of the polish national identity specific roles assigned clearly to men and women based on the traditional division of duties also had particular patriotic connotations the model of gender polarisation was therefore part of the process of transmission of the polish culture this model not only preserved the existing social and intrafamily relations but also a specifically understood polishness which in the absence of polish statehood was based primarily on the traditional family 12 however it is essential to note that in the conditions of west prussia this discourse had a noble character ie it was strongly associated with the views proclaimed by the polish national elites whose individual members even if they did not have noble lineage nevertheless adopted the noble culture as their own superior and most significant culture the polish journalism publications in west prussia strengthened conservative social relations moreover family relations of the time despite the modernisation of society and the economy most often still reflected a feudal mentality in which the position of man in the family reflected the role of the monarch in the state 13 it is worth adding however that in the light of polish publications this role was definitely not to be despotic in character but enlightened based on respect for the subordinate household members such as wife and children although a man had the right to physically punish his children which was in line with the widespread belief that the use of corporal punishment had a generally positive effect on upbringing 14 moralists of the time strongly condemned the abuse of offspring and wife15 in the polish lands as late as the mid19 th century the image of the strict parent was widely accepted excessive leniency and indulgence towards children were perceived as detrimental 16 what is significant is the coherence of the narratives of the various polish authors writing texts on social and family issues in the studied region it resulted from the essentially monolithic structure of the polish intelligentsia of west prussia dominated by the catholic clergy17 the dominance of the clergy among the polish intelligentsia of the region was the result of complicated national relations but also of the views of the local population in the second half of the 19 th century and at the beginning of the 20 th century clergyman was one of the few professions of the intelligentsia that allowed the preservation of polish identity in a relatively straightforward way moreover the peasant community dominant among the polish inhabitants of west prussia saw no need nor had financial means to educate its sons in other professions requiring more than a basic education namely that of a priest meanwhile candidates for the priesthood were often supported by scholarship assistance the views presented by the catholic clergy strongly influenced the entire polish movement including the publishers and editors of the polish press it is therefore not surprising that the polish journalism of west prussia ignored alternative views on the role of men and it expressed strong criticism of various socialist revolutionary emancipatory etc movements developing in western europe18 which could contribute to upsetting the established social relations in west prussia and thus also lead to a redefinition of the current position and role of men meanwhile the uniform coherent conservative model of masculinity created by polish publicists was a serious factor in shaping the local populations ideas about the place of men in the world and provided the men themselves with concrete guidelines on how to structure their own identity the place of men in social structure the coherence of the dominant discourse of traditionally understood masculinity in west prussia was also rooted in the social structure of the region in question it was a peripheral poorly industrialised region the largest city of which had in the paweł śpica mid19 th century a permanent population of no more than 60000 19 as i have already mentioned the polish population was dominated by peasants living in rural areas who despite internal stratification generally held an unequivocally conservative world view as there was no middleincome or wealthy polish bourgeoisie in the area under study the leading role in polish society during the studied period was played by the nobility this was a relatively small but influential social layer with a conservative outlook on malefemale relations similar to the one that characterised the peasants in the 19 th and early 20 th centuries belonging to a particular social stratum determined mens professional activity their functions in the public space and significantly influenced their mentality in the rural environment the more austere farmers fishermen or forest workers differed in their manners from the representatives of the nobility while the former were mostly focussed on how to make ends meet and provide for their families through hard work the latter could devote themselves to politics the economy the national cause etc men from the privileged strata stepped into the role of statesmen fathers of the nation their vocation or even their national duty resulting from the ideals of organic work was to educate the people and try to raise them to a higher economic and cultural level 20 their conviction of their unique role played in the society somehow legitimised the views they proclaimed in its noble version traditional masculinity was characterised by broadly defined fatherhood which meant taking moral responsibility for the local community polish men representatives of nobility were supposed to be guides leaders models of the masculine virtues however in their relations with the representatives of the peasant strata despite the shared faith and language a certain distance and distrust was apparent resulting from the different lifestyle and economic position 21 the stratifying context of the structuring of masculine identity was particularly visible in mens attitudes to education in the mid19 th century concern for a good intellectual education for boys was a clearly discernible trend among the nobility which reflected the change that had taken place in the approach of the elite to the upbringing of their offspring for at the beginning of the 19 th century noble fathers did not yet attach such an important role to the education of their children many fathers belittled the education of their sons claiming that the wealth they would inherit in the future would be far more useful to them than studying meanwhile more or less from the 1840s onwards a belief in the moral and social value of education and upbringing prevailed among the local nobility 22 these views significantly differentiated the men of nobility from those of peasant origin who did not see in academic education any chance of improving their situation as they usually could not afford to send their children to secondary and higher schools in addition peasants often regarded their childrens compulsory schooling as a burdensome necessity reducing the number of hands needed to work the land23 organic work ethos versus insurrectionary ethos the model of masculinity propagated by the polish journalists of west prussia consisted of various components it was an ideal based both on catholic morality inscribed in the polish national context and on elements of prussian culture which somewhat differentiated the polish inhabitants of prussia from their compatriots from russia or austria in this model however we do not find all the features constituting the prussian mentality but only those perceived as valuable from the perspective of shaping and developing the polish identity these qualities included above all the values constituting the prussian work ethos including industriousness thrift and frugality and stemming directly from the german bourgeois mentality and the capitalist mentality 24 this ethos in turn was one of the factors creating the ideals of organic work and groundwork popular especially among poles in the prussian partition starting from the period of the spring of nations 25 the foundations of these ideals included the abovementioned characteristics and were a pattern particularly socially desirable in the last decades of the 19 th century and in the early 20 th century due to the economic struggle between poles and germans these ideals were therefore strongly inscribed in the context of national antagonisms nevertheless the promotion of this peculiarly organic work ethos also involved the creation of a rational masculinity model although for west prussia this was undoubtedly a hegemonic model the local polish journalism used to refer also to the opposite ideal which we can call the sentimentalemotional masculinity when i write about the sentimentalemotional masculinity i mean the model based on the insurrectionary ethos characteristic especially of the polish nobility of the russian partition clearly dominant from the end of the 18 th century until the fall of the january uprising in 1863 but also present in later years especially at the beginning of the 20 th century the model of sentimentalemotional masculinity contrary to rational masculinity was based on the insurrectionary ethos and consisted of a longing for lost independence and the former greatness of the polish state a sense of national injustice and pride expaweł śpica pressed in a kind of moral superiority over the partitioners and the need to undertake armed struggle for independence the insurrectionary ethos assumed that irrespective of previous experience ie defeats authors note the moral duty of a pole a duty from which one cannot evade regardless of one or another rational argumentation is to fight for independence to shed blood for poland if necessary to give ones life for it26 it was therefore a martyrological discourse showing the defeats suffered in terms of ethical victory due to the conditions of west prussia in practice this model never found fertile ground for growth however it was present in the local press for example in the quote from a short excerpt from the heroic deeds of hetman stefan czarnecki referring to the glory of the polish army from the times of the first republic and published by the biedaczek magazine in 1849 it was pointed out that in the past it used to be more glorious to fall in battle than to flee while creating the insurrectionary ethos specific masculine features were pointed out including bravery courage resignation of oneself for the sake of the homeland soldiers hardship honour and above all trust in god the possession of the abovementioned qualities was supposed to inspire pride in the eyes of other people especially women and relatives happy is the mother who gives birth to such sons27 it was written despite the martyrological motifs clearly present in the polish journalism of west prussia the key component of hegemonic masculinity in the studied region remained masculine rationalism which directly resulted in a downtoearth attitude and anticipation of the farreaching consequences of decisions and actions especially in the areas of economics and education this ideal was also strongly associated with the criticism of all selfishness iniquity and immoral behaviour they were opposed with the idea of a man of character ie capable of acting properly according to reason and will as explained on the pages of farmer in 1850 this truth acquired by reason constitutes the scope of mans duty in social and moral life and this virtue which is the realisation of duty by the will constitutes the mans character where there is a correspondence between duty and will between conviction and execution there is the power of character and the weaker the will in working towards the execution of ones conviction the weaker the character28 the influence of faith and the views proclaimed by catholic moralists on the role of men in the family and society irrespective of the place occupied by men in the social structure the perception of masculinity and the role of the man in the polish environment of west prussia was shaped to a large extent by the roman catholic religion and more specifically the interpretation of the truths of faith by the catholic moralists of the time in relation to the family in particular to the role played by the father as i have already mentioned the religious context as a factor constructing male identity was extremely important in the case of the polish community of west prussia as the principles transferred by the catholic church were more important to the poles than the views proclaimed by the prussian ruling elite perceived as foreign and protestant as the parish community was the centre of social life for the local community the views expressed by the clergy were widely heard which does not mean however that they were accepted by everyone and implemented as an everyday practice interesting light on the role of a man in the family and society is shed by moralistic articles published in the mid19 th century on the pages of katolik dyecezyi chełmińskiej they referred primarily to the ideal of a good husband and father in the light of the texts published in katolik it can be concluded that in the perspective of authors a masculine man is above all a person characterised by chivalry a cheerful and lively manner and a fiery mind moreover he should possess the qualities required of a model woman ie physical and mental health strength and firmness diligence thrift and resourcefulness in various situations 29 in the light of the common understanding of masculinity the behaviour of men in the mid19 th century especially those recruited from the noble class was guided by the principle of honour nevertheless it was often understood in a different way than the catholic publicists would have wished for the common understanding of honour quite often boiled down to extravagance and living beyond ones means this way of thinking was strongly criticised by the clergy who condemned the mismanagement and profligacy often seen in the polish environment according to the editors of katolik this problem affected the nobility peasants and craftsmen alike and in each case it had negative consequences in the form of poverty marital conflicts etc 30 however according to both catholic and secular moralists the greatest bane of polish society was drunkenness downplayed by many and associated primarily with men which was seen as a defiance of 29 p śpica relacje małżeńskie seksualność i wychowanie do życia w rodzinie w połowie xix wieku w świetle wydawanego w prusach zachodnich katolika dyecezyi chełmińskiej marital relations sexuality and education for family life in the mid19 th century in the light of katolik dyecezyi chełmińskiej published in west prussia in rodzina i dziecko w zmieniającym się świecie perspektywa historyczna i pedagogiczna family and child in a changing world historical and pedagogical perspectives eds k jakubiak r grzybowski toruń 2020 p divine destiny including the conjugal vocation 31 excessive consumption of alcohol was a common phenomenon a kind of ritual accompanying various occasions holidays funerals etc some people celebrated this ritual every sunday immediately after the holy mass by heading to the local inn 32 while drunkenness was regarded as a typically male trait living beyond ones means was a fault for which the catholic moralists condemned the entire polish community however the phenomena cited above were part of a social diagnosis but were excluded from the hegemonic discourse that unequivocally assessed them as resulting from flawed attitudes 33 as i have already mentioned despite the fact that catholic publicists did not use the category of masculinity directly it can be concluded that they most closely linked it with the performance of the functions of husband and father which on the one hand in accordance with the model of gender polarisation included maintaining and ensuring the material existence of the family 34 and on the other faithfulness and fulfilment of the marriage vow associated with the attitude based on faith love respect and the indissolubility of marriage 35 according to 19 th century catholic moralists publishing in west prussia masculinity therefore meant above all the maturity to build a lasting marital relationship maturity in faith taking responsibility for the family the ability to go beyond the zone of ones own comfort to forgive to endure any inconvenience and to persevere despite various adversities despite such an idealistic vision catholic publicists also pointed to human imperfection and the need to forgive each other for their mistakes 36 beliefs about male sexuality the ideal indicated above was also associated with a strict vision of the male sexuality in the polish journalism of west prussia sexuality was not the subject of extensive analyses it was tackled mainly by catholic moralists who however very rarely referred to it and when they did they wrote about it in a denunciatory way ie in terms of danger the possibility of committing a sin their content was most often limited to listing the negative consequences of unwanted and extramarital pregnancies hence more attention was paid to the virtuous conduct of girls than of boys 37 the polish population of west prussia at that time was prudish and sexual issues constituted a taboo the views of local poles on human sexuality including male sexuality were determined by the catholic ethics this ethics required men to shun all adultery as well as all other external and internal impurities and cruelty to their wives acting in accordance with the abovementioned qualities was at the same time identified with paternal care for the upbringing of children the catholic moralists thus tried to make men aware of the importance of influencing their offspring by their own example as well as of the longterm and social consequences of the selfish behaviour of some men who focus mainly on satisfying their own needs 38 the catholic morality dominant in the polish community of west prussia forbade men to have any extramarital relations however this ethic was not always followed in practice which is evidenced by the number of preand extramarital pregnancies it was also forbidden to relieve sexual tension through masturbation which according to the views of the swiss doctor samuel tissot popular in many countries and in west prussia 39 was supposed to have disastrous consequences for physical and mental health 40 male sexuality was to serve mainly procreative purposes the dominant discourse was thus marked by the idea of a controlled and restrained masculinity it is worth mentioning that in the conservative polish community of west prussia divorce was considered unacceptable according to the principle what god has put together let no man break apart 41 the subject of homosexuality remained almost completely tabooed almost never appearing in the polish journalism of the studied region and when raised it was presented in a very laconic way and reduced exclusively to the sin of sodomy which aroused disgust among catholic moralists 42 paweł śpica conclusion in the polish journalism of west prussia in the middle of the 19 th century men were very rarely written about as men and the category of masculinity typical for contemporary cultural studies was not used at all in contrast a little more was written about men as husbands and fathers but with little space devoted to their parenting function this was because the polish environment in west prussia was strongly influenced by the discourse of gender polarisation dominant in the 19 th century central and eastern europe which proclaimed that men and women had different roles in society and the tasks of the man in the family were primarily focussed on its material stability sense of security and external representation although a man as such played a decisive role in deciding on the education and future of his children as well as in administering physical punishments to his offspring the vast majority of the daily care and upbringing of the youngest members of the family was delegated to the wifemother this state of affairs was by the way seen as natural the dominant discourse of masculinity in the polish environment in west prussia of the mid19 th century was thus clearly in line with essentialist concepts at the same time it was a discourse that preserved traditional social relations and treated secular currents coming over time from western europe increasingly strongly as a threat not only to the existing social order but also to the existence of the polish nation hegemonic masculinity in the polish community of west prussia was constituted by many cultural factors in particular by the national ideas and catholic morality although it was a postnoble masculinity it was dominated by a bourgeois and capitalist ethos it was therefore at the same time a rational masculinity however not devoid of the sentimental and emotional component characteristic of the noble insurrectionary ethos despite the fact that in the 19 th century west prussia the position and role of the male in the family and society was clearly defined determined among other things by the patriarchal standards dominant in the european cultural it must be emphasised that in the practice of family and social life this patriarchalism took on different shades and in individual cases was only a formal legal and ideological construction not fully reflecting the everyday reality nevertheless the traditional understanding of masculinity typical for the 19 th century west prussia was so firmly founded that it was not shaken by the turbulent history of the first half of the 20 th century more pronounced changes in the understanding of the male role in polish society and the family as a whole began to take place as late as from the 1970s onwards and have become particularly evident only recently bibliografia

the article presents cultural factors contributing to hegemonic masculinity in the polish community of west prussia in the mid19 th century starting from the perspective of social constructionism raewyn connells theory of hegemonic masculinity was used in the research process to reveal the dominant discourse of masculinity in the studied milieu the source base for the research was the polish journalism of the region in question predominantly the local press mainly from the late 1840s and 1850s less frequently from later periods the contextual analysis of the research material made it possible to identify five basic cultural determinants cultivating hegemonic masculinity in the polish community of west prussia in the period studied analysed in detail in separate parts in the present article these determinants include the dominant narrative on the role of the male in the family the position of the male in social structure the role of the insurrectionary and organic work ethos the influence of professed faith including the views proclaimed by catholic moralists and the resulting beliefs about male sexuality the research has shown the significant influence of catholic ethics and national ideas derived from the nobility on the creation of a hegemonic image of masculinity in the polish community of the studied region this discourse was explicitly conservative and essentialist in nature it also played an important role in maintaining and developing polish identity in the absence of the polish statehood

introduction nonbiomedical research especially that using methodologies typical of the humanities and social sciences has been chiefly grounded on the epistemological pillars of qualitative research as described by diniz and guerriero this type of research involves participant observation ordinary observation open or closed interviews ethnography selfethnography and focus groups and other methodologies in the field of research involving human beings the differentiation between biomedical and nonbiomedical research occurs even in the definition of termsresearch in human beings in biomedical areas designating research that may be more invasive and research on human beings which has a more social character exploring the nature of these different approaches to research involving humans we note that they reflect distinct scientific cultures and readings of ethical research including readings and application of documents supporting the mainstream ethics regulation of humansubject research such as the nuremberg code the declaration of helsinki in its versions endorsed in brazil and the universal declaration on bioethics and human rights for guerriero the approach in the biomedical field is supported by practices and methods aligned with these guidelines and regulatory standards for research in humans in brazil based on the resolutions of the national health council such as resolution cns 4662012 thus the norms resulting from this regulatory framework have a solid biomedical nature and are aligned with the particularities and research practices in this field of knowledge regarding the ethical regulation of studies in nonbiomedical fields that adopt methods typical of those in hss it is grounded on resolution cns 5102016 it assumes that the researcherparticipant relationship is continuously built up in the process of the research and can be redefined at any time in the dialog between subjectivities implying reflexivity and the construction of nonhierarchical relationships highlighting the universal declaration of human rights of 1948 and the interamerican declaration of human rights and duties as pillars that support the dignity freedom and autonomy of humans these distinct perspectives on the ethical regulation of research involving humans configure different research cultures with peculiarities in the epistemological and scientific domains for research culture we mean … the behaviours values expectations attitudes and norms of our research communities it influences researchers career paths and determines the way that research is conducted and communicated in the context of research involving humans there are cultural and epistemic clashes in the ethics review and research practices between biomedical and nonbiomedical fields especially those associated with hss this conflictual situation reminds us of charles snow s two cultures which has been applied to different epistemological and disciplinary battlefields the clash of two cultures in the conduct of humansubject research in brazil in the two cultures snow demonstrated the misunderstanding between two large groups the literati and the scientists as a physicist and a writer he traversed these two environments and noted how different the ways of thinking were among the two groups he even stated that they almost did not communicate at all although he noted no significant differences among them regarding factors such as social origin or economic status regarding the distorted image of one group concerning the other snow describes the following scenario literary intellectuals at one poleat the other scientists and as the most representative the physical scientists between the two a gulf of mutual incomprehensionsometimes hostility and dislike but most of all lack of understanding they have a curious distorted image of each other their attitudes are so different that even on the level of emotion they cant find much common ground the appropriation of the two cultures embedded in snows view has been made in different academic contexts in humansubject research this perception of conflict is also evident when comparing research involving humans in the biomedical sciences and nonbiomedical sciences especially in hss udo krautwurst in his culturing bioscience a case study in the anthropology of science discusses the assumptions that inform the ethics review processes in the biosciences the author argues that there is a tacit assumption that there is only one way to be ethical and that as subjects of research humans are equally powerless over what the researcher says or does it is presumed that the research is necessarily on people rather than about people when it comes to research involving humans it is usually assumed that there is a power imbalance between the researcher and the participants ie as the researcher would hold a position of power in this relationship ethical concerns over this asymmetry becomes a sensitive issue addressing this power dynamic is among the elements underpinning the work of research ethics committees which are usually expected to protect the rights and dignity of research participants yet some controversy over this role exists and this idea of protection of research participants is another issue that krautwurst explores in ethnographic studies for example the assumption that research participants necessarily need to be protected by research ethics committees is among the sources of conflict despite the lack of mutual understanding over the ethics of humansubject research in biomedical and nonbiomedical fields discussions on criteria for ethics review of hss research protocols have put research ethics in the spotlight in brazil bridging two cultures of research on humans through a heated debate on ethics review notwithstanding the conflicts underlying the ethics review of humansubject research in biomedical and nonbiomedical sciences these two cultures somewhat mingle in the cepconep system since its inception this regulatory system has the premise of encompassing all areas of research involving humanswhether biomedical or nonbiomedical in the hss academic community researchers and scholars in education have been among the most sensitive to the issue of ethics in humansubject research mainardes writes that in addition to concerns with the ethics review standards and procedures it is considered essential to conceive research ethics as a training issue which involves the study and discussion of research ethics at undergraduate and graduate levels… we believe the perceived importance that the role of ethics in research plays in the educational context has contributed to reflexive stances such as that by mainardes the launch of a document entitled ethics and research in education subsidies volume 1 by the national association of graduate studies and research in education reflects the attention on the big picture of research ethics in this document anped reaffirms its commitment to the constant improvement of research in education and to the issue of research ethics with contributions by various relevant authors addressing risks consent confidentiality vulnerability plagiarism research with vulnerable populations etc guilhem novaes observe that notwithstanding the differences between the fields of social and biomedical research there are similarities for example respect for the autonomy and dignity of people is a common central issue participants free and informed consent is essential for research in both domains differing only in the form of registration and in some cases time of obtaining consent aligned with this observation the view that research ethics is not and should not be restricted to concerns in the regulatory field echoes several authors grisotti cites the limitations of establishing this ethical debate based on submitting projects to the research ethics committee and thus reducing it to filling out forms on plataforma brasil in fact there needs to be more than this process to ensure responsible conduct in research this thought is corroborated by authors such as sobottka who argues that the type of social control laid out by the resolutions is that mediated by the ceps as an ex ante procedural control it is limited in its scope and above all in its reach brooks te riele maguire in ethics and education research point to the relevance of ethical discussions in education based on real situations experienced by researchers despite this sensitivity in the field of education a study by nunes has revealed the limited inclusion of research ethics in graduate programs in brazil this study analyzed 8892 subjects in 37 education programs and found that only 078 of them include research ethics in their course syllabus nunes points to the urgent need to guarantee disciplinary training and systematic on the topic of research ethics in graduate programs in education mainardes highlights this gap as he emphasizes the need for more studies in the field of research ethics an increase in the number of publications on procedures related to research ethics in hss translations of texts in foreign languages and the need for a document with general guidelines on research ethics in conduct of research in education given this context the goal of this study was to shed light on perceptions of coordinators of graduate programs in hss on the ethics review of humansubject research in brazil specifically we investigated perceptions about the ethics regulation of research involving humans through a survey instrument sent to 148 coordinators of graduate programs in hss in public universities we sought to explore the relationship they had established with the brazilian national cepconep system which has been implementing changes in recent years impacting research in these areas as part of a previous study the main hypothesis was that research practices for the ethical conduct of humansubject research in the biosciences in brazil have established conversations with those in hss studies by engaging in the heated debate over ethics review researchers in hss have facilitated a reduction in the gap between these two cultures of conducting research involving humans methods our research was based on a survey instrument sent to the coordinators of 148 graduate programs in hss they were distributed among six universities among the top 20 public universities in the national ranking in southeast brazil the region with the highest share of research funding and graduate programs in the country federal university of rio de janeiro fluminense federal university state university of rio de janeiro university of são paulo state university of campinas and federal university of são paulo the protocol associated with this step was approved by the cep at the clementino fraga filho university hospital ufrj caae 93926818600005257 the sampling was intentional and nonprobabilistic this type of sampling seeks to collect information from a particular group intentionally selected and of vital importance to the research with the potential of understanding the problem drawing upon previous studies palinkas et al describe that purposeful sampling involves the identification and selection of people especially knowledgeable about or experienced with a phenomenon of interest and the importance to have the ability to communicate experiences and opinions in an articulate expressive and reflective manner the survey instrument consisting of a demographic section with five questions and a content section with four questions was prepared on the surveymonkey platform and then sent to the email of the invited participants the survey began on december 3 2018 and the last response was received on january 7 2019 among the issues of interest in this study were those exploring how the relationship with the cepconep system had occurred during the transition process still underway regarding resolution cns 5102016 after the independent analysis of the corpus compiling the content of the responses we drafted thematic categories which we then refined in an iterative analytical process that led to our defining of four categories as described by duarte thematic categories are articulated to the central objectives of the research as well as to the theoreticalconceptual references that guide the view of the researcher results and discussion the survey of coordinators of graduate programs in hss about the cepconep system explored their perceptions on aspects of the submission of research protocols for ethics review in their fields with this survey we also sought to understand the relationship of resolution cns 5102016 with the setting investigated among participants quantitative findings from the survey across hss fields interacting with and reading the cepconep system for an overview of participants institutions represented through their graduate programs figure 1 shows the percentages for each university and figure 2 shows the distribution of graduate programs main fields represented by the coordinators according to the assessment areas of capes most coordinators who participated in our research were serving their programs in this capacity for one to five years half of respondents declared that they had already served as coordinators or vicecoordinators before taking that position at the time of the survey among respondents to question p7 whether heshe or hisher supervisee had already had a research protocol submitted to the cepconep system 67 did not have submitted their research for ethics review by the national regulatory system one speculation could be that neither these participants nor their supervisees conducted humansubject research in our sample only one coordinator alleged that no member of the graduate program had conducted humansubject research up to the time of the survey yet it is unlikely that it was the case for most hss programs in our study given the nature of most research in hss studies which encompass human behavior agency mindsets social and cultural processes among other phenomena instead this result is aligned with the status of humansubject research in hss in brazil in which the ethical framework has not been traditionally relying on the ethics review by the cepconep system this observation echoes results shown in figure 3 when asked about the submission to the cepconep system of research projects involving humans in their graduate programs including those using interviews andor questionnaires only 32 declared that it was mandatory however 21 of the respondents indicated mandatory but not included in any document of the graduate program based on the selfreports of the coordinators surveyed the absence of normative guidance in almost 90 of these hss programs is prevalent despite this lack it is interesting to note that 60 of coordinators indicate existing recommendations or requests in their programs for submission to the system which gives insight into the changes in the landscape for ethics in humansubject research in brazil qualitative findings from selfreports of participants the qualitative results from the textual corpus based on the selfreports collected from the survey were organized into four thematic categories as described in the methods section on aspects related to the plataforma brasil and bureaucracy the bureaucratic nature of the process of ethics review is an issue in many countries in brazil researchers submitting research protocols to the cepconep system are also voices of complaints over the long material and or time involved in the submission process in fact such criticism is a common topic in biomedical and nonbiomedical fields among our respondents excessive bureaucracy was mentioned by six coordinators one comment that illustrates this concern is from respondent 21 t he system is super important and certainly prevents abuse but it is also excessively bureaucratic it gives importance to side issues and asks for an excessive number of documents overall however despite their criticism of several aspects and based on their final comments the coordinators surveyed seemed to be more supportive of the system than unsupportive box 1 final comments of 38 respondents coordinators of graduate programs in humanities and social sciences in brazil on the role of national regulatory system in brazil for humansubject research how do you see the role of the ethics regulatory system in human research in brazil supportive i consider it an important safeguard for all parties involved however it is always important to have very clear risk typification in order to streamline and reduce bureaucracy in research processes with minimal or zero risk to participants consistent and necessary but needs adjustments in nonhealth areas it matters it gave rise to an important debate in which it is important to take into account the characteristics of ethnographic research such as those that predominate in the field of anthropology and also the particularities of each context as fundamental to the development of our research after the translation of the selfreports into english minor edits related to punctuation misspelling andor capitalization were made for clarity práxis educativa ponta grossa v 18 e21955 p 115 2023 disponível em 9 important although we have the risk of excessive bureaucratic regulation the most interesting thing would be selfregulation based on general normative principles by the university and research institutions themselves with due regard for broader legal implications important and guiding good and i believe that researchers should be aware of the importance of respecting research collaborators as well as giving them feedback as soon as the research is completed as a necessity positive but generalizes procedures from one area to another i consider it important but it should be done based on a broad survey with researchers in the area i think its important indispensable i believe it to be extremely important and fundamental both in terms of preserving those involved in the research and the researchers themselves and avoiding possible abuses in the case of the humanities however especially in situations involving only oral or written language data collection the intense bureaucratization can generate major obstacles for research e ssential t he system is super important and certainly prevents abuse but it is also excessively bureaucratic it gives importance to side issues and asks for an excessive number of documents important but needs to be flexible to cover different areas of knowledge fundamental it should be extended to fields other than the biomedical sciences this is a relevant subject that deserves attention from researchers supervisors and program coordinators since it may involve interviews and experiments with humans on the one hand it is essential to establish some kind of regulatory system based on discussions with the scientific community on the other hand it is important to pay attention to the specificity of each area and the uniqueness of each research so that there is no excessive bureaucratization and a stiffening of procedures positive but we have to be careful not to make research unfeasible especially those that use the interview and photography procedures i think its adequate but perhaps too bureaucratic especially regarding the functioning of plataforma brasil which could be more userfriendly and require less extensive use of handwriting i also think that it is neither possible nor advisable for research in social sciences and humanities to be so tied to the formats and protocols of medical research there is also a lack but this is the case worldwide of a specific resolution for searches on the internet or with data collected via the internet in social media for example in addition to clearer delimitations on what public access public domain and intellectual property are in internet content and clarity for researchers about the differences between business ethics on the internet and research ethics in that context for example regarding the construction of applications for generating research data fundamental adequate every time i needed ethics committees for my research or for my supervisees we found possibilities of extreme relevance and importance fundamental research with socalled vulnerable populations such as indigenous people has to be regulated and looked at very carefully it is a pity that in social sciences we are treated as if we were health professionals collecting blood samples from the people we ask in general questions that do not involve any risk to their integrity unsupportive the system sometimes becomes more demanding and rigorous than necessary mainly with research with humans and not on these humans in many cases the human being is not the object of study but the practices regulations or systems in private and public organizations even so having to submit the research to the system becomes a timeconsuming and unnecessary obstacle because it does not bring risks or harm to individuals often the system is cunningly used as an argument to deny access to organizational data even if there is no contact with humans or there is no risk of exposure to them complicated and controversial c omplex and confusing excessive with regard to conducting research that require interviews and application of questionnaires práxis educativa ponta grossa v 18 e21955 p 115 2023 disponível em 10 pretty confusing it does not help the researcher much neutral i feel that the discussions are very much based on references from the socalled hard sciences addressing our methodologies as based on excessively objective aspects i think it has not yet been made clear that research in human sciences must follow this regulation the faculty of philosophy at university was discussing the creation of a research ethics committee but i do not know its outcome not aware still under development and could be improved centralizer we would need to have a more diffused system created by the specificities of each university institution and with its guaranteed autonomy for the management of ethicalacademic processes i think it has improved u nknown in the case of human sciences i believe it is still very little publicized i cannot say that there has been a more direct and effective concern to frame research according to this system note that while bureaucracy is an issue raised by several coordinators respondent 47 reasoned that ethics review by the system is … an important safeguard for all parties involved however it is always important to have very clear risk typification in order to streamline and reduce bureaucracy in research processes with minimal or zero risk to participants one factor that is consistent with a relatively new ethics regulatory framework for research involving humans in hss in brazil is that the views of the cepconep system among the coordinators surveyed are not mature some of these respondents demonstrate that learning about the ethics review system is a gap to be filled respondent 39 states that i think it has not yet been made clear that research in human sciences must follow this regulation the faculty of field omitted was discussing the creation of a research ethics committee but i dont know about the outcome this selfreport is aligned with that from respondent 2 … research with socalled vulnerable populations such as indigenous people has to be regulated and looked at very carefully it is a pity that in social sciences we are treated as if we were health professionals collecting blood samples from the people we ask in general questions that do not involve any risk to their integrity accordingly only some of the coordinators surveyed showed complete familiarity with or expressed a clear position on the cepconep system of the 14 respondents with comments associated with thematic category 3 familiarity with andor position regarding the ethical regulation of hss eight indicated that they had begun to approach the cepconep system this observation is demonstrated in the following statement by respondent 38 although i was aware of the resolution through indirect references i had never read its content carefully given the specificities of research in history however in practical terms there was always a concern of the supervisors of the area with the ethical values in research involving living human beings or with direct descendants up to the third generation such as oral history and research involving written documents or audiovisual records under public protection about recent history however as a program coordinator this research caught my attention motivating me to more clearly formalize and standardize the specific issues in the field of history in terms of research ethics with and in humans thank you this recent encounter is also shown when for example it is declared that the cepconep system though not unknown to researchers in hss is still distant from the reality of the research culture in their areas as indicated by respondent 19 ive already heard of it but i never studied it in depth in fact approximately 30 of the respondents were unaware of resolution cns 51016 suggesting that despite resolution cns 51016 putting the ethical debate on another level it takes time to consolidate a new resolution other coordinators alleged that although the regulation was known in hss the research they developed had not approached more burning issues to be governed by the resolution as respondent 14 comments for respondent 10 knowledge of resolution cns 510 was eventually gained once the coordinator became a member of the cep otherwise i would not have known nor would i have sought to know for other coordinators their knowledge of resolution cns 51016 is o nly in general terms this lack of specific knowledge is also reflected in the comment of respondent 39 i was aware of the one resolution for health research i didnt know about the normative demand for the humanities respondent 42 wrote that o nly now in 201819 we will have the first research project submitted to the ethics committee in human sciences these comments echo the results in figure 3 previous data have shown a timid number of graduate programs in hss recommending or requiring submission of research protocols to the ethics review by the cepconep system the changing landscape with growing awareness of the ethics review system among hss researchers may be understood in light of an analysis by diniz guerriero the authors reasoned that the imposition of the review system through research funding agencies health institutions where data is collected or journals at the interface between biomedicine and the humanities… motivated social researchers to seriously address research ethics finally on the regulatory aspects of the graduate programs consistent with figure 3 there were different situations about the submission of research protocols to the cepconep system some of the coordinators reported at the time of the survey that their universities were implementing requirements or beginning to consider developing them respondent 8 claimed that we havent included it as part of some normative guidance but we consider this inclusion a mandatory step when it comes to normative guidance respondent 16 wrote that t he rules at the university are changing and submission to the system will become mandatory and documented in line with these times of transition respondent 22 explained that when students enrolled in their graduate program they had to acknowledge awareness of the obligation to submit humansubject research to ethics review by signing a specific document other coordinators reported that there was no recommendation as can be seen in figure 3 respondent 26 is among the 21 of respondents reporting that submission to the system was mandatory but not included in any document of the graduate program as also shown in figure 3 this respondent reported that the program heshe coordinated did not deem it necessary to make such a recommendation in any specific document as it was assumed that researchers were expected to follow the principles of the national regulatory framework cepconep system for the ethical conduct of humansubject research overall as can be seen in box 1 a considerable number of respondents seem to be willing to get acquainted with explore the possibilities of and discuss research ethics in light of the ethics review process underway in brazil whereas the challenges to address specificities and demands related to the ethics review of research involving humans in hss remain these coordinators surveyed suggest there is a promising space in hss graduate programs to strengthen the role of research ethics in the design and conduct of research relying on human participation final considerations our results indicate that some reluctance to interact with the brazilian national regulatory framework for the ethics review of humansubject research in hss is noted as a factor in our dataset nevertheless according to our results the majority of the hss coordinators of the graduate programs surveyed is willing either to get acquainted with this regulatory system andor exploring the ethics of conducting humansubject research in hss this finding comes from both the quantitative and qualitative data collected whether this finding has been influenced by the affiliation of these hss coordinators with public universities in southeast brazil which accounts for the highest share of research ethics committees is an open question irrespective of this possible source of bias the data suggests that these coordinators representatives of their programs seem to appreciate this regulatory framework at the reflexive and normative levels although bureaucracy is an issue that may discourage interaction with the cepconep system most of the comments in the corpus pointed to willingness to take a step further and address the growing demand for addressing the ethics regulation of humansubject research in hss fields yet these are the views of coordinators and do not necessarily reflect those from the faculty members in their graduate programs notwithstanding this caveat according to these results it seems reasonable to suggest that two cultures with their own scientific practices shaping research involving humans have been bridged by an ongoing debate over research ethics which goes beyond the normative aspects of ethics review we believe the perceptions of these coordinators in hss reinforce the need for broadening the look at the role of research ethics in conducting humansubject studies in the humanities and social sciences limitations this study is not immune to different kinds of biases including social desirability bias which is the tendency to underreport socially undesirable attitudes and behaviors and to over report more desirable attributes leading to the possibility of inaccurate selfreports and thus unreliable conclusions in surveybased research looking ethical in research is scientifically and socially desirable which makes investigations on perceptions of the ethics review challenging irrespective of being related to humansubject research additionally the hierarchical position of these coordinators in their graduate programs and burden of responsibility to take a position toward a highly sensitive issue in the hss community might have led to more conservative responses however we sought to minimize these potential biases by the type of survey questions more related to factual information than behavior organized into a semistructured instrument that offered space for participants to elaborate on their responses

the ethics regulation of humansubject research in brazil is by the research ethics committee cep national commission of research ethics conep system while primarily focusing on biomedical research this system also oversees the ethics of nonbiomedical research however a distinct clash between these two research cultures is evident in brazil despite existing guidelines the cultural clash this manuscript is an adaptation of part of the first authors masters dissertation supervised by the second with editions modifications and adjustments made in collaboration between the coauthors the dissertation is listed in the references rocha 2020 doctoral student in the area of science education management and dissemination in biosciences of the graduate program in biological chemistry of the institute of medical biochemistry leopoldo de meis ibqm at the federal university of rio de janeiro ufrj with a scholarship from the coordination for the improvement of higher education personnel capes

introduction several studies have demonstrated an increased prevalence of mental illness among medical students relative to the general population 1 2 3 4 for example gaspersz et al found that the incidence of common mental disorders among medical students was 54 in the preclinical phase and 48 in the clinical phase 5 a metaanalysis of 59 studies providing a comprehensive summary of the mental health of medical students in brazil found the prevalence of depression stress common mental disorders and burnout to be 306 499 315 and 131 respectively 6 these and other studies recommend acknowledging and making attempts to alleviate the mental health consequences of studying medicine 78 experiencing mental illness during medical studies has implications for students ability to apply cognitive social and clinical skills ultimately leading to reduced competency in providing future patient care 9 several researchers in the arab region have addressed the high prevalence of mental illness among medical students in a systematic literature review elzubeir et al asserted that studies on arab medical students mental health report a high prevalence of perceived stress depression and anxiety 10 a study conducted in jordan reported a high level of exhaustion disengagement and minor psychiatric illness among medical students 11 the same study also used the cage questionnaire to evaluate alcohol use among students and found that 8 of students qualified as possibly alcoholic 11 another study conducted among medical students in oman a gulf state with a socioeconomic context similar to qatars found that the prevalence of burnout syndrome and depressive symptoms were 74 and 245 respectively these figures were higher among preclinical stage undergraduates than among clinical stage students 12 these and other studies highlight the importance of addressing medical students mental health problems and call for a deeper understanding of the factors behind them mental health stigma is a major barrier to seeking help for mental health problems among medical students leading to the exacerbation of the symptoms of mental health disorders 113 erving goffman described stigma as a process by which an individual with an attribute that is deeply discredited by their society is rejected as a result of that attribute 14 based on this definition the world health organization refers to stigma as a mark of shame disgrace or disapproval which results in an individual being rejected discriminated against and excluded from participating in a number of different areas of society 15 in 2001 the who identified mhs as a key barrier to effective treatment of mental illness due to its negative impact on individuals willingness to seek treatment 16 studies conducted in western contexts show a correlation between mhs hesitancy to seek help and increasing symptom burden 1 17 18 19 for example a cross sectional study of medical students at michigan university identified stigma as an explicit barrier to the use of mental health services for 30 of firstand secondyear medical students experiencing depression 1 in another study conducted in poland both medical students and psychiatrists reported negative implicit attitudes towards mental illness 18 maalouf et al point out that stigma is scarcely addressed in mental health reports coming from the arab region 19 similarly dardas and simmons argue that little is known about how mhs manifests within the arab community making it difficult to design and test interventions 20 despite this gap in the literature a few studies have reported on the impact of sociocultural values and religious beliefs on mhs for instance ghuloum et al found that over a third of respondents in qatars general population believed that people with mental health disorders are intellectually disabled and 483 believed that mental illness is a punishment from god 21 shehata et als study of stigmatizing beliefs about mental illness among health sciences students and medical students in egypt found that the majority of students held stigmatizing beliefs 22 the positive correlation between mhs and medical students reluctance to seek help has been evidenced by several researchers 113 the prevalence of mhs among medical students can impact whether and how they seek help when they face mental health problems which may lead to poor academic performance substance abuse damaged selfimage and eventually a decline in clinical practice and fitness to work with patients in the future in this study we aim to determine the prevalence of mental illnesses among medical students in qatar taking the students in college of medicine at qatar university as a case study to represent medical students in similar middle eastern contexts this is the first study of its type in qatar and as such it contributes valuable knowledge for building tailored mental health preventive and intervention programs for medical students this study is also the first to investigate these issues in the context of a problembased learning curriculum in the arab region elzubeir et al 10 noted that literature on medical students mental health in this specific type of academic programme was lacking in the region methods study design a crosssectional survey was conducted using the online survey platform google forms in august and september 2019 targeting all 250 medical students in the second to fifth years of the programme participants were required to complete a consent form before accessing the survey the survey consisted of three parts the first gathered sociodemographic data on each student the second identified the prevalence of mental health problems among the students using standardized screening tools and the third examined students views on stigma since the instruction language in the college is english and students are fully proficient in the english language all materials were distributed using the original english versions setting the college of medicine at qatar university was established in 2015 and is one of the only two medical schools in qatar the medical program in cmed at qatar university consists of six years the first year is transition phase in which students study the basic core subjects that prepare them for the medical curriculum this is followed by two and a half years which constitute the preclerkship phase in which students study the basic medical sciences using a problembased learning pedagogical approach finally in the last two and a half years known as the clerkship phase students continue their studies in hospitals and other clinical environments the students are of different nationalities with a majority of arabmuslims and a minority of muslims nonarabs from asian countries such as pakistan bangladesh and the philippines all nonqatari students are children of expatriates and were born and raised in qatar inclusion and exclusion criteria the inclusion criteria included respondents who were in at least their second year and were actively enrolled in medical studies the study excluded phase i students who were not yet studying basic medical sciences the study also excluded students who had dropped out at the time of the study there were no sixthyear students survey instruments the survey consisted of a total of 64 questions divided among the three sections sociodemographic data this section was based on the sociodemographic section of the whos study of global aging and adult health sage is a longitudinal study implemented in several countries with the primary goal of generating valid reliable and comparable information on a range of health and wellbeing outcomes that hold importance to public health 22 it is a standardized survey instrument which collects basic sociodemographic data such as age gender nationality marital status current accommodation status family income and parents level of education and employment history in addition we added two questions about year of study and a year repetition symptoms of depression anxiety and psychological distress the second section collected data on the students mental health using three standardized screening tools the patient health questionnaire generalized anxiety disorder and kessler psychological distress scale these tools have been previously validated for screening purposes globally and regionally and they are commonly used in qatar in clinical settings and for research and screening purposes with the general population 23 24 25 the american psychological association reports based on previous studies assessing the phq9 that the tool exhibits good diagnostic validity scores greater than 10 had a sensitivity and specificity of 88 for major depressive disorder 26 it also has high internal consistency and wellconstructed psychometric properties 26 accordingly the diagnostic and statistical manual of mental disorders 5 recommends its use as a tool to evaluate the severity of depression 27 this study utilized the 9item phq9 to assess for selfreported symptoms of depression a score of 59 indicates mild symptoms a score of 1014 moderate symptoms a score of 1519 moderately severe symptoms and a score of 2027 severe symptoms several international studies conducted in bangladesh korea portugal united states iran germany and peru have examined the validity and reliability of the gad7 tool across many different populations and found it to have high internal consistency as well as good convergent validity 28 spitzer et al 29 confirm that the gad7 has good reliability in addition to criterion construct factorial and procedural validity indicating that it is a valid and efficient tool for the assessment gad in research and in clinical practice a score of 610 on the gad7 indicates mild anxiety a score of 1115 moderate anxiety and a score of 1621 severe anxiety countryspecific validation studies assessing the k6 tool in different languages including english have come to the consensus that this tool has good internal consistency reliability and factorbased and other construct validity across various populations furthermore multiple studies have demonstrated its effectiveness in measuring nonspecific psychological distress in nonclinical populations including arab populations and student populations 3031 a score of 15 on the k6 indicates mild distress a score of 610 moderate distress and a score of 1124 severe distress mental health stigma the third and final section consisted of 27 questions adopted from schwenk et al 1 which were used to evaluate respondents levels of stigmatizing beliefs about mental health and their attitudes toward seeking help the items in this section addressed points identified in previous studies and implemented both positive and negative framing to allow for an internal consistency check section three also included validated instruments on stigma used in studies of the general population focus group discussions and pilottesting were performed to modify the questions these items were specifically tailored to fit medical students 1 cronbachs alpha was used as a measure of internal consistency reliability for this section and was found to be 0789 which represents acceptable internal consistency study size and bias the population of our study was welldefined and small since the medical student community in qatar is limited therefore total population sampling was used to minimize potential bias occurring through sampling technique five responses were eliminated due to possible response bias as these participants had selected extreme values on the likert scales for all items statistical data analysis statistical analyses of the survey responses were performed using the stata 160 software package determination of depression generalized anxiety and psychological distress to evaluate the prevalence of depression generalized anxiety and psychological distress the scores for the three screening tools in the second section of the survey were calculated the established standardized cutoff scores for each screening tool were then used to classify respondents as exhibiting no mild moderate moderately severe or severe symptoms of depression and no mild moderate or severe symptoms of anxiety and psychological distress to further facilitate statistical analysis students were then divided into lowrisk and highrisk groups for each disorder using standardized cutoff scores that indicate a highly likely requirement for medical intervention separate stepwise logistic regressions were run to test the correlation between the risk of depression anxiety and psychological distress and each of the sociodemographic factors to assess the impact of these factors on the students mental health determination of mental health stigma the questions in the third section of the survey were classified as positive or negative with regard to the respondents viewpoints on stigma positive questions were those for which a response of agree demonstrated stigmatizing view therefore agree responses were assigned a score of 1 and disagree a score of 0 negative questions were those for which an agree response revealed no evidence of stigma therefore agree responses for such questions were assigned a score of 0 and disagree a score of 1 an overall stigma score was calculated for each respondent the mhs scores were then divided into three quantiles with the two lower quantiles defined as students holding lower levels of stigma and the upper quantile as students with high stigma stepwise regression using a pvalue 02 was used to determine which sociodemographic factors were associated with high stigma ethics and informed consent this study complies with the declaration of helsinki and received ethical approval from qatar universitys institutional review board participants gave informed consent using an online form which they were required to complete prior to accessing the survey questions as this study was anonymous participants who were found to have severe depression anxiety or psychological stress could not be referred for care however the survey included a section that advised the students to call a hotline operated by hamad medical corporation if they answered certain questions positively results characteristics of the participants the overall survey response rate was 748 the response rates for second fourth and fifthyear students were 83 85 and 76 respectively the response rate for thirdyear students was lower at 48 five responses were eliminated due to response bias as these participants had selected extreme values on the likert scales for all items of the remaining sample of students 681 were female and 319 were male 363 of respondents were qatari 451 were from other gcc and middle eastern countries and 189 were from other countries the largest age groups represented in the sample were 1720 and 2125 the mean age of the students was 21 with a standard deviation of 91 prevalence of selfreported symptoms of mental health disorders depression the prevalence was 31 for mild depressive symptoms and 30 for moderate depressive symptoms eight students exhibited severe depressive symptoms and 32 had moderately severe depressive symptoms representing a prevalence of 44 and 176 respectively when categorized into lowand highrisk groups 522 of the students were classified as having a high risk of depression generalized anxiety the rates of mild and moderate symptoms of generalized anxiety were 29 and 275 respectively additionally 104 of the students exhibited severe symptoms of generalized anxiety when classified into lowand highrisk groups 379 of the students were found to have a high risk of anxiety psychological distress a total of 60 students or 33 of participants were found to demonstrate mild symptoms of psychological distress while 44 students or 24 showed moderate symptoms the prevalence of severe symptoms of psychological distress was 396 when categorized into lowand highrisk groups 22 exhibited a high risk of psychological distress stepwise logistic regression indicated that students whose fathers had graduate or postgraduate degrees had lower odds of developing symptoms of depression than those whose fathers had only a primary or secondary education as indicated by an odds ratio of 014 and an or of 015 respectively association between sociodemographic factors and risk of symptoms of anxiety students whose fathers held graduate or postgraduate degrees also had lower odds of developing symptoms of anxiety compared to students whose fathers had only completed primary or secondary school this was shown by an or of 026 and an or of 025 respectively association between sociodemographic factors and risk of symptoms of psychological distress students whose mothers were never employed had higher odds of developing symptoms of psychological distress compared to students with working mothers as shown by the or of 365 stigma analysis the calculation and categorization of students stigma scores revealed that 319 of the students exhibited signs of high stigma against mental illness stepwise logistic regression revealed several associated factors including nationality whether the student had repeated an academic year the year of studies the student was currently in and maternal and paternal levels of education discussion prevalence of mental illness symptoms in this study we used selfreport screening tools to measure mental illness symptoms our findings indicate a higher prevalence of depression among medical students compared to the general population of qatar 203233 sharkey argues that the reported numbers in the general population are likely to be underestimated because of the limited diagnostic abilities of primary care doctors p20 34 the gap between our findings and past studies on the general population may be explained by the excellent access to and preexisting relationships with research subjects that our context and sample afforded andor to our use of screening tools that depend on selfreportingand thus reflect experience of symptomsrather than official diagnosis of mental illness however the discrepancy remains alarming 522 of the students in our study had moderate to severe levels of depression this is in line with the results of other studies of medical students in the arab region including studies in saudi arabia jordan egypt and oman 8 9 10 11 35 for instance a study conducted recently in oman reported high prevalence of depressive symptoms among medical students 11 the similar environmental and cultural backgrounds in these countries could explain these comparable levels of depression among medical students these findings are also supported by a metaanalysis conducted by puthran et al who found that the global prevalence of depression among medical students is 28 and medical students in the middle east are more likely than nonmiddle eastern students to be depressed 36 the prevalence of generalized anxiety disorder among medical students in our study based on the gad7 scale was found to be 67 this is also substantially higher than the prevalence among the general population which has been measured at 103 2032 it is also higher than the global figure reported in a metaanalysis of 69 studies conducted in february 2019 which reported the prevalence of anxiety among medical students as 333 3 our study found the prevalence of psychological distress among participants to be 9671 with 6383 reporting moderate to severe symptoms this is higher than prevalence of psychological distress among medical students in saudi arabia and egypt 83839 our analysis suggests that these high levels of stress may be attributable to both academic and nonacademic factors the medical curriculum and workload do contribute to the reported stress levels but mhs and sociodemographic factors also help to explain the numbers amongst medical students in qatar and other nearby countries 37 association between sociodemographic factors and reported mental health problems we found correlations between mental health and several sociodemographic factors including parents education academic year year repetition gender and nationality our study found that students whose fathers had higher education 975 were less likely to develop depression and anxiety this is in line with park et al who found that the children of mothers with less than a secondary school education had higher odds of experiencing a major depressive episode 40 they concluded that a low level of maternal education was associated with mde in early adulthood independent of paternal education and other childhood and earlyadulthood risk factors this may be because parents with higher education are more aware of the challenges and stressors of academic life and are therefore better able to support their children during their journeys students in their fifth year reported a higher prevalence of depression and anxiety symptoms than students in other years this finding is in line with other studies conducted in the middle east 41 but differs from studies conducted elsewhere 35 as a result there is no consensus in the impact of the year of studies on medical students mental health the differences could be explained by the different medical curricula employed in each college and the different sociocultural factors between the middle east north africa and the gulf we found that arab students were at higher odds of developing anxiety compared to their peers from other nationalities and cultural backgrounds this is consistent with quek et al who found that medical students of middle eastern and asian origin are at higher odds of anxiety than students from other parts of the world 3 this could be attributed to the fact that mhs in middle eastern societies is considerably higher than in other regions which could discourage students experiencing mental health challenges from seeking help this stigmatization leads them to reject being labeled as mentally ill exacerbating their mental health symptoms due to delays in seeking help suboptimal treatment and poor outcomes 3940 hankir et al found a positive correlation between mhs and reluctance to seek help among medical students they posited that medical students hesitated to seek help due to fear of being perceived as less capable and discredited by their colleagues and mentors 12 mhs in general is also a barrier for applying for jobs renting homes finding partners and more 44 our findings reveal that male students were at twice the odds of developing psychological distress compared to female students we believe that these findings are due to the patriarchal beliefs common in middle eastern cultures in which men are shamed for revealing mental health problems and those who do are perceived as weak and unworthy or not a man 42 another possible explanation is the higher mental health literacy among women 45 our study also found that students whose mothers had never been employed were at greater odds of experiencing psychological distress this differs from the results reported by others such as ibrahim et al who found lower anxiety risk among students with unemployed mothers but a higher risk for those with unemployed fathers 37 we argue that the interplay between the medical curriculum and social and sociodemographic factors explains these diverging results in different contexts association between sociodemographic factors and stigma middle eastern cultures value family honor and the concealing of emotions these values contribute greatly to stigma regarding mental health services as those who seek such services could be viewed as weak and thus bring shame to their families 42 mental health stigma leads to delays in seeking help suboptimal treatment and poor outcomes 43 hence preventive programs in medical schools should be seen as an essential component of the curriculum in a systematic review of studies addressing mhs in the general population in qatar zolezzi et al concluded that most people have poor mental health literacy insufficient information about the causes and symptoms of mental illness and stigmatized perceptions toward people with mental illness p1324 47 zolezzi et al also found a wide range of stigmatizing beliefs actions and attitudes regarding the treatment of mental illness 48 this explains our finding that students in qatar are likely to have stigmatized views of mental health problems influenced by several sociodemographic factors such as parents education year of studies and repetition of an academic year past studies have shown that students who have repeated a year of their studies develop low selfesteem and perceive the cause of repeating the year as personal inability to perform which leads to higher risks of mental health problems and stronger mhs 4546 we also found a correlation between living with family and higher mental health stigma living with family can affect a person with mental illness either positively or negatively depending on whether or not their family responds supportively to the difficulties they face families attitudes in general often reflect the social stigma toward mental illness past studies have indicated that family members of persons with mental illness often express stigma in relation to dovepress advances in medical education and practice 202213 976 their relatives illnesses 47 this stigma is transferred to the people experiencing mental illnessin this case the medical studentswho feel increasingly stigmatized and avoid seeking help implications for practice the results of this study demonstrate the need for more effective and numerous awareness campaigns workshops and lectures designed to break the stigma surrounding mental illness in the general population and among medical students in particular in qatar this will increase the chance that students will seek help in earlier stages of their illnesses and alleviate academic social and other complications we believe that incorporating wellbeing programs in medical schools curricula tailored to the sociocultural context and the needs of students can be a preventive action that will encourage students to seek help when they need it such programs can help students in manage their time stress and energy in a way that helps them find time to care for themselves and boosts their mental health we also recommend that medical educators act as role models to their students and discuss these issues openly sharing their personal stories of mental illness and how they sought help and recovered we recommend including activities like empowerment and life skills workshops within the curriculum which can indirectly help to prevent and treat mental illness among students conclusion and limitations based on the data we collected in this study we conclude that the medical curriculum is not the sole cause of mental health problems among medical students rather a combination of several factors and structures is responsible the heavy academic demands on students interact with sociodemographic factors and with social attitudes and stigma towards mental illness such stigma prevents them from seeking help and leads to a deterioration that could be prevented with earlier intervention although this study provides evidence for the association of several factors with stigma it is important to consider further factors that could contribute to students hesitancy to seek help among these factors are level of religiosity selfesteem family support and reasons for choosing to pursue medicine this study invites deeper analysis and further qualitative investigation to better explain its findings in addition it should be noted that the covid19 pandemic which began a few months after our survey was conducted has caused significant impact on medical students mental health it is important to examine this impact and any decrease in mhs and subsequent changes in students helpseeking behaviors which may have resulted from the widespread mental health crisis which accompanied the pandemic the main limitation of this study was its inability to include medical students from the other college of medicine in qatar due to bureaucratic obstacles of the two colleges of medicine in qatar the one in which this study was conducted is larger and more diverse however future studies that include both medical schools in qatar may be able to determine whether the type of curriculum influences students mental health in the same context disclosure the authors declare no conflicts of interest in relation to this work

past studies have shown high prevalence of mental illness among medical students this is often linked to the demands of the medical curriculum and to mental health stigma that prevents students from seeking help this study aimed to examine experiences of mental health problems among medical students of different nationalities in qatar and to uncover sociodemographic factors related to their prevalence and associated stigma methods a crosssectional online survey was conducted with medical students in their second through fifth years at the college of medicine at qatar university the survey began with a consent form and those agreed to take the survey were directed to the questionnaire the survey comprised 64 items across three sections the first section collected sociodemographic data the second section screened depressive symptoms using the phq9 anxiety symptoms using gad7 and psychological distress symptoms using kessler6 the third section included 27 questions adopted from schwenk et al which evaluate students perceptions of stigma and their attitudes toward seeking help with their mental health results one hundred and eightytwo students participated in the study the prevalence of selfreported symptoms of severe depression anxiety and psychological distress was 44 95 ci 29 104 95 ci 716 and 396 95 ci 3347 respectively the prevalence of high stigma was 319 95 ci 2539 parental education repetition of an academic year progress in medical studies gender and nationality had statistically significant correlations with mental health problems and stigma conclusion in addition to the impact of the requirements of medical study the high prevalence of reported mental illness among medical students is impacted by sociodemographic factors and the mental health stigma that constitutes a barrier to seeking help preventive wellbeing programs should be an essential component of medical curricula

introduction we are in the same storm but we are not all in the same boat barr cited in zhou and kan the arrival of covid19 brought with it unprecedented global change at the time of writing the usa had almost 47 million cases and britain was on its way to 10 million with numbers rising as the winter months approached the most effective strategy to minimise transmission of the virus has been to restrict movement of people including quarantine isolation and a series of national lockdowns in the uk in a global first this has included the closure of schools and universities who instead opened their virtual doors to students for much of 2020 though the vaccine has enabled greater movement including the return of facetoface higher education the pandemic associated restrictions and their collective impact persist those with direct experience of covid19 are more likely to be depressed anxious and experience posttraumatic stress disorder while as a wider group feelings of stress and loneliness are at their highest in over a decade the title of this paper highlights how different ethnic groups within the usa and uk are not all in the same boat but actually all in the same storm as damian barr explains while some of us are on superyachts some have just the one oar when a storm like covid19 hits it became visible that people racialised as black are some of the most vulnerable in society caught in the eye of the storm with very few material tools to survive it while the impact of covid19 has been farreaching evidence points to specific groups being at greater risk of its effects in terms of mental health impacts for example those at highest risk are young adults women ethnic minority communities people experiencing socioeconomic adversity unpaid carers and clinically vulnerable groups such as those with disabilities the doreen lawrence review captures the systemic nature of the problem recognising that covid19 has thrived on inequalities that have long scarred british society the impact of covid19 on black asian and ethnic minority communities the pandemic has further illuminated the widereaching consequences of structural racism black men are 42 times more likely to die from a covid19related death than white men while the risk of infection is 56 higher within black asian and ethnic minority communities compared to white british the first ten healthcare professionals in the uk to die from covid19 were from the black asian and ethnic minority communities as were onethird of the covid19 patients admitted to critical care units in 2020of which the highest percentage were black accompanying the aggregate of research in the uk a similar pattern is observed in the usa with death rates for indigenous pacific islander latinx and black higher than white and asian americans and rates of hospitalisation higher across ethnic minority communities than white with each covid19 death leaving behind bereaved family members there is a predicted surge in postpandemic mental health disorders disproportionately affecting ethnic minorities the current mental health impacts of covid19 on ethnic minorities are notable with ethnic minorities in the usa reporting disproportionately worse mental health outcomes and in the uk reporting higher levels of depression anxiety abuse selfharm and thoughts of suicide since before the pandemic findings from proto and quintanadomeque indicate that bangladeshi and indian men experienced a higher risk of mental health problems than white men though research from the uk household longitudinal study found no interethnic differences in mental health problems when comparing preand duringpandemic data other studies suggest that it is unlikely ethnicity itself causes differences in mental health outcomes but rather correlations with other factors such as occupation low income higher likelihood of infection or death and racism the clear and disproportionate effect of covid19 on ethnic minorities across the usa and uk thus highlights the impact of racism on physical and mental health as razai et al racism both shapes social determinants of health and has its own effect on the health of ethnic minorities these social determinants include socioeconomic status living in urban areas poor and overcrowded housing high risk occupations comorbidities and cultural barriers all of which ethnic minority groups are more likely to be adversely impacted by razai et al over time these have and continue to lead to worse health outcomes for minoritised communitiesas j kēhaulani kauanui states racism is a structure not an event it is unsurprising then that public health england have suggested racism and discrimination may have contributed to increased risk of exposure to and death from covid19 among ethnic minority groups and that discrimination cultural and institutional racism are empirically associated with ethnic disparities in covid19 outcomes white supremacy much like covid19 is a virus when speaking about the impact of covid19 on ethnic minorities therefore we must never stray far from the topic of racism black lives matter while the purpose of this article was not to explain why black lives matter 1 it has done so by virtue of the data as the evidence reflects black people are among the most disproportionately impacted by covid19 both across the usa and uk contexts considering the current and historic experiences of black people in a multitude of areas such as housing employment income poverty rates criminal justice and health the impact of covid19 on the black community is devastating but unsurprising and yet it was the public murder of george floyd by minnesotan police that marked a restoftheworld awakening to the lived reality of black communities by summer 2020 the black lives matter movement rose to global prominence which whilst reigniting a collective desire to fight for black human rights also reopened psychosocial wounds together with arrival of covid19 itself considered a traumatic event for black communities 2020 and 2021 have been a pandemic within a pandemic the ongoing traumatisation of black communities thus persists and 1 rather it is assumed with it a need to tend to and centre black mental health this is echoed in the evidence base which calls for more attention to be given to black lives particularly black women and especially black women in academia who are centred in the current study black in academia one of the hotspots where inequality thrives is the academy which has long been associated with structural racism black students experience greater mental health problems and difficulties transitioning into the academy having navigated a schooling system with a whitewashed curriculum disproportionate rates of exclusions and antiblack racism for example bird and pitman examined the lack of diversity on reading lists at two research intensive uk universities and found only 7 of the social sciences authors reviewed were from bame backgroundsdespite there being a 39 uk domiciled student population also in mwangi et al study black elephant in the room black students contextualising campus racial climate within us racial climate black student participants demonstrated how the systemic antiblack racism being resisted through larger movements such as black lives matter is also reflected and reproduced in us universities the effects of these show antiblack racism is fluid and relentless reflected in attainment and outcomes of young black students at key educational stages including school and university among black staff institutional racism yields different but equally immobilising effects such as higher numbers of precarious contracts lower retention rates and restrictions to development and progression as bowden and buie note the way these manifest are often covert and insidious one does not need explicitly racist policies to yield racial disparities for example providing grant supplements only to those with active awards is not openly racist however when you consider that black principal investigators are funded at a much lower rate than their white colleagues the result is less access for black researchers to these funding opportunities these challenges are reflected in the mental health experiences of black students and staff perpetuated by stigmatisation lack of belonging isolation and marginalisation for black women in particular the lack of support beyond that which is selfand communally cultivated creates pressures that can lead to mental health implications with staff in particular these pressures are exacerbated when their white female counterparts are active participators in their exclusion in the workplace and thus strategies are taken for selfcare and survival compounding these experiences are the differential healthcare outcomes for black staff and students who do attempt to access support which include overdiagnosis and undertreatment as well as a lack of culturally responsive services unsurprisingly when considering the evidence the sudden imposition of online teaching cancellation of lectures use of alternative assessments and adjustments to new technology have had differential impacts on students and staff of colour research shows that over the pandemic ethnic minority groups including those from the black community have had reduced access to research resources and have been more adversely affected in terms of mental wellbeing social isolation and academic support undoubtedly there are also incoming black university students impacted by the use of algorithms and teacher assessments which together produced disproportionate downgrading of gcse and alevel results2 in the usa there are higher levels of attrition in higher education among ethnic minorities and steep declines in university and college enrolment since the pandemic began with a 143 drop among black men some of the largest barriers reported were acclimation to the online curriculum financial constraints and prioritising caregiving responsibilities though without disaggregation of ethnic minority data it is unclear whether these experiences represented those of black students similarly in the uk while young carers are 15 times as likely to be from black asian and minority ethnic communities it is not clear what proportion of these are black young people this exemplifies and further reinforces the need to disaggregate ethnic minority data if we are to better understand the impact of covid19 on black students as pennant notes there is a need to support black students especially black girls and women who continue to endure the sharper end of both racism and the pandemic for instance prior to the pandemic young black girls have been rendered invisible in secondary education regarding academic success therefore the racialisation of gender is multidimensional and important to consider amongst young black pupils in the academy meanwhile university staff are feeling the weight of responsibility to manage the impact covid19 has had on their studentsand in particular black academic staff who do so with an additional black tax3 black women bear the weight of this even more so describing the pressure to save our students from the stress and weight of the pandemic and save our departments from the increased scrutiny around how we view assess and address diversity equity and inclusion particularly in line with the concurrent upsurge of the black lives matter movement just as bowden and cullen write truth be told having to work harder to obtain similar opportunities to our colleagues takes an emotional toll we are tired walton and colleagues say we are sick and tired of being sick and tired the impact of covid19 on the next generation of black graduates and the black staff in higher education is thus significant however its longterm effects on black staff and students are unknown and there are a number of calls for further research that explores the impact of covid19 on black communities indeed many of the recommendations arising from such research are around engaging in further study such proto and quintanadomeque who call for additional research on the potential differential effects of the covid19 pandemic by ethnicity similarly the uk centre for mental health highlights a need for research that goes beyond outdated and homogenised comparisons of white and bame to focus on specific ethnic groups without which we cannot truly understand the variances in health and outcomes that emerge between different communities given the paucity of such research within the academy it is the aim of the current study to explore the experiences of black students and staff within the context of the covid19 pandemic recognising that within the us and british education systems black girls and women are often ignored this research places particular emphasis on these voices critical race theory one way in which to uplift the voices of the black community is through critical race theory a theoretical framework that examines the role of race racism and power with its roots in legal studies and black feminism a founding tenet of crt is in its commitment to eliminate all forms of oppression through an interdisciplinary approach solórzano and yosso define critical race theory in education as a framework or set of basic insights perspectives methods and pedagogy that seeks to identify analyse and transform those structural and cultural aspects of education that maintain subordinate and dominant racial positions theoretic elements of crt include the centrality and intersectionality of race and racism race as a social construct whiteness as property the challenge to dominant ideology and the value of experiential knowledge the first centrality of race is about the permanence of racism and how it is so embedded within society that it is difficult to recognise and hard to address it should therefore be foregrounded in research this includes intersectionality crenshaw 1991 acknowledging how the centrality of racism is impacted by other interrelated identities and social structures such as gender sexuality and class the second element social construction means race is not inherent within itself or a person but is a complex and longstanding product of society third whiteness as property refers to the value whiteness holds in relation to other races historically this was in the context of property and rights but over time has become associated with other abstract concepts such as time creativity or education the fourth challenge means countering dominant narratives around neutrality objectivity colourblindness and meritocracy in society all of which maintain the value of whiteness one way in which to challenge these majoritarian stories4 is through a fifth element experiential knowledge crt research values the lived experiences and narratives of minoritised communities ie counterstorytelling hence its use in the current study utilising a critical race theory framework this paper attempts to explore the disproportionate impact of the covid19 pandemic on black students and academic staff in uk and us higher education importantly this paper will argue that systemic racism within the academy plays an integral part with regard to reproducing social and health inequalities particularly in the midst of a global pandemic this ran concurrently alongside the murder of george floyd and subsequent global outcry which was a key topic for discussion the study emanates from the marginalised voices of fortythree black students and academic staff within the uk and us higher education sector exploring the impact of the pandemic against of backdrop of structural and institutional racism serves as an important vehicle not only for promoting counterstorytelling narratives but also advocating to redistribute the labour of antiracist endeavour away from black members of the academy methodology procedure participants engaged in individual semistructured interviews and focus groups to explore their lived experiences of navigating the pandemic whilst in higher education to inform the focus groups all participants completed a reflective journal to chart and document their experiences of covid19 these became reference points and points of departure within the facilitated group discussions participants were contacted through purposeful sampling aided by both researchers institutional and personal affiliation to uk and us institutions the objectives of the study were explained to all the participants and informed consent was ethically obtained participants were drawn from a combination of staff and students from uk and us higher education institutions these ranged from the russell group 5 and post1992 6 universities in the uk and ivy league 7 historical black universities 8 and r1 universities in the usa 9 the sample comprised of eighteen students and twentyfour members of staff at midcareer level in the total sample of fortytwo participants there were twentysix black women and sixteen black men all were interviewed on multiple occasions between 2019 and 2021 through a mixture of inperson and online interviews discussions were facilitated by the researchers who had experience in crosscultural working and qualitative methods all focus group sessions and interviews were audiorecorded and transcribed verbatim before being coded in nvivo and data analysis applied across the 3year period a total of eight different focus groups containing a minimum of three participants during each session were conducted design the analytic process was driven by a crt conceptual framework which informed the development of knowledge constructed through interactions between the researcher and participants in terms of positionality the researcher had lived experience both as a black academic and students within higher education it is recognised that associated insideroutsider statuses can be both a benefit and a limitation of the research process and thus the role of the reflexive researcher becomes especially important here for example both researchers sharing lived experiences of racism could display bias andor racialised flashbacks affecting the procedure stage illustrated in the previous section it is undeniable researcher bias affects data validity and thus to limit our biases the researchers kept their subjectivity to not conform to one truth supporting different perceptions additionally countering racialised flashbacks was considered ie the researchers personal experiences of diverse forms of racism coinciding with participants perceptions during the interviews thus selfreflective notes and jointresearcher communication was used to protect mental health preventing any responsive emotions during the interview processes the interview design was informed by a critical racegrounded methodology process that captured the experiences of black staff and students during the pandemic including the concurrent black lives matter movement a grounded theory rejects the notion of positivist paradigms and methods taking a deductive approach to research creating an apartheid of knowledge which results in reoccurring narratives of deficit approaches towards people racialised as black this is congruent to crt where a crt methodology centres the voices 6 new university synonymous with post1992 university or modern university is a former polytechnic or central institution in the uk that was given university status through the further and higher education act 1992 or an institution that has been granted university status since 1992 without receiving a royal charter 7 1 the ivy league consists of eight private researchintensive universities in the north east of the usa these universities regularly score highly in league tables based on research and teaching the ivy league are the most selective universities in the world 8 historically black colleges and universities are institutions of higher education in the usa that were established before the civil rights act of 1964 with the intention of primarily serving the africanamerican community 9 there are 146 institutions that are classified as r1 doctoral universities very high research activity in the carnegie classification of institutions of higher education as of the 2021 update of groups who are racially marginalised to challenge these constructions from traditional orthodoxies aka eurocentric epistemologies coconstructing racism in the form of white supremacy in sum this means while crt was used conceptually to guide the structure of the interview schedule the amalgamation of grounded theory was flexible enough to allow participants to divulge their stories another methodological point of significant importance was the fact that both researchers were black men and some of the key findings in the forthcoming discussions concerned the gendered implications of racism and covid19 for black women in particular as well as contending with the ways in which lived experiences of racism and especially antiblack racism would be an unavoidable aspect of both the way we conducted the research and our interpretation of the data it was essential for our crt framework to reflexively contend with race gender and power this required the researchers to firstly consider how they engaged with the participants and secondly how they interpreted the black womens reflections concerning how institutions had disproportionality treated them in comparison to some of the black mens narratives while this paper contributes to scholarly interventions on the particularities of blackness racism and covid19 the researchers remain cognisant of how the intersection of gender should not be understood as supplementary to the findings but rather as an always already symptom of what bell hooks contends as a key pillar of white supremacist capitalist patriarchy which infiltrates all forms of racism in this way as custodians of antiracist endeavour it becomes our scholarly duty as well as being integral to our position as black men to be conscious that when discussing and researching the treatment of black women in the workplace we keep hooks note on how interlocking systems of classism racism and sexism work to keep women exploited and oppressed these intersectional and gendered structures poignantly highlighted by hooks remained that at the forefront of how we engaged with the participants and the data we interpreted on the connection between covid19 and racism in universities findings and discussion three themes were identified through analysis the first theme pandemic within a pandemic had two subthemes around racial traumatisation and loneliness and isolation a second theme emerged job precarity alongside a third theme exploitation of black labour the key tenet of crt incorporated in the aforementioned themes is concerned with asserting that racism as ordinary not aberrational thus though the discussions are located in the context of universities the analytical framework demonstrates that racism is normal and the living everyday experience it is our contention through crtand connecting individual narrative with the aforementioned global racist structuring of societythat covid19 exacerbated all forms of racisms and in particular antiblack racism pandemic within a pandemic there was a strong theme around racism and covid19 representing a pandemic within a pandemic for black people for many participants it was impossible to separate the impact of antiblack racism which was especially illuminated by the black lives matter movement and the impact of covid19 which was disproportionate among black communities the impact has been difficult as a black member of faculty my experience has obviously been compounded by the events of george floyd and blm and a president10 that had no care for black lives for participants three and thirteen both black us staff experiences of racism during the pandemic were not only magnified through covid19 and the murder of george floyd but also within the white house president trump compounded the us racial divide with both participants experiencing an acute disregard for black lives the pandemic was hard in the us we were up against it on several fronts we were being failed terribly by a xenophobic president 5 who was whipping up as many racial divisions as possible all of this in the midst of the george floyd murder and the disregard by the president for his life former president trump was a percolating theme for us participants as it was continuously perceived that his actions played an important role in their experiences during the pandemic for the us participants the pandemic was exacerbated by the lack of involvement from the government which clearly had demonstrable effects on their sense of self as the governmental system reverted from a true engagement with antiracist policies it instead constructed racist policies this highlights the systems connectivity with an original crt doctrine white dominance where white supremacy ie everyday mundane actions and policies that shape the world in the interests of white people impact communities who are racially marginalised moreover participant perceptions also illustrate how white dominance creates discrepancies in the black and white experience during the pandemic for example as reflected in the comments from participant nine for black people living in a world designed by and for white communities requires constant negotiation and navigation while their white counterparts were dealing with one pandemic black people were dealing with two negotiating the pandemic has been very difficult as a black person its highlighted even more the blatant disregard for black lives yosso identifies navigational capital as ethnic minority students skills and abilities to traverse social and educational institutions which are often unsupportive or hostile environments that neglect and were not created with communities of colour in mind this additional resource which beneficiaries of white supremacy are neither required to develop nor value speaks to the black tax and burdens described both by walton et al and participant eighteen during the pandemic seeing the rise of the black lives matter movement globally it makes you sit and think about the inequality we suffer as people of colour including covid it weighs heavy on you after a while this comment reflects wider research naming racism as a cofactor to covid19 and the acute awareness that the black communities experiences have been worse as a result as well as pointing to the centrality of racism which for many of the black participants underscored their experiences of the pandemic the participant also speaks to a subtheme regarding the reinforcement of black suffering ie structured emotional consequences at the hands of racism racial traumatisation this subtheme theme was around the impact of racism on mental health during the pandemic and specifically how the murder of george floyd and subsequent black lives matter movement was linked to feelings of trauma and suffering particularly among student participants for young black men death was represented not just in rising and disproportionate covid19 figures but in policing which was the leading cause of death in young black men in america a big thing for me during covid was trying to access mental health support through my university and when i tried to explain the impact that george floyd murder had on me like being a triggering incident for my own personal experiences of racism they the counsellors dismissed it as me being hypersensitive this participants experience is consistent with the findings of a large us study demonstrating that police killings of unarmed black americans have adverse effects on mental health among black americans their account also reflects existing research highlighting the challenges black students have accessing mental health services black men are seen as stronger more impervious to pain and as such are undertreated across both mental and physical health spheres both are indicators of racism and patriarchal masculinity and point to a need for reform within current mental health and pastoral services given research into collective trauma which the black community experience both through ongoing racism and the covid19 pandemic the experiences of student participants are perhaps unsurprising the above and previous comments suggest the intersections of race and location illustrate the role george floyd and black lives matter had within the student sample during the pandemic despite participants residing in the uk the george floyd murderin the usahad an impact and this coincides with p18 above mentioning the role and rise of black lives matter globally thus racism can be experienced vicariously for black participants also known as secondhand racism whereby black people on the witnessing end of racial abuse are impacted by it too this reference to the everyday and daily nature of racism often referred to as death by a thousand cuts sits alongside how the participants understanding of the murder of george floyd was a more deeply felt wound in black communities that extends beyond the individuals that directly experience it…this type of collective trauma must be understood as an urgent public health crisis these repeated lacerations are linked in the wider literature to racial stress racial trauma and racial battle fatigue especially among african american students in higher education institutions ragland woods and colleagues highlight how these experiences both compound and are compounded by feelings of isolation and disconnectivity which also emerged as a subtheme in the current study loneliness and isolation a second subtheme emerged around feelings of loneliness and isolation this is consistent with wider research that student and ethnic minority groups were at higher risk of being lonely during the uk lockdown although the latter were already considered at greater risk prior to the pandemic participant five describes the challenge these feelings brought with them it was really difficult i felt a sense of loneliness that was really difficult…and disconnectivity for participant nine this difficulty was directly linked to disconnection from the black student community the pandemic was a very difficult period i missed the sense of community that being around other black people i entered university as a mature student id say this really impacted in terms of my mental health and what i was achieving we are communal beings and a central tenet of black resilience is in what yosso describes as community cultural wealth the lack of access to support and community highlighted by participant nine a black woman reaffirms the question asked by pennant whos checkin for black girls and women in the pandemic within a pandemic this is important when considering ways in which to increase support for black students particularly black women who typically receive less support from the educational systems around them the intersections between race and gender play a pivotal role in the pandemic within a pandemic as the system is especially susceptible to neglecting the lives of black women having access to supportive relationships not only underpinned participant nines mental wellbeing but also her productivity this is also echoed in the experience of a black female staff member it gets a bit lonely sometimes it feels like a lot is on you you know its a lot of pressure to keep it up…sometimes you feel like you cant but you have to especially in these times where you dont know if youre coming or going participant ten associates her loneliness with pressure and a sense that she must keep going regardless for black staff who may not know if they are coming or going perhaps due to job precarity or fear of reprisal or exclusion stopping or slowing down might be seen as privilege not afforded to them this speaks to the type of loneliness experienced through a lack of care from others as well as an emergent theme around job precarity and how this may be compounded in these uncertain times the participant testimonies highlight that the pandemic within a pandemic is conditioned and maintained by the structures of whiteness that marginalise the lives of black people both physically and psychologically through the neglect of the health and wellbeing of black students and staff in higher education the ongoing backlash at both governmental and institutional level has created a perfect storm of marginality underpinned by a global emergency and the ongoing generation of antiblack racism therefore the theme pandemic within a pandemic is underpinned by the normalisation of white dominance and antiblack racism where the government and higher education institutions reinforce a racist system that creates negative emotional consequences for black lives precarious employment black staff in higher education institutions relayed their anxieties around job insecurity including the uncertainty around what this could mean for them the pandemic has been very difficult i was on a temporary contract so my thoughts also gravitated towards the economic impact of covid and where this would leave me professionally black people in the uk are twice as likely to be employed on zerohour contracts the associated uncertainty as described by participant four feels even more compounded when factoring in national economic crisis and global recession it is unsurprising that job insecurity interrelated with wellbeing as was the case with a us participant i found the pandemic really debilitating not only did i lose my job but my mental health was also severely impacted this for me was extremely difficult given how long it had taken me to gain employment in academia my redundancy was because of the pandemic and i guessed what i noticed at my institution and the sector my generally was that a lot of black people people of colour were the ones being made redundant importantly this suggests that redundancy practices are experienced as a form of institutional racism this speaks to both the centrality of racism and whiteness as property rendering black staff feeling more vulnerable and more disposable in more juxtaposing narratives participant blamed the pandemic for their adverse circumstances but are absent in blaming their racist institution again an interpretation could be the camouflage of institutional racism and how it can use the pandemic as an excuse to conduct racist practices by threatening their job security additionally and similarly to students gender discrepancies amongst black staff were evident participant four fears losing his job while participant eleven was made redundant here we play close attention to the tenants of crt and intersectionality in foregrounding the gendered implications of race and power for black women in particular the racegender element has been shown to have diverse impact amongst black staff supporting studies and statistics emphasising the difficulties for the roles of black women in academia these patterns of oppression reinforce black peoples having to work twice as hard to get half as far paving the way for the exploitative practices that are central to black staffs experiences within the uk and us academy exploitation of black labour a strong theme that emerged related to participants experiences of exploitation specifically staff the impact has been increased workload and for most black members of staff a feeling of exploited labour during these very difficult times participant sixteen revealed exploitative practices as a shared experience among the black community which replicates the findings of a recent uk study experiences of exploitation were welldocumented in the literature prior to the pandemic tuitt and stewart argue that us higher education institutions are designed on the premise of plantation politics and resemble entrenched colonial systems and practices of exploitation and domination the exploitation of black people in the academy is not only violent its normal to the point that none even questions it this comment reflects the permanence and normalcy of racism in the us education system and how little remedial or reparative action is taken participant fifteens use of the term violence also speaks to the significant harm caused by these practices the cuts wounds and lacerations discussed earlier taking yet another structural form for participants in the present study their experiences of exploitation are confounded by the pandemic and concurrent black lives matter movement where the spotlight on racism following the murder of george floyd brought with it an increased global awareness of the plight of black communities the additional labour required to elevate and respond was outsourced to black staff in the academy i became the person of colour that was designated to mobilise and complete anything to do with race equality my labour was not acknowledged and i was positioned as being the person that should lead this without any resource time or support this comment subtly illuminates an entrenched pattern of white fragility which sits on the other side of the proverbial coin to the notions of black strength invulnerability and invincibility described earlier from these myths arise the expectation that black people must care for soothe and protect white people historically this was most visible on the plantations but continues systemically today as reflected in participant experiences and the wider literature in essence to uphold this ideology the burden of racism and the labour of antiracism must fall to black staff as a black academic member of staff i felt that the burden of the universitys objective to become antiracist fell squarely upon me this was not only physically crushing but also emotionally crushing there was this exploitative expectation that as a black member of staff i would relish the opportunity to have my workload added to without any concession i found this period pandemic deeply stressful the george floyd murder actually created more work for me as my institution placed a lot of pressure on me as the only black member of faculty to deliver antiracist interventions and decolonising things… it was a lot and very stressful the experiences of participants thirteen and two highlight the emotional and physical toll of racism harking back once again to the literature around racial stress and trauma not mentioned in participants comments are the silent beneficiaries their white colleagues who remain invisible and thus weightless within the previous two themes there is a familiarity amongst black staff and students which suggest that both precarious employment and the exploitation of black labour are underpinned by a very particular form of antiblack racism dependant on the structures that allow for race or the racialisation of blackness to be hidden by whiteness it seems pertinent to conceptualise that whiteness is not solely used to normalise eurocentric culture and its predominant representation in literature which camouflages processes of black exploitation and white passivity it is therefore important that as well as counterstorytelling dominant discourses are challenged in action including the prioritisation of black care with a shift in labour away from black staff and students in the academy conclusion utilising a crt framework this study qualitatively explored the impact of the pandemic on black students and academic staff in uk and us higher education institutions in doing so it provides a counternarrative to dominant racial discourse that platforms the voices of black people as a distinct group firstly as was evident from the dominant theme black communities experienced covid19 as a pandemic within a pandemic racism the other pandemic underscored all participants experiences which for us staff and students in particular were compounded by the politics and presidency at the time the use of students and staff together in the overall discussion and arguments presented a move within sociologies of education in higher education which takes seriously the importance of the academic lifecycle in unison significantly the findings show the correlations and continuation of racism experienced across the academic landscape demonstrating the need for more connections to be made between service users and providers especially concerning global emergencies like covid19 and systemic racism the concurrent murder of george floyd and subsequent black lives matter movement added to a collective trauma experienced by both us and uk participants many of whom also described feelings of loneliness and isolation importantly the results replicate existing findings from before the pandemic surrounding the exploitation of black labour and precarious employment these represent longstanding systemic issues within the academy that require urgent redress these themes and subthemes which are discussed against the existing research landscape serve to illuminate some of the structural and societal problems that black students and academic staff experience unceasingly ultimately as every racial group had adverse experiences under the same storm ie covid19 those experiences are diverse requiring different levels of bespoke attention the juxtaposition of experiences is evident as people racialised as black remain in the eye of the storm ie pandemic within a pandemic underpinned by antiblack racism and the dominance of whiteness the subsequent neglect experienced by black people aligns with their encounters which metaphorically situate them in stormy terrain therefore purposeful recognition from institutions which take seriously how the inequitable structures of society infiltrate university cultures remains integral if black people are to be given the space to locate the tools required to navigate the storm limitations as with all qualitative research the findings in the current study are not generalisable rather the purpose of this study was to tell the stories of black students and academic staff navigating the us and uk academy during the covid19 pandemic one of the benefits of crt is that these voices which are often marginalised from discourse or homogenised with other ethnic groups are centred and brought to the fore it is recognised that wider perspectives may have further informed this area of research such as exploring the experiences of black professional service staff as well as scholars conversely narrower perspectives may also benefit further study such as more detailed exploration of the experiences across the intersection such as gender class or disability implications and recommendations for black students and academic staff this study points to the complex and intersecting nature of two pandemics covid19 and racism while the present study initially set out to explore the covid19 pandemic it was impossible to separate participants experiences of racism together they continue to reproduce greater inequalities for black communities reinforcing the need for each to be considered urgent public health crises specifically both should be recognised as a type of collective cultural trauma as reflected in the current study and wider literature and particularly in respect to the murder of george floyd this recognition must take place at every level with appropriate fiscal investment to ensure culturally responsive support is available this might for example look like embedding in policy the recognition of racial trauma as a serious life event as is the case at goldsmiths university of london it could also look like reform within university mental and pastoral care provision such as improving racial literacy among counsellors or engaging in more robust data monitoring practices perhaps also universities and policymakers might consider abolition of precarious contracts or local ringfencing of funding for equality and diversity resources at the very least senior leaders should be initiating courageous conversations which start from the premise that racism is central and pandemic regardless of the approaches taken there must be a clear shift in where the labour of this work sits not just formally and in the more observable spaces but in the quieter moments where everyday racism takes place

the permanence of systemic racism in the uk and usa means that black people are disadvantaged in myriad ways including within the academy while the disproportionate impact of covid19 alongside the black lives matter movement has increased awareness of the challenges faced by black communities these issues remain both in and beyond higher education furthermore there is still a paucity of research individualising the experiences of black people who are often homogenised with other ethnic minority groups this paper explores the impact of covid19 on uk and us black students and academic staff utilising a critical race theory crt framework analysis revealed that black students and staff experienced covid19 against the backdrop of racism as a pandemic within a pandemic laurencin and walker cell systems 11910 2020 including racial re traumatisation loneliness and isolation other themes included precarious employment and exploitation recommendations are offered for penetrative interventions that can support black students and staff in the wake of strained race relations neglecting their adverse experiences and a global pandemic

i introduction grassroots civic tech or software for social change is an emerging practice where people create and then use software to create positive change in their community such as using citizen sensing to record evidence of air pollution to support environmental activism 1 it is related to freelibre and open source software movement and participants are diverse calling themselves for example civic innovation tech for good civic crowdsourcing free software and community technology 2 like their names for the field the participants and groups motivations and working practices are diverse civic tech itself is a wider field 34 with studies for example in examining the role of information technologies in governance 5 supporting participatory democracy practices of technology in society 6 understanding the role of software in society 7 developing agile methods and techniques to support software development in society 89 and more recently architecting smart cities open data with and for people 1011 however civic tech software development processes from a systems perspective have been less often studied especially when it comes to groundsup development processes similarly there have been studies on what drives individuals to participate and keep contributing in floss 1213 or tech for good 14 but less analysis on how volunteer motivations interact once the development process is ongoing we propose that this is an open question that is worth addressing since development processes in action 1516 evolve based on team needs a study on motivations of a project in action can reveal how different volunteer motivations can be negotiated towards a compromise in this paper we apply engeströms expanded activity theory 17 as a theoretical lens to analyze motivations how they relate to for example group goals or development tool supported processes and what contradictions emerge when a civic tech groups development process is in progress the research case is based on the activities of code from ireland civic tech group from 2018 to 2019 with the group structure described in more detail in 18 during the case study period code for ireland was engaged in two projects transparent water for publishing data on water quality and finding vacant homes for identifying residences that could alleviate the irish housing crisis more specifically our research question is what motivation motive or goal contradictions emerge in a grassroots civic tech project in action in the following section 2 we detail related research on grassroots civic tech and motivations we continue then in section 3 about case study and analysis findings are presented in section 4 and conclusions in section 5 13 they found that key motivational factors were social aspects and intrinsic motivations such as fun learning and altruism similarly barcomb et al 12 found that social norms satisfaction and community commitment were supporting factors in episodic volunteers coelho et al 19 who studied motivations of core developers mainly had similar results in friendly community and opportunity to engage in volunteer work by contrast core developers were also motivated by technical quality such as improving projects they use lack of project complexity and lack of complex or buggy code huang et al 14 studied specifically floss for social good project participant motivations and found that they are more motivated by project impact such as the societal issue being addressed and who are the project owners community and social characteristics were also important pern and kitchin 20 analyze frictions from a broader social and cultural systems perspective in civic tech development using an earlier irish case study as a data source they found that complex urban issues can have only partial or imperfect solutions that can in turn lead to or reveal further complications the main frictions pern and kitchin discuss were stakeholder engagement shifting goals and varying commitment from participating developers iii research context and analysis the case we studied is focused on a grassroots group creating civic tech code for ireland which describes its mission as developing innovative and sustainable solutions to realworld problems faced by communities across ireland by fostering collaboration with civicminded individuals businesses and public sector organizations the research and data collection occurred during 2018 and 2019 the process is summarized in this section and is reported in further detail in an earlier study on the group 18 case study data includes interviews development activity logs from github and an ethnographic study with a researcher embedded with the group for six months in the first half of 2018 of these the main data source was semistructured interviews with six key group contributors the interviewees included the community leader a project manager an open data advocate and several programmers the interviews were recorded transcribed and analyzed with qualitative data analysis software the interview guide is archived in the zenodo repository 1 other collected data was used to contextualize the analysis findings other related research on the group has been performed by perng and kitchin 20 who discussed code for ireland from a civic and cultural perspective and defined code for ireland as a civic hacking group where civic hacking binds together elements of civic innovation and computer hacking with citizens quickly and collaboratively developing technological solutions 20 pp 2 a analysis method to accomplish our goals we framed our research as an interpretive case study 2122 using an iterative qualitative data analysis process aiming towards increasing abstraction 2324 case study research was found to be the most suitable for the purposes of this research it is a qualitative approach in which the investigator explores a bounded system over time through detailed indepth data collection involving multiple sources of information and reports a case description and casebased themes 212225 initial codebook for motivations was based on the work of barcomb et al 12 silva et al 26 and gerosa et al 13 novel goals and motives were coded inductively when encountered for rigour in our research process we used a selection of techniques by lincoln and guba 27 for qualitative research we used prolonged engagement to get rich data from the context used referential adequacy in the transcription and coding process and used peer debriefing to get additional neutral viewpoints into data analysis b theoretical lens from an activitytheoretical perspective human life is fundamentally rooted in participation in activites that are oriented towards objects 28 these activities are driven by their own or collective purposes mediated by social rules shared with a community and facilitated by tools 29 for this paper we use engeströms culturalhistorical activity theory 17 which distinguishes shortlived goaldirected actions and longterm activity systems 29 this version is suitable for the study of work and technologies 30 and has been used in is 31 software engineering 32 and hci 33 in engeströms culturalhistorical activity theory 17 activity systems are depicted as a set of mediation triangles such as in fig 1 it displays the subject object and facilitating tools the activity is moderated by rules community and the agreed division of labour between actors another key concept within activity systems are disturbances and contradictions while rules objects and motives give the system stability they are often contradictory internally or between actors and also tilt the system towards increasing instability an activity system therefore constantly evolves towards a new balance based on internal contradictions in what engeström has named cycles of expansive learning contradictions can occur inside the key concepts or between them based on the distances the contradictions are labeled as follows 17 1 primary 2 secondary 3 tertiary or 4 quarternary when applying engeströms culturalhistorical activity theory as a theoretical lens we use the diagram representation to contextualize the motives and contradiction levels to analyze where the contradictions in motives occur in the following sections where we present the analysis we use terminology from the theory which discusses actions outcomes and motives instead of the adjacent word motivation in this paper we define motivation as a big picture energization and direction of behavior 34 by contrast motive is a specific reason for taking an action iv findings in this section we present our qualitative data analysis outcomes step by step as we progress towards increasing level of abstraction following lightweight qualitative data analysis practises by saldana 23 and miles et al 24 in the first step of analysis open coding we analyze the interviews and note any motivations and motives in the second round of analysis we extract activity descriptions from interviews and online materials and relate the motives to activities using our theoretical lens in the final step of analysis where we generate a situated explanation of the case we present levels of contradictions inside and between the activities a discovering motives in case in this section we present the findings of open coding analysis where we discovered individual motivations and motives and then performed a sorting exercise to group the discovered motivations into larger themes four most common themes are listed in table i in a descending order of frequency b contextualizing motives in activities in the second step of analysis we performed another iteration of open coding to detect activity system concepts in two first motivation representative example to have an practical impact on society okay were working on software projects its very different its something good for the community its something to give back p5 commitment to community but really ill do whatever i can to try and keep the code for ireland going on p3 learning and developing skills i do at some point maybe see myself managing some people so getting some project management experience those help as well p5 enjoyment and fun i think the reason for that is that they like the freedom of these projects because if you have worked in a big company like sap or facebook youre pretty much told what to do p1 stages of the software project planning and design the stages were originally discovered and defined in 18 then we used activity theory mediation triangles to contextualize and visualize the constituent interactions in activity systems of 1 project planning and 2 software design finally we analyzed how the stated big picture motivations translate to individual activity system motives planning and design activity systems were selected for presentation in this paper due to them featuring key contradictions implementation and evaluation stage analyses were omitted from this short paper due to size and scope limitations 1 planning activity in the first activity system the key motive for project participants is to negotiate software development practises which current urban issue should be addressed and work division between current projects used tools involve communication tools such slack and whatsapp project management tools such as trello and meeting memos the key actors are the community leader and project managers the optimal outcome would be a project plan that all participants agree on the activity system is visualized in fig 2 2 design activity in the second activity system the key motive for a development group participants is to decide in more detail what the final software artefact should be like and how to divide the work inside the group used tools include wireframing design sessions and comparison between visual designs the outcome of the activity system is a design document the activity system is visualized in fig 3 c contradictions of motives in activities in the final stage of analysis contradictions inside activity systems between system concepts and between activity systems were analyzed inside each activity system concept participant motivations were mainly in alignment whether participant was motivated by impact commitment to friends learning or fun they agreed with the overall motives and what the activity system should accomplish what caused most contradictions inside activity systems was how these goals should be accomplished in project participant envisioned better processes such as codesign or better support in design however the current system had no capability to implement them leading to tensions quarternary design activity ⇔ programming activity the activity systems were only loosely coupled programming activity system sometimes disregarding the outputs and motives of design activity ii between activity systems two main contradictions were loose coupling between software engineering stages d discussing the findings some of the largest contradictions emerged in communication and task management where a phonebased instant messenger was used for communication and task tracking a second major issue occurred in design and choosing the technical specification design went through several rapid iterations was loosely coupled and several competing instead in our case study we found that the big picture motivations of participants were in alignment and what differs is how participants want to achieve those goals this follows expectations set by huang et al 14 where they mention that tech for good group membership can be selfselecting for aligned goals our findings indicate that a richer view into participant motives appears when examining a process in action in detail even though earlier surveybased research indicated that in tech for good projects motives are initially in alignment we found that contradictions rose up in the details of decisionmaking and in varying levels of commitment these included how to divide tasks communication tools and details how to select implementation details and how to select the technical approach majority of the participants were highly motivated but the volunteer nature of participants and the lack of specialized facilitators meant that good compromises were not achieved on all viewpoints v conclusions in this paper we analyzed what motivation motive or goal contradictions emerge in a grassroots civic tech project in action the main contradictions occurred inside activity systems on details of implementation or between system motives instead of big picture motivations two most significant contradictions involved planning and converging on design and technical approaches our recommendations for practice are what perhaps professionals in established volunteering and nongovernment organisations already know have skilled and committed facilitators that can keep volunteers pointed in the same direction and sustain participant engagement based on our case study it appears that it is essential to have efficient communicators shared task management tools and a compromise on technologies that most participants can commit to finding an acceptable lowest common technology denominator is important since participant skill levels in civic tech can vary 3536 we extend the body of knowledge in civic tech software engineering through two main contributions first we demonstrate activity theory can be used as a theoretical lens to evaluate software engineering methods in action 1516 as evolving inaction activity systems second we demonstrate that examining participant motives together as an activity system can shed light on contradictions that arise during civic tech or tech for good development the tradeoff between contextual richness of a single case study and generalizability of a multiple case study points towards a potential limitation in our work however seminal literature 3738 acknowledge single case study as a method of inquiry especially when undertaking novel exploratory research to capture the complexity of the context in which the case is situated looking forward we advocate for more comparisons between different civic tech software engineering activity systems for broader findings and more generalizability

grassroots civic tech or software for social change is an emerging practice where people create and then use software to create positive change in their community in this interpretive case study we apply engeströms expanded activity theory as a theoretical lens to analyze motivations how they relate to for example group goals or development tool supported processes and what contradictions emerge participants agreed on big picture motivations such as learning new skills or improving the community the main contradictions occurred inside activity systems on details of implementation or between system motives instead of big picture motivations two most significant contradictions involved planning and converging on design and technical approaches these findings demonstrate the value of examining civic tech development processes as evolving activity systems

introduction throughout human history pornography has continued to be an issue of concern initially it drew attention for its depictions of nudity and sexual acts and more recently for the pervasive violence in its content and the consequential societal impact in recent decades the availability of pornography on the internet has given rise to a remarkable surge in its popularity attracting an everwidening audience indeed its presence has now become normalized for most of western societyparticularly among menleading to an escalation in both supply and demand for pornographic content however this consumption continues to be shrouded in social taboos particularly in the context of interactions between young people and adults as a result fostering critical thinking about pornography consumption has proven to be challenging furthermore there are even studies suggesting a waning influence of universities teaching on critical thinking and a diminishing level of critical discourse among teaching staff concerning pornography a pivotal step in addressing this issue could involve destigmatizing the subject within the educational community although this still seems to be a distant goal in this context the present study aimed to analyze how pornography is represented by young people who will become educators and teachers in the future pornography consumption among young people concerning the younger demographic recent spanish research suggests that the age at which users start consuming pornography is currently 8 years moreover according to some reports more than 60 of spanish adolescents between 14 and 17 years old tend to regularly watch pornography on the internet one of the repercussions of pornography consumption among adolescents and young adults is the phenomenon of perceptual distortion this concept refers to the formation or deformation of attitudes since the cognitive and emotional development of young individuals may not yet be sufficiently mature to contextualize and interpret what they see more specifically the content of mainstream pornography is predominantly biased toward catering to male gratification a trend characterized by the objectification and commodification of women to satisfy male desires furthermore this portrayal fosters a sexist relational model wherein women are frequently reduced to the status of sexual objects available for the gratification of men and in which instances of both physical and verbal assault against women are disturbingly prevalent consequently some researchers suggest that adolescents who habitually consume pornography are more likely to internalize and endorse rape myths leading to the adoption of negative sexual values or a propensity toward sexual aggression therefore this consumption of mainstream pornography also has an impact on their perception of sexual relationships and may directly affect their sexual activity in addition the consumption of pornography is more stigmatized among women as they may fear potential judgement or disapproval of their reported consumption pornography as an educational tool while comprehensive affectivesexual education has been in place for more than 50 years in some european countries such as sweden this is unfortunately not the case in spain in this country adolescents often rely on pornography as their primary source of education given the absence of regulated affectivesexual education that could enable them to develop a critical perspective additionally educators working with children adolescents and young people have expressed a growing concern about the effects of pornography on their students it is important to note that historically educators have been illequipped to address this issue primarily because it is considered a taboo subject and difficult to approach hence several academics have also emphasized the importance of training future teachers on the issue of pornography however as a starting point it is important to determine how future educators understand and relate to pornography in this context the present research draws on social representations theory to investigate how pornography is understood and represented by future educators according to this theory social representations are systems of values ideas and practices with two functions first they establish an order that allows people to navigate and comprehend the world they inhabit and second they enable communication between members of a community this theoretical framework allows us to explore how future educators understand pornography based on both their knowledge and their daily social discourse concerning this issue we understand their representations of pornography as serving three fundamental functions a knowledge function enabling understanding and communication an orientation function guiding behavior and practices and a legitimization function rationalizing positions and behavior therefore the present study focused on university students of education this particular demographic was chosen because they are young individuals who are a primary target of pornography consumption additionally they hold the potential to become the future educators of the next generation and can thus play a pivotal role in driving changes in sex education thus the general goal of the present study was to explore the representations of pornography among these future educators that is students of infant education primary education and social education the specific objectives of the study were as follows • to describe using a free association exercise how pornography is represented by trainee teachers • to identify whether the types of pornography or reasons for its consumption are also incorporated into these representations • to explore whether these representations also include reflections on the potential impact of pornography on their affectivesexual lives methodology instrument and procedure the data for this study were collected online from january to may 2021 in accordance with the declaration of helsinki and approved by the ethics committee of the university of the basque country the questionnaires were administered into two parts first we collected sociodemographic data including age gender the subject they were studying and whether they had received affectivesexual education second a free association exercise was administered based on the grid elaboration method to analyze the participants social representations of pornography this method allows for gaining a deeper insight into the shared representations of the participants when compared with interviews or other types of questionnaires as it elicits not only a cognitive but also a behavioral and affective representation of the issue under analysis this methodology has previously been used to explore the shared representations of young people on a range of controversial and even taboo subjects specifically participants were asked to write down the first four ideas that came to their minds when they thought about the word pornography then they had to write each word or idea in a box and fill in the four empty boxes subsequently participants were asked to complete their responses by clarifying as thoroughly as possible the meaning of each of their ideas to gather further information and explanations about the elicited items again there was no word limit in this exercise this allowed us to obtain a complete explanation about each word or idea which formed the basis of the subsequent analysis data analysis method the reinert method using the iramuteq software for lexical analysis was employed to analyze the text corpus this method has frequently been used in the study of social representations confirming that the results obtained agree with those of other methods used in this field of research two types of analysis were carried out using the iramuteq software the first was based on the reinert method and the second employed lexical similarity analysis the use of the reinert method using the iramuteq software for lexical analysis eliminates problems of reliability and validity in text analysis as it is an automatic instrument first the software creates a dictionary of whole words then the initial text corpus is broken down into segments that have the approximate length of a sentence or two the corpus is analyzed in terms of the presence of whole words in the segments the segments and reduced forms are then used to create a contingency table which shows the distribution of vocabulary per segment from this contingency table the program generates a squared distance matrix implying that two segments are close if they share some of the words analyzed subsequently the software following the reinert method runs a descending hierarchical cluster analysis on this distance matrix which yields classes of segments that best differentiate the vocabulary in so doing this software assists in the interpretation of texts it extracts sets of words that are referred to as classes which cooccur and are best distinguished from other classes the software does not name these classes but instead assigns each of them with a number in essence the software identifies the words and text segments with the highest chisquare values that is those words and text segments that best identify each class or idea that the participants have repeatedly mentioned in accord with previous research using the reinert method the raw data were entered into the iramuteq software and the most significant items of vocabulary in each class were selected based on three criteria an expected value of the word greater than 3 evidence of an association based on the chisquare statistic tested against the class df 1 and the word appearing mainly in that class with a frequency of 50 or more the software also determined which text segments were associated with each class or group of words and classified them according to their chisquare value in this study the text segments with the most significant chisquares of each class were recorded once these lexical universes were identified they were associated with passive variables in the present case the passive variables were gender and whether they had received affectivesexual education consequently the analyst obtained a series of classes composed of typical words and typical text segments with the highest chisquare values this provided the basis for interpreting the classes as lexical worlds the reinert method produces statistical transparent and reproducible data until the final point of interpretation where the analyst then assigns a label finally the researchers will give a title to the group of words and text segments grouped by the software in this final phase of the study we used a systematic process to create the labels or titles of each class during this process two of the researchers independently named each class based on the words and associated quotations after which a third researcher created a final label that was approved by all three researchers second the software also conducted a lexical similarity analysis this type of analysis looks at the corpus as a whole regardless of whether the responses were from one participant or another it considers that the more times two elements are treated in the same way the closer they will be in the representational structure to the corresponding object to do this the software identifies the cooccurrences between words according to their connections in the text helping to identify the structure of the content of the textual corpus by generating a visualization in graphic form which illustrates the content of the social representation of the object studied and its internal organization its common elements and specificities results first to analyze the main discourses produced by the participants the response corpus was entered into the iramuteq software this allowed us to clarify which terms were used to represent the concept of pornography the full corpus contained 22595 words of which 2385 were unique reinert method results the reinert methods descending hierarchical analysis divided the corpus into 567 segments and six classes the results of this analysis are observed in fig 1 fig 1 the hierarchical clustering dendrogram of the free association exercise showing the most frequent words and those with the greatest association χ 2 p 0001 extracted by the reinert method the analysis identified the main ideas held by the participants regarding pornography elicited through the free association procedure each issue or idea is represented by a set of typical words and text segments referred to as a class the results revealed six different classes four of these classes refer to the reasons why participants distance themselves from pornography or cause them to evaluate it with more negative connotations and were named as the following violence and sexual exploitation denigration of women removed from real life and pornography bodies however the other two classes are much more personal and explain young peoples relationship with pornography among the classes that express the notion of being distanced from pornography the first of these is violence and sexual exploitation which emerged with a weight of 2141 and was more frequently mentioned by women within this class it can be observed how pornography has been defined as an industry that carries out sexual exploitation and is sexist abusive dominant and mistreats its actresses the characteristic text segments of this class should help to provide a context for these words thus the following are the most significant quotations within this class abuse sexism manipulation in many of the videos women are forced to do certain things pornography promotes sexist violence they want you to believe that this is reality when it is only fiction people who watch pornography without any sex education tend to show the same behaviors i think that many of the people who work in pornography are being raped all the time there will be many things they do out of obligation but the current reality of pornography is one of massive violence towards women showing violent sexual scenes it makes me sick to see how a man treats a woman like this and she seems to like what he does women are sexually exploited and the pornography industry is very sexist second and continuing with the reasons why participants reject pornography the denigration of women class emerged with a weight of 2474 this class was also more frequently mentioned by women within this class pornography is characterized as a malecentered cinematic genre that denigrates and disrespects women often displaying aggression and sexualization through the abuse of power the following are some of the most significant quotations of this class many of the freely recorded videos usually represent scenes in which a woman is raped or abused and i am disgusted because i cannot understand how there can be sick minds that enjoy violence porn revolves around mens pleasure and on many occasions women are denigrated nothing you can see is real there is a lot of violence especially towards women and there are very strong scenes on many occasions women are forced to maintain relations during prolonged periods of time with different people and even with several people at the same time pornography is made for male consumption the woman appears as a completely passive subject and many times is viewed as an object to be treated in a violent and abrupt manner besides the vast majority of acts end when the man or the dominant person reaches climax regardless of whether the other person has gained pleasure the third class named removed from real life emerged with a weight of 1036 this class emphasizes the stark disparity between what is portrayed in pornographic movies and reallife experiences noting the exaggerated and largely unrealistic nature of pornographic content additionally some participants pointed out that attempting to replicate what is seen in these movies can be risky and potentially harmful in real life the following are some of the most significant quotations of this class porn is a lie because its not real its all a role and its exaggerated to be seen more this disgusts me because it is unreal and creates false expectations it is unreal young people make movies in their heads and then try to bring to real life those violent actions learned from pornography false stereotyped forced unnatural it is not a real thing that happens in peoples lives the way they show it it always follows the same pattern its all fake its not real sensations its sex that doesnt happen in peoples lives and they sell it to us as if it were real this affects the image of sex that people can create the final class to express a rejection of pornography was named pornography bodies this class argues that the bodies of pornographic actors and actresses are disproportionate and unrealistic and in some cases can cause individuals to develop certain complexes the most significant text quotations of this class are the following most womens bodies follow the same pattern which is what attracts the male population only sexual attributes are highlighted they are not looking for intelligent educated people or those capable of working at nasa they are looking for sexualized bodies that sell pornography presents totally perfect bodies perfect for the canons of beauty which prevail in this society depilated of certain sizes or shapes the bodies have to be with exaggerated penises and breasts of exaggerated sizes and small vaginas therefore many people end up creating complexes for not achieving what is shown in those videos or for not having a body like the one in those videos in contrast the last two classes explain young peoples relationship with pornography the first of these classes was labeled as why do we consume pornography and emerged with a weight of 2114 this class was significantly associated with men and individuals who have received affectivesexual education in this class the participants indicate the two main reasons why they consume pornography first they state that they consume pornography to masturbate and second they use it to learn about sex given the inadequate provision of affectivesexual education some of the most significant quotations of this class are the following when i watch pornography it gives me pleasure even though i know that it shows a wrong image of healthy sex however in pornography you can see many types of sex and that is why it is a tool that i use to masturbate relaxing exciting quality pleasure while watching videos i dont worry about other things it makes me horny normally i relate it to masturbation i have always watched pornography to masturbate and i combine porn with masturbation a lot it excites me to watch pornography and it gives me pleasure to masturbate watching pornography although i am aware that porn is not real and that there is a lot of money behind this industry when teenagers start to get interested in sex and want to investigate they consume pornography either to satisfy their sexual desire or to learn but they learn little or rather they learn badly but thats normal who are they going to talk to about explicit sexwith their parents at school someone comes to explain everything but its not a place where you can talk about it either nowadays it is the only sex education we have because what is done in schools is a lecture that is useless porn is probably often the main source of learning about different subjects the final class was labeled influence of pornography on our sexual relations with a weight of 1332 this class was significantly associated with individuals who have received affectivesexual education and indicates how the consumption of pornography shapes the sexual experiences of young people the most significant text quotations of this class are the following after all pornography as sex is pleasurable you can discover new things in porn and then you can explore the new things you have discovered and put them into practice in your life i like what i see and at the same time i dislike it but then my relationships with my partner are different in the society in which we live pornography is frowned upon but then we consume onlyfans and there are pictures and videos i look for other types of empowered womens porn and watching it makes me feel more comfortable lexical similarity analysis second a lexical similarity analysis was conducted to generate an image to represent the cooccurrences between all the words in the corpus beyond their division into classes the idea was to analyze how the words of the corpus were interconnected on a common plane for this purpose the lexical similarity analysis was carried out only with the words having a frequency greater than 20 the results of which are displayed in fig 2 the similarity analysis revealed that the corpus is structured around different nuclei first at the uppermost part of the figure the word sex appears associated with penetration and the role of pornography in masturbation which differs from real life second as we move to the center of the figure pornography emerges as something that makes money through the internet and is consumed globally in any location and at any time additionally the onlyfans phenomenon is also linked to this concept moving on to the nucleus composed of the word woman this is related to the violence and sexism suffered in pornographic videos in addition the female bodies are also questioned in the lower part of the figure we also see that pornography is related to sexual relations sex education and sexual exploitation finally and linked to the nucleus of pornography we can observe a complex emotional response with various emotions mentioned by young people such as pleasure fear disgust or guilt discussion this study set out to examine the primary representational patterns elicited by pornography in young people who will be future educational professionals the results of this research offer invaluable insights into identifying how pornography is represented by trainee teachers whether the types of pornography or reasons for its consumption are also incorporated into these representations and to explore whether these representations also include reflections on the potential impact of pornography on their affectivesexual lives one of the most significant findings of this study is the ambivalent relationship that young future educators have with pornography on the one hand they maintain a distant and critical perspective associating pornography with violence sexual exploitation denigration of women and disconnection from real life and real bodies however on the other hand they utilize it for both masturbation and as a source of pleasure and sexual education therefore this ambivalence in the social representation of pornography will be key since it will shape the understanding and communication of this subject influence behaviors and practices and impact its legitimization or delegitimization to begin with following the representational patterns extracted from the cluster analysis it becomes apparent that the young participants in this study perceive pornography as conflicting with many of their core values this distant and at times negative assessment is underpinned by several ideas rooted in two main arguments first both men and women express the belief that pornography deviates significantly from reallife sexual relations by presenting an exaggerated portrayal that includes unrealistic bodies these bodies often feature disproportionate shapes and sizes of penises vulvas and breasts the discourse surrounding the authenticity of pornography among viewers has been explored previously concluding that viewers can and should make judgements about what is and is not real in pornography and that this is an integral part of the experience of viewing pornography second being unreal or fictional is not the only factor that leads young people to express a distant representation of pornography a further important reason for this fig 2 results of the lexical similarity analysis with words that emerged with a frequency higher than 20 distantand sometimes negativeevaluation is that participants in this study particularly women contend that a significant quantity of pornographic content is characterized by violence and sexism in support of this perspective some participants highlight that in addition to demeaning women the pornography industry also sexually exploits women to further corroborate this argument some participants express the view that almost all pornographic content is centered around providing pleasure to men often featuring scenarios where women are raped by one or more men who do not respect their right to say no the notion that pornography influences many people to disregard the importance of respecting consent is well established in both academic research and public discourse following highprofile rape cases along these lines some participants in this study who are aspiring educators express concerns about this potential risk they advocate for the need to generate debate and implement concrete measures aimed at strengthening affectivesexual education for children and young people the aim is to help them understand the importance of sexual consent and the notion that sex should be joyful equal and free indeed alternative approaches within the industry such as feminist pornography seem to have limited reach among this young population this might suggest that such content characterized by a distinct representation of pleasure and the role of women is predominantly consumed by an older audience with greater purchasing power and have not yet had an impact on the younger generation previous research has suggested that young people often simplify their consumption of mainstream pornography characterizing it from a distanced and risky standpoint in contrast to the more nuanced considerations of pleasure and arousal that adults are allowed to make however our findings indicate an association between such considerations and active pornography consumption among young individuals young people cite two main reasons for watching pornography to masturbate and for educational purposes previous studies have identified pornography consumption as a source of information about sexual practices bodies sexual orientation and desires often catering to preexisting or emerging fantasies and interests furthermore along with the consumption of pornographic material masturbation remains a significant sexual taboo several participants closely associate these two activities with some even admitting that they cannot masturbate without watching pornography it is important to note that while male participants talk more openly about this issue we must recognize that both pornography consumption and masturbation are taboo subjects that are rarely discussed among women moreover in line with previous research it is also worth considering that boys tend to consume more pornography than girls many of the participants highlight the inadequate provision of affectivesexual education for young individuals let alone a platform where sex can be talked about explicitly they assert that sex is not discussed openly within either families or in the affectivesexual education that is offered in schools consequently youngsters often turn to pornography even though they are aware that it can perpetuate stereotypes present unrealistic portrayals and even promote violence thus creating highquality affectivesexual education represents a significant contemporary challenge in spain the legal framework has been established to address this need since the current education law has regulated the implementation of affectivesexual education in compulsory education in addition our participants also explain how pornography can affect the sexual relationships or behaviors of young individuals while some acknowledge its role as a learning resource others express concerns that due to pornography many young peoples sexual relationships prioritize male pleasure with limited emphasis on female satisfaction some participants also state that while traditional pornography may be frowned upon platforms such as onlyfans are highly successful therefore it becomes apparent that the impact of these new social networks on the emergence of fresh approaches to consuming or even creating pornography among young people warrants further investigation moreover one of the most striking findings to emerge from our research is that those participants who have received affectivesexual education tend to speak more openly about their reasons for consuming pornography this implies that although the notion of pornography being bad is prevalent among young people they consume it nonetheless thus our results suggest that affectivesexual education could encourage individuals to talk more openly and even reflect on why they consume pornography additionally it is important to address empathy within the context of affectivesexual education since previous studies have indicated that low levels of cognitive and affective empathy are associated with extensive pornography consumption and a greater prevalence of associated risk behaviors for this reason it is important to focus on empathic disconnection processes in essence the fact that pornography remains a taboo and stigmatized subject it does not deter young people from its consumption let alone promote thoughtful consumption the similarity analysis also highlights the concerning widespread availability of pornography and at increasingly younger ages underscoring the pressing need to urgently address this issue moreover on an emotional level our analysis reveals that the emotions linked to pornography consumption are on the one hand pleasure but on the other hand disgust fear and guilt an inconsistency that has also been observed in other studies therefore it would be interesting to analyze to what extent pornography is considered a guilty pleasure that is a way of furtively satisfying oneself through taboo acts this view of pornography and potentially sex itself perpetuates the legitimization of taboo and discourages open communication an issue that needs to be addressed within the context of affectivesexual education finally this research has several limitations first this work employed a crosssectional design with a nonprobabilistic sample recruited from a specific regionthe north of spain therefore our conclusions cannot be generalized to any other society or context furthermore the degree subjects being studied by our participants have a clear gender imbalance and it would therefore be interesting to analyze students of subjects with a more balanced gender ratio to determine how they are influenced by their context in addition in future studies it would be advisable to examine the impact of the variables of gender identification and type of pornography consumed nonetheless the strength of the present study is that it lays bare the voices of young people and reveals novel findings that have not been reported in previous studies in conclusion this research suggests that pornography serves as both a source of pleasure and a trigger of emotions such as disgust fear and guilt among young people indeed the symbolic perceptions of pornography held by future educators are determined by their gender and the affectivesexual education they have received moreover it is essential to further explore whether critical appraisals of pornography are rooted in social desirability or reflect a genuine capacity for critical analysis of this subject consequently we stress the importance of implementing highquality affectivesexual education rooted in emotional awareness and a gender perspective not only for children but also for current and future educators furthermore it is imperative that this affectivesexual education aimed at young adults begins by recognizing these ambivalent emotions and promoting the values of respect and selfempowerment thereby dismantling societal taboos in other words we need to equip educators with the tools to address the issue of pornography with both adolescents and younger children however as a first step it is necessary to encourage these future educators to reflect on the possible impact of pornography on young people in general as well as on their own perceptions while taking into account the gender perspective availability of data and material the raw data supporting the conclusions of this article will be made available by the authors without undue reservation code availability software application or custom code iramuteq author contribution all authors contributed equally funding open access funding provided thanks to the cruecsic agreement with springer nature this research was funded by kideon research group of the basque government ref it134219 and upvehu conflicts of interest 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 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 publishers note springer nature 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introduction although pornography has existed throughout human history contemporary society finds itself immersed in a digital era that significantly facilitates its accessibility this heightened ease of access particularly affects the perceptions and practices of sexuality among youngsters in this context the present study aimed to explore the representations of pornography among education students methods a total of 276 university students participated by completing a free association exercise based on the grid elaboration method gem results future educators distance themselves from pornography perceiving it as a medium that projects an unrealistic portrayal of reality moreover participants also linked pornography to situations of violence exploitation and denigration of women however students also show a direct relationship with pornography using it to both masturbate and learn about sex particularly in the case of men educational students also recognize the influence of pornography on their own sexual life and knowledge finally they report that pornography produces mixed emotions such as pleasure disgust fear and guiltthis study highlights the urgent need to equip future education professionals with the necessary tools for reflective engagement with pornography and its consumption paving the way for a more thoughtful and informed approach to educating on this subject

introduction childhood obesity has increased dramatically in developing and developed countries 1 unhealthy diet and physical inactivity are two major risk factors for childhood obesity 1 caregivers may influence childrens diet and physical activity making child care defined as parental informal or formal a potentially important modifiable factor in childhood obesity in developed western countries one crosssectional study 2 and three prospective cohort studies 3 4 5 have found informal rather than parental child care during infancy or early childhood to be associated with obesity whereas associations were less clear for formal child care 2 5 6 7 it has also been suggested that the association of informal child care with obesity may be limited to more advantaged socioeconomic groups 5 in western populations both child care and childhood obesity are socially patterned such that low socioeconomic position is associated with both informal child care 7 8 9 10 and childhood obesity 1112 however in a nonwestern population nonmaternal care was not associated with obesity in young children 1314 but informal care was not distinguished from formal care examination of this question in another developed setting with a different social patterning of informal child care and childhood obesity can clarify whether the observed associations are socially confounded or are an attribute of informal child care where intervention could be justified moreover it is not known whether it is the current exposure to informal child care that matters the cumulative exposure or whether there are any critical periods when informal care has a longlasting effect hong kong has a recently developed postindustrial servicebased economy with a gross domestic product per head and social infrastructure comparable with western europe or north america in hong kong the labour participation rate for women aged 2534 years increased from 478 to 787 over the past three decades 1516 parents generally rely on informal child care provided by extended family or domestic helpers 17 childhood obesity is less clearly socially patterned than in western settings 18 here we took advantage of a large contemporary populationrepresentative hong kong chinese birth cohort children of 1997 to examine the association of child care at different ages with body mass index and the presence of overweight at 11 years we also examined whether associations varied with sex or family sep methods source of data the hong kong children of 1997 birth cohort is a populationrepresentative chinese birth cohort covering 880 of all births from 1 april 1997 to 31 may 1997 it has been described in detail elsewhere 19 the study was initially established to investigate the effect of secondhand smoke exposure on infant health 20 families were recruited at the first postnatal visit to any of the 49 maternal and child health centres in hong kong 20 which parents of all newborns are encouraged to attend for free postnatal care developmental checks and vaccinations until the child reaches 5 years baseline characteristics obtained at recruitment included sep birth characteristics infant feeding and secondhand smoke exposure using a selfadministered questionnaire in chinese followup at regular wellbaby visits to the mchcs was continued until 18 months postnatally in 2005 the birth cohort was resurrected and information enabling record linkage to routinely collected data was obtained lifetime routine height and weight measurements taken by the department of health at wellbaby or wellchild visits public hospital discharges from the hospital authority and deaths from the death registry have since been retrieved in early 2007 a programme was instituted to reestablish direct contact with the birth cohort families it included repeated mailings to their last known addresses and schools telephone calls and general publicity about the cohort including a press conference and a television programme a postal survey was sent in july 2008 then resent a second and third time as necessary to nonrespondents over the following 9 months the survey in chinese included questions on food frequency activities developmental progress and family and medical history with each wave of data collection any missing baseline data were updated and any discrepancies between waves reconciled as shown in figure 1 of the 8327 chinese children in the birth cohort by june 2010 12 were known to have died 22 had permanently withdrawn 79 were known to have migrated and 281 were untraced probably migrated whereas 7933 remained living in hong kong of these 7933 3682 returned survey i the 3682 respondents and 4251 nonrespondents to survey i were similar in sex birth weight birth order mothers birthplace weight status at 11 years of age and measures of baseline sep as shown in table 1 the cohen effect sizes were small 21 the study obtained ethical approval from the university of hong konghospital authority hong kong west cluster joint institutional review board and the ethics committee of the department of health government of the hong kong special administrative region exposure our primary exposures were child care at 6 months and at 3 5 and 11 years obtained from this question in survey i who was your childs main caregiver at the following different ages 6 months 3 years 5 years and now our participants were 11 years old when survey i was conducted responses were categorized as parental care or informal care with the latter including care by grandparents other family members or domestic helpers the small number reporting formal care in a nursery or cre che was excluded those reported to have more than one main caregiver were also categorized as informal care making parental and informal care mutually exclusive in this study outcome the primary outcome was adiposity at 11 years proxied by age and sexspecific bmi zscore relative to the 2007 world health organization growth standard 22 to facilitate comparison with other studies we also defined childhood overweight as a bmi for age and sex corresponding to an adult bmi525 kgm 2 using the international obesity task force cutoffs 23 due to the relatively small number of obese children overweight here included those who were obese not all height and weight measurements were at exactly 11 years of age so we used the closest measurement between 9 and 12 years we interpolated the who references and the iotf cutoffs on a daily scale using the akima package 2425 in r 26 among the 7933 cohort members alive living in hong kong and not withdrawn 6782 children had a bmi measurement at 11 years of age excluding children with formal child care of these 525 had missing data for child care and 244 had missing data for mothers birthplace birth weight highest parental education highest parental occupation or household income multiple imputation is the gold standard in this situation because the assumptions required for validity of a complete case analysis are a superset of those required for multiple imputation 27 we predicted missing values of these exposures and confounders based on a flexible additive regression model with predictive mean matching 28 incorporating data on the primary outcome 29 exposures and other factors potentially associated with child care we imputed missing values 10 times using the hmisc package in r 31 and analysed the 10 complete data sets separately we summarized the results into single estimated bcoefficients with confidence intervals adjusted for missing data uncertainty 27 we also performed a complete case analysis for comparison statistical analysis we used multivariable linear and logistic regression models to estimate the association of child care with bmi zscore and the presence of overweight at 11 years of age adjusted for sex mothers birthplace birth weight zscore highest parental education highest parental occupation monthly household income per head and the interaction of mothers birthplace and highest parental education 183233 following mishra et al 34 we compared models representing child care in terms of a critical period or an accumulation of exposures preliminary analysis suggested that child care at older ages had most influence we also assessed whether there was any additional contribution of child care at earlier ages than that of current child care by adding exposures at previous ages sequentially we used model fit akaike information criterion to compare these different representations of child care 28 a lower aic indicates a better fitting model we assessed whether the association of child care with the outcomes varied with sex or markers of sep from the heterogeneity across strata and the significance of interaction terms we compared the statistical significance of the likelihood ratio test of the difference between models with and without interaction terms between child care and sex highest parental education occupation or income interaction terms with other relevant confounders were also included to ensure that any observed difference by sex or sep was not due to confounding by other interactions with child care 35 we used residual plots and hosmerlemeshowcressie tests 36 to check the goodnessoffit of linear and logistic regression models respectively cohen effect sizes have three levels 01 for small 03 for medium and 05 for large 21 cohen effect sizes are calculated as ˇ 2 p 0i where the sum is over the categories and p 0i is the proportion in the ith category in the respondents and p 1i is the proportion in the ith category in the nonrespondents results informal child care was quite common at 6 months 3 years and 5 years but less so at 11 years table 2 shows the association of child care with sociodemographic characteristics before imputation using an available case analysis ie pairwise deletion of observations with missing data at younger ages informal care was slightly more likely for boys than girls at all ages informal care was more likely for children with mothers born in hong kong highest parental education occupation and monthly household income were all positively associated with informal care residual plots for linear regression models showed no violation of normality for the logistic regression models pvalues from hosmerlemeshowcressie tests were all 408 suggesting no evidence of significant lack of fit there was no indication that considered separately the association of child care at each age with bmi or overweight varied with sex highest parental education occupation or household income table 3 shows that considered separately informal care at 3 5 or 11 years was associated with higher bmi zscore and with the presence of overweight at 11 years the associations were similar when informal care was separated into grandparents other family members or domestic helpers table 4 shows that considering child care at 5 and 11 years only produced the best fitting model for both bmi zscore and the presence of overweight this was better than additionally including child care at younger ages or than considering child care as an accumulation of exposures to informal care the associations for informal childcare as an accumulation of exposures are shown in supplementary table s2 available at ije online table 5 shows how child care jointly at 5 and 11 years contributed to bmi zscore and overweight to 059 and the presence of overweight or obesity the complete case analysis produced similar results discussion in this large populationrepresentative birth cohort of chinese children from a developed nonwestern setting informal child care at each of 3 5 or 11 years considered separately was associated with higher bmi zscore and the presence of overweight at 11 years current informal care had the strongest association however informal child care at 5 years also made a contribution considering only child care at 5 and 11 years produced the most parsimonious model and was preferable to considering the accumulation of exposures to informal child care at all four ages as such our findings are largely consistent with those from western populations 25 although we did not find different associations by family sep which was only found in one previous study however that study did not explicitly test for differences by sep 5 therefore those findings may simply be the chance variation which would be expected on stratification our study extends previous studies by showing that the association between child care and childhood bmi occurs at older ages our study also adds by replicating these findings in a setting where informal care is common and sep has different associations with child care and childhood obesity from those in western countries 18 the consistency of results in western and nonwestern contexts suggests that these findings may be due to attributes of informal child care rather than residual confounding there are several limitations in our study first bmi at 912 years of age might have been assessed before survey i which was first sent in july 2008 when our cohort members were aged 11 years however informal child care at earlier ages was also prospectively associated with higher bmi zscore and the presence of overweight second information on child care was based on parental recall and could be subject to recall error however there is no reason to think that parents answers depended on their childs bmi third we do not have information on child care duration during the day so those who reported more than one main caregiver were classified as informal care however there were relatively few in this category and excluding these children did not change the overall pattern of results misclassification of child care may bias any associations towards the null and make our results conservative fourth we do not have complete information on child care however we used multiple imputation which uses all available data preserves uncertainty for missing data 37 minimizes inclusion bias and increases statistical power 27 moreover a complete case analysis produced similar results fifth western studies showed inconsistent results for formal child care 2 5 6 7 however in our setting formal care is not as common as in western countries formal child care services provided by nurseries take up only a small market share moreover most families are concerned that there may not be adequate attention given to their children in a group care setting 17 in our cohort the low use of formal care makes it impossible to evaluate its influence on obesity finally we do not have detailed information on the childrens diet and physical activity at each age caregivers may influence childrens dietary style and physical activity 3839 in a japanese cohort children with maternal care were less likely to snack and more likely to be physically active 14 we were unable to compare these characteristic between parental care and informal care so we were unable to determine which factors may underlie the observed associations there are several possible explanations for our findings first informal child care particularly at 6 months of age may represent a different infant feeding pattern for example greater use of formula feeding a shorter duration of breastfeeding or an earlier introduction of solid foods however in this birth cohort there was no association between breastfeeding and childhood bmi 40 nor in this study was there any association between child care at 6 months and adiposity at 11 years of age second it is possible that parents may be more aware of health recommendations than grandparents or domestic helpers neither grandparents nor domestic helpers in hong kong are usually trained in child care grandparents and domestic helpers may also be less exposed to health advice if parents take the child for routine wellbaby and wellchild visits when health advice may be given moreover domestic helpers in hong kong are usually from south east asia and may not be able to read information leaflets in chinese third parents may also be more likely to adhere to health recommendations on child rearing an older generation may have experienced poverty and so may consider fatness a symbol of wealth 41 and health 42 possibly resulting in overfeeding of their grandchildren similarly domestic helpers come to hong kong from other parts of south east asia to earn remittance money and may also have grown up in relative poverty if overfeeding was an issue we might have expected informal child care to be more strongly associated with adiposity in boys given the traditional asian cultural preference for boys however we did not find any evidence of differences by sex fourth parents may put more effort into controlling the childs lifestyle for example by supervising the childs eating or encouraging physical activity in contrast grandparents may put more emphasis on playing with the child 17 grandparents may also be more likely to spoil the child by giving energydense favourite foods as rewards or by allowing large amounts of video games and television viewing 4 in hong kong domestic helpers are usually hired for housework as well as child care so they may not be able to spend much time and effort on the child nor be able to play a parental role in child care according to working mothers views from semistructured interviews 17 fifth children may mimic the caregivers behaviour 38 grandparents and domestic helpers may have different patterns of physical activity from parents 4 and may discourage the childs physical activity 14 from a public health perspective this study suggests that grandparents or others providing child care may be a potential target for education and intervention to counter the emerging epidemic of childhood obesity further research delineating the knowledge of child care of informal caregivers their attitudes concerning child health their child care practices and their own behaviour may help in designing effective interventions conclusion in this populationrepresentative chinese birth cohort informal child care rather than parental care at both 5 and 11 years was associated with higher bmi zscore and the presence of overweight at 11 years our study contributes evidence of a prospective influence of informal child care on childhood obesity in a different sociohistorical context in asia future research is needed to understand better the characteristics of different types of child care so that effective targeted interventions can be developed to reduce the increasing prevalence of childhood obesity supplementary data supplementary data are available at ije online conflict of interest none declared key messages western studies suggest that informal child care is associated with childhood obesity however in western populations informal child care and childhood obesity are socially patterned making these observations vulnerable to residual confounding in a developed nonwestern setting informal child care was also associated with childhood obesity consistency in different contexts suggests that the association may be due to attributes of informal child care interventions might be warranted with informal caregivers for childhood obesity prevention

background in western populations informal child care is associated with childhood obesity however informal child care and obesity share social patterning making evidence from other settings valuablewe used multivariable linear and logistic regression models to estimate the association of child care at 6 months and at 3 5 and 11 years with body mass index bmi zscore and overweight including obesity at 11 years in a hong kong chinese birth cohort we assessed whether associations varied with sex or socioeconomic position sep we used multiple imputation for missing exposures and confoundersof the original 8327 cohort members 7933 are alive participating and living in hong kong at 11 years 6796 had their bmi clinically assessed higher sep was associated with informal care after imputation informal care at each of 3 5 or 11 years was separately associated with higher bmi zscore 3 years 010 95 confidence interval ci 003018 5 years 012 95 ci 004021 11 years 017 95 ci 004031 and with the presence of overweight odds ratio or 3 years 119 95 ci 103137 5 years or 120 95 ci 103140 11 years or 121 95 ci 102145 adjusted for sex sep and birth weight zscore current informal care had the strongest association however informal child care at 5 years also contributed there was no evidence of differences by sex or sep conclusions in a developed nonwestern setting informal child care was associated with childhood obesity modifiable attributes of informal child care warrant investigation for obesity prevention

leading to emotionallyrich communication between involved peers consequently instant communication should require specific tools and models for analysis that are capable of covering these predominant features nowadays irc channels are still one of the most used platforms for collective realtime online communication and are used for various purposes eg organization of opensource project development internet activism dating etc our dataset consists of 20 irc channels covering topics as diverse as music sports casuals chats business politics or computer related issues which is important to ensure that there is no topical bias involved in our analysis for each channel we have consecutive daily recordings of the open discussion over a period of 42 days which amounts to more than 25 million posts in total generated by more than 20000 different users we process our analysis as follows first we look into the communication patterns of instant online discussions to find out about the average response time of users and its possible dependence on the topics discussed this shall allow us to identify differences between instantaneous chatting communities and other forms of slower persistent communication in a second step we look more closely into the content of the discussions and how they depend on the emotions expressed by users remarkably we find that most users are very persistent in expressing their positive or negative emotions which is not expected given the variety of topics and the user anonymity this leads us to the question in what respect online chats are different from offline discussions which are mostly guided by social norms we argue that even in instantaneous anonymous online chats users behave very much like normal people our quantitative insights into users activity patters and their emotional expressions are eventually combined to model interacting emotional agents we demonstrate that the stylised facts of the emotional persistence can be reproduced by our model by only calibrating a small set of agent features this success indicates that our modeling framework can be used to test further hypothesis about emotional interaction in online communities results user activity patterns an irc channel is always active and enables the real time exchange of posts among users about a specific topic user interaction is instantaneous the post written by user u 1 is immediately visible to all other users logged into this channel and user u 2 may reply right away fig 1 illustrates the dynamics in such a channel as time evolves new users may enter others may leave or stay quiet until they write followup posts at a later time to characterize these activity patterns we analyzed the waitingtime or interactivity time distribution p where t refers to the time interval between two consecutive posts of the same user in the same channel and ask about the average response time we find that t is powerlaw distributed p t 2a with some cutoff with an exponent a 5 153 6 002 the fit is based on the maximum likelihood approach proposed by clauset et al 9 and the powerlaw nature of the distribution could not be rejected this finding is inline the powerlaw distribution already found for diverse human activities 1 2 3 5 6 7 and classifies the communication process as belonging to the regime where posts arrive faster than they can be processed we note that for a 2 no average response time is defined further we observe in the plot of fig 1b a slight deviation from the powerlaw at a time interval of about one day which shows that some users have an additional regularity in their behavior with respect to the time of the day they enter the online discussion such deviations were usually treated as powerlaws with an exponential cutoff and can even be explained based on simple entropic arguments 1011 however because of the bump around the one day time interval our distribution also seems to provide further evidence to the bimodality proposed by wu et al 12 we should note however that the tail is better fitted by a lognormal distribution rather than an exponential or a weibull one as shown in fig 1b here ks stands for the kolmogorovsmirnov statistical test the smaller this number the better the fit we now focus on an important difference between online chats and previously studied forms of communication such as mail or email exchange which mostly involve two participants due to the collective nature of chats a chatroom automatically aggregates the posts of a much larger amount of users which allows us to study their collective temporal behavior if v denotes the time interval between two consecutive posts in the same channel independent of any user we find that the distribution p is is still fattailed but does not follow a powerlaw interestingly the time interval between posts significantly depends on the topic discussed in the channel some hot topics receive posts at a shorter rate than others which can be traced back to the different number of users involved into these discussions specifically we find that the average interevent time aevae ch depends on the amount of users in the conversation and becomes smaller for more popular channels as one would expect if we rescale the channel dependent interevent distribution p ch using the average interevent time aevae ch per channel and plot aev ch ae p ch versus v ch aev ch ae we find that all the curves collapse into one master curve the general scaling form that we used is p 5 f where f is independent of the average activity level of the component and represents a universal characteristic of the particular system such scaling behavior was reported previously in the literature describing universal patterns in human activity 13 we fit this master curve by a stretched exponential 14 15 16 p v ð þ a c v h i e b c v v h i à á cð1þ where the stretched exponent c is the only fit parameter while the other two factors a c and b c are dependent on c 14 a histogram of the c values across the 20 channels is shown in supplementary figure s2 using only the regression results with p 0001 we find that the mean value of the stretched exponents is aecae 5 021 6 005 we note that stretched exponentials have been reported to describe the interevent time distribution in systems as diverse as earthquakes 15 and stock markets 16 these systems commonly exhibit long range correlations which seem to be the origin of the stretched exponential interevent time distributions 14 long range correlations have also been reported in human interaction activity 517 and we tested their presence in the temporal activity over irc communication as shown in the supplementary figure s3 we verified the existence of long range correlations in the conversation activity we found that the decay of the autocorrelation function of the interevent time interval between consecutive posts within a channel is described by a powerlaw c dt ð þ dt ð þ nvð2þ with exponent n v 082 in addition we applied the detrended fluctuation analysis technique 18 described in detail in the methods section and we found a hurst exponent value h v 06 which is well in agreement with the scaling relation n v 5 2 2 2h v for a more detailed discussion about scaling relations and memory in time series please refer to 19 in conclusion our analysis of user activities have revealed a universal dynamics in online chatting communities which is moreover similar to other human activities this regards the temporal activity of individual users and the interevent dynamics across different channels if rescaled by the average interevent time we will use these findings as a point of departure for a more indepth analysis because obviously the essence of online communication in chatrooms as compared to other human activities is not really covered from the perspective of activity patters there is not so much new here which leads us to ask for other dimensions of human communication that could reveal a difference emotional expression patterns human communication in addition to the mere transmission of information also serves purposes such as the reinforcement of social bonds this could be one of the reasons why human languages are found to be biased towards using words with positive emotional charge 20 humans from the early stages of our lives develop an affective communication system that enables us to express and regulate emotions 21 but emotions are also the mediators of our consumer responses to advertising 22 and many scientists acknowledge their importance in motivating our cognition and action 23 however despite the increasing time we spend online the way we express our emotions in online communities and its impact on possibly large amounts of people is still to be explored consequently we are interested in the role of expressed emotions in online chatting communities users by posting text in chatrooms also reveal their emotions which in return can influence the emotional response of other users as illustrated in fig 1a to understand this emotional interaction we carry out a sentiment analysis of each post which is described in detail in the methods section this automatic classification returns the valence v for each post ie a discrete value 21 0 11 that characterizes the emotional charge as either negative neutral or positive instead of using the real time stamp of each post as in the analysis of the user activity we now use an artificial time scale in which at each time step one post enters the discussion so the number of time steps equals the total number of posts we then monitor how the total emotion expressed in a given channel evolves over time we use a moving average approach that calculates the mean emotional polarity over different time windows in fig 2a we plot the fraction of neutral negative and positive posts as a function of time for different sizes of the time window while it is obvious that the emotional content largely fluctuates when using a very small time window we find that for decreasing time resolution the fractions of emotional posts settle down to an almost constant value around which they fluctuate from this we can make two interesting observations the emotional content in the online chats does not really change in the long run ie we observe fluctuations that depend on the time resolution but no evolution towards more positive or negative sentiments for the low resolution the fraction of neutral posts dominates the positive and negative posts at all times in fact there is a clear ranking where the fraction of negative posts is always the smallest both observations become even more pronounced when averaging over the 20 irc channels as fig 2b shows our findings differ from previous observations of emotional communication in blog posts and forum comments which identified a clear tendency toward negative contributions over time in particular for periods of intensive user activity 2425 such findings suggest that an increased number of negative emotional posts could boost the activity and extend the lifetime of a forum discussion however blog communication in general evolves slower than eg online chats hence we need to better understand the role of emotions in real time internet communication which obviously differs from the persistent and delayed interaction in blogs and fora to further approach this goal we analyse to what extend the rather constant fraction of emotional posts in irc channels is due to a persistence in the emotional expressions of users for this we apply the dfa technique 18 to the time series of positive negative and neutral posts since our focus is now on the user we reconstruct for every user a time series that consists of all posts communicated in any channel where the time stamp is given by the consecutive number at which the post enters the users record in order to have reliable statistics for the further analysis only those users with more than 100 posts are considered as the examples in the supplementary figure s4 show some users are very persistent in their emotional expressions whereas others are really antipersistent in the sense that their expressed emotionality rapidly changes through all three states the persistence of these users can be characterized by a scalar value the hurst exponent h which is 05 if users switch randomly between the emotional states larger than 05 if users are rather persistent in their emotional expressions or smaller than 05 if users have strong tendency to switch between opposite states as the antipersistent time series of fig s4 shows if we analyse the distribution of the hurst exponents of all users shown in the histogram of fig 3a we find that the emotional expression of users is far from being random and that it is clearly skewed towards h 05 which means that the majority of users is quite persistent regarding their positive negative or neutral emotions this persistence can be also seen as a kind of memory in changing the emotional expression ie the following post from the same user is more likely to have the same emotional value the question whether persistent users express more positive or negative emotions is answered in fig 3b where we show a scatter plot of h versus the mean value of the emotions expressed by each user again we verify that the majority of users has h 05 but we also see that the mean value of emotions expressed by the persistent users is largely positive this corresponds to the general bias towards positive emotional expression detected in written expression 20 the lower left quadrant of the scatter plot is almost empty which means that users expressing on average negative emotions tend to be persistent as well a possible interpretation for this could be the relation between negative personal experiences and rumination as discussed in psychology 26 antipersistent users on the other hand mostly switch between positive and neutral emotions are the more active users also the emotionally persistent ones in supplementary figure s6 we show a scatter plot of the hurst exponent dependent on the total activity of each user even though the mean value of h does not show any such dependence we observe large heterogeneity on the values of h for users with low activity furthermore in supplementary figure s7 we show that the hurst exponent of a very active user varies only slightly if we divide his time series into various segments and apply the dfa method to these segments thus we can conclude that active users tend to be emotionally persistent and as most persistent users express positive emotions they tend to provide some kind of positive bias to the irc whereas users occasionally entering the chat may just try to get rid of some negative emotions this leads us to the question how persistent the emotional bias of a whole discussion is while fig 3a has shown the persistence with respect to the different users fig 3c plots the persistence for the different channels which each feature a very different topic this persistence holds even even if we analyse only certain segments of the channel as it is shown in supplementary figure s8 so we conclude that the persistence of the discussion per se reflects a certain narrative memory precisely for each chat we observe the emergence of a certain tone in the narration which can be positive negative or neutral dependent the emotional expressions of the persistent users if we reshuffle these time series such that the same total number of positive negative and neutral posts is kept but temporal correlations are destroyed then the persistence is lost as well as fig 3c shows we note that we could not find evidence of correlations using the autocorrelation function of the emotion time series while the observed persistence in the fluctuations of user emotional expression as captured by the hurst exponent is very robust this indicates that the chat community assumes an emotional memory locally encoded in the current messages while the size of the conversation is too large to detect it through averaging techniques an agentbased model for chatroom users after identifying both the activity patterns and the emotional expression patterns of users in online chats we setup an agentbased model that is able to reproduce these stylized facts we start from a general framework 27 designed to model and explain the emergence of collective emotions in online communities through the evolution of psychological variables that can be measured in experimental setups and psychological studies 2829 this framework provides a unified approach to create models that capture collective properties of different online communities and allows to compare the different emotional microdynamics present in various types of communication the case of irc channel communication is of particular interest because of its fast and ephemeral nature thus we have designed a model for irc chatrooms as shown in fig 4a the agents in our model are characterized by two variables their emotionality or valence v which is either positive or negative and their activity or arousal which is represented by the time interval t between two posts s in the chatroom the valence of an agent i represented by the internal variable v i changes in time due to a superposition of stochastic and deterministic influences 2730 v i c v v i zb ã h z h ð þãv i za v j ið3þ the stochastic influences are modeled as a random factor a v j i normally distributed with zero mean and amplitude a v and represent all changes of the individual emotional state apart from chat communication the deterministic influences are composed of an internal decay of parameter c v and an external influence of the conversation the change in the valence caused by the emotionality of the field is measured in valence change per time unit through the parameter b previous models under the same framework 2731 had an additional saturation term in the equation of the valence dynamics this way the positive feedback between v and h was limited when the field was very large but as we show in fig 2 chatrooms do not show the extreme cases of emotional polarization observed in other communities thus we simplify the dynamics of the valence without using any saturation terms since a large imbalance between h 1 and h 2 is unrealistic given our analysis of real irc data in general the level of activity associated with the emotion known as arousal can be explicitly modeled by stochastic dynamics as well 31 here the activity of an agent is estimated by the timedelay distribution that triggers the expression of the agent ie by the powerlaw distribution p t 2153 shown in fig 1b assuming that an agent becomes active and expresses its emotion at time t it will become active again after a period t the agent then writes a post in the online chat the emotional content of which is determined by its valence this information is stored in an external field common for all agents which is composed of two components h 2 and h 1 for negative and positive information and their difference measures the emotional charge of the communication activity since we are interested in emotional communication we assume that all neutral posts entered or already present in a chatroom do not influence the emotions of the agents participating to the conversation thus the dynamics of the field is influenced only by the amount of agents expressing a particular emotion at a given time n 1 5 s i and n 2 5 s i where h is the heaviside step function therefore the time dynamics of the fields can be described as h c h h zc ã n t ð þð4þ these two field components h 1 and h 2 decay exponentially with a constant factor c h ie their importance decays very fast as they move further down the screen each field increases by a fixed amount c from every post stored in it the values of the valence of the agents are changed by the field components as described by eq 3 in contrast with traditional means of communication online social media can aggregate much larger volumes of usergenerated information this is why h is defined without explicit bounds chatrooms pose a special case to this kind of communication as they can contain large amount of posts but limited amount of users most irc channels have technical limitations for the amount of users that can be connected at once which in turn is reflected in the total amount of posts present in the general discussion in our model h might take any value but the empirical activity pattern combined with the fixed size of the community dynamically constraints it to limited values whenever an agent creates a new post in an ongoing conversation the variable s i obtain its value in the following way s i 1 if v i vv z1 if v i wv z 0 otherwise 8 ð5þ the thresholds v 2 and v 1 represent a limit value of the valence that determines the emotional content of each post and in general can be asymmetric as humans tend to have different thresholds for the triggering of positive and negative emotional expression each action contributes to the amount of information stored in the information field of the conversation increasing h 2 if s 5 21 or h 1 if s 5 11 we emphasize that the way we model the agent behavior is very much in line with psychological research where emotional states are represented by valence and arousal following the dimensional representation of core affect 32 the valence v represents the level of pleasure experienced by the emotional state while the arousal represents the degree of activity induced by the emotional state and determines the moment when posts are created continuously the agents valence relaxes to a neutral state and is subject to stochastic influences as show empirically in 33 the effect of chatroom communication on an agents emotionality is modeled as an empathydriven process 34 that influences the valence in the valence dynamics we propose in eq 3 agents perceive a positive influence when their emotional state matches the one of the community and a negative one in the opposite case when a post is created its emotional polarity is determined by the valence as it was suggested by experimental studies on social sharing of emotions 2635 all the assumptions of our model are supported by psychological theories parameter values and dynamical equations can be tested against experiments in psychology providing empirical validation for the emotional microdynamics 2829 furthermore our model provides a consistent view of the emotional behavior in chatrooms leading to testable hypotheses that can drive future psychology research we performed extensive computer simulations using different parameter sets by exploring the parameter space we identified which parameter sets lead to similar conversation patterns as observed in the real data we used such set to simulate chats in 10 channels and we analysed the agents activity and their emotional persistence the results are shown in fig 4bc specifically we find that the distribution of hurst exponents for individual agents is shifted towards positive values similar to the one observed in real data this way reproducing the emotional persistence of the conversation without assuming any time dependence between user expressions further we reproduce the empirically observed stretched exponential distribution for the rescaled time delays v9 between consecutive posts without any further assumptions we do note however that the stretched exponent c 5 059 of the simulated distribution is different from real irc channels where it was c 5 021 ie there is a faster decay in the simulations this could be explained by the fact that in the real chat users usually write after they have read the previous post ie there are additional correlations in the times users enter a chat these however are not considered in the simulations because agents post in the chat at random after a given time interval t ie there is no additional coupling in posting times following the same approach as we did for the real data we calculated the hurst exponent of the inter simulated event timeseries of the discussions we found that h v9 5 075 however we did not observe a powerlaw decay of the autocorrelation function this suggests that the observed correlations are due to the powerlaw distributed interevent times used as input to our model and it is inline with the above discussion about the absence of coupling that also explains the difference in the stretched exponents eventually we observe the emotional persistence in the simulated conversations the mean hurst exponent for the 10 simulated channels is h s 5 0567 6 0007 whereas for the real irc channels h r 5 0572 6 0021 was found these results suggests that our agentbased model reproduces qualitatively the emergence of emotional persistence in the irc conversation and thus based on all findings is able to capture the essence of emotional influence between users in chatrooms discussion we started with the question to what extent human communication patterns change on the internet to answer this we used a unique dataset of online chatting communities with about 25 million posts on 20 different topics our analysis considered two different dimensions of the communication process activity expressed by the time intervals t at which users contribute to the communication and v at which consecutive posts appear in a chat and the emotional expressions of users with respect to activity patterns we did not find considerable differences between online chatrooms and other previously studied forms on online and offline communication specifically both the interactivity distribution of users and the interevent distribution of posts followed the known distributions thus we may conclude that humans do not really change their activity patterns when they go online instead these patterns seem to be quite robust across online and offline communication the picture differs however when looking at the emotional expressions of users while we cannot directly compare our findings on emotional persistence to results about offline communication we find differences between online chatrooms and other forms online communication such as blogs fora while the latter could be heated up by negative emotional patterns we observe that online chats which are instantaneous in time very much follow a balanced emotional pattern across all topics but also with respect to individual users which are in their majority quite persistent in their emotional expressions this observation is indeed surprising as online chats are mostly anonymous ie users do not reveal their personal identity however they still seem to behave according to certain social norms ie there is a clear tendency to express an opinion in a neutral to positive emotional way avoiding direct confrontations or emotional debates one of the reasons for such behavior comes from the repeated interaction underlying online chats as the daily bump the activity patterns also suggest most users return to the online chats regularly to meet other users they may already know this puts a kind of social pressure on their behavior to behave similar to offline conversations in conclusion we find that the online communication patters do not differ much from common offline behavior if a repeated interaction could be assumed eventually we argue that the emotional persistence found is indeed related to the nature of human conversations after all the correlations shown in the emotional expressions of different users indicate that there is some form of emotional sharing between participants this suggests the presence of social bonds among users in the chatroom 26 and confirms similarities between online and offline communication the fact that we could reveal patterns of emotional persistence both in users and in topics discussed does not mean that we also understand their origin one important step towards this microscopic understanding is provided by our agentbased model of emotional interactions in chatrooms by using assumptions about the agents behavior which are rooted in research in psychology we are able to reproduce the stylized facts of the chatroom conversation both for the activity in channels and for the emotional persistence specifically our model allows us to test hypotheses about the emotional interaction of agents against their outcome on the systemic level ie for the chatroom simulation this helps to reveal what kind of rules are underlying the online behavior of users which are hard to access otherwise methods data collection and classification the data used in this article is based on a large set of public channels from efnet internet relay chats to which any user can connect and participate in the conversation based on the assessment of the initially downloaded set of recordings 20 irc channels were selected aiming to provide a large number of consecutive daily logs with transcripts of vivid discussions between the channel participants measured in number of posts the finally used data set contained consecutive recordings for 42 days spanning the period from 04042006 to 15052006 the general topics of discussions from the selected channels include music sports casuals chats business politics and topics related to computers operating systems or specific computer programs the irc data set contains 2688760 posts the total number of participants to all this channels is 25166 however because some people participate to more than one channel the total number of unique participants is 20441 on average the data set provides 3055 posts per day in the recorded period 15 users created more than 10000 posts the distribution of the user participation ie the number of posts entered by every user is shown in supplementary figure s1 the mean of the distribution is 97 posts per user and as we can see from fig s1 it is skewed with most of the users contributing only a small number of posts the acquired data was anonymized by substituting real user ids to random number references the text of each post was cleaned by spam detection and substitution of url links to avoid them from influencing the emotion classification the emotional content was extracted by using the sentistrength classifier 36 which provides two scores for positive and negative content each score ranges from 1 to 5 and changes with the appearance of emotion bearing terms from a lexicon of affective word usage specifically designed for this purpose each word of the lexicon has a value on the scale of 25 to 5 which determines the strength of the emotion attached to it the classifier takes into account syntactic rules like negation amplification and reduction and detects repetition of letters and exclamation signs as amplifiers when one of this patterns is detected sentistrength applies transformation rules to the contribution of the involved terms to the sentence scores it has been designed to analyze online data and considers internet language by detecting emoticons and correcting spelling mistakes the perception of emotional expression varies largely across humans and traditional accuracy metrics are not useful when there is lack of an objective space human ratings of emotional texts have certain degree of disagreement that needs to be considered by sentiment analysis in order to have a valid quantification of emotions sentistrength scores are consistent with the level of disagreement between humans about how they perceive written emotional expressions 37 this classifier combines an emotion quantization of proved validity with a high accuracy and is considered the state of the art in sentiment detection 38 due to the short length of the posts in chatrooms we calculate a polarity measure by comparing the two different scores of sentistrength the sign of the difference of the positive and negative scores provides an approximation to detect positive negative and neutral posts the accuracy of this polarity metric was tested against texts tagged by humans and messages including emoticons from myspace 39 and twitter 40 which are of a similar length to the ones in our chatroom data the data are freely available for research purposes and are provided as supplementary material detailed information about their structure is provided in the data section of the supplementary information text detrended fluctuation analysis the method of detrended fluctuation analysis 18 is a useful tool in revealing longterm memory and correlations in time series 51516 the method maps the system into a onedimensional random walk and enable us to compare the properties of the real time series with the time series produced by the random case the dfa analysis of a time series x with length t which can be divided into n segments is performed as follows first we integrate the time series by calculating the profile y t ð þ p t t x t ð þ vx t ð þw ½ next we divide the integrated time series into n boxes of equal length dt each box has a local trend which in a first level approximation can be fitted by a linear function using least squares we denote with y dt the y coordinate of the straight line segments that represent the local trend in each box and we subtract this local trend from the integrated time series y next we use the function f dt ð þ ffi ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi 1 n x n k 1 y k ð þ y dt k ð þ ½ 2 v u u tð6þ to calculate the rootmeansquare fluctuation of the integrated and detrended time series and we characterize the relationship between the average fluctuation f and the box size dt typically f will increase with box size as f h which indicates the presence of powerlaw scaling therefore the fluctuations can be characterized only by the scaling exponent h that is analogous to the hurst exponent 41 and it is calculated from the slope of the line relating logf to logdt if only shortrange correlations exist in the time series then it has the statistical properties of a random walk therefore f 12 however in the presence of longrange powerlaw correlations h 12 a value h 12 signals the presence of long range anticorrelations while a value h 12 signals the presence of long range correlations additional information supplementary information accompanies this paper at scientificreports competing financial interests the authors declare no competing financial interests license this work is licensed under a creative commons attributionnoncommercialsharealike 30 unported license to view a copy of this license visit

how do users behave in online chatrooms where they instantaneously read and write posts we analyzed about 25 million posts covering various topics in internet relay channels and found that user activity patterns follow known powerlaw and stretched exponential distributions indicating that online chat activity is not different from other forms of communication analysing the emotional expressions positive negative neutral of users we revealed a remarkable persistence both for individual users and channels ie despite their anonymity users tend to follow social norms in repeated interactions in online chats which results in a specific emotional tone of the channels we provide an agentbased model of emotional interaction which recovers qualitatively both the activity patterns in chatrooms and the emotional persistence of users and channels while our assumptions about agents emotional expressions are rooted in psychology the model allows to test different hypothesis regarding their emotional impact in online communicationow do human communication patterns change on the internet round the clock activities of internet users put us into the comfortable situation of having massive data from various sources available at a fine time resolution but what to look at which aggregated measures are most appropriate to capture how new technologies affect our communicative behavior and then are we able to match these findings with a dynamic model that is able to generate insights into their origin in this paper we provide both a new way of analysing data from online chats and a model of interacting agents to reproduce the stylized facts of our analysis in addition to the activity patterns of users we also analyse and model their emotional expressions that trigger the interactions of users in online chats validating our agentbased model against empirical findings allows us to draw conclusions about the role of emotions in this form of communication online communication can be seen as a largescale social experiment that constantly provides us with data about user activities and interactions consequently time series analyses have already revealed remarkable temporal activity patterns eg in email communication such patterns allow conclusions how humans organize their time and give different priorities to their communication tasks 1 2 3 5 6 7 one particular quantity to describe these patterns is the distribution p t of the waiting time t that elapses before a particular user answers eg an email different studies have confirmed the powerlaw nature of this distribution p t t 2a its origin was attributed either to the burstiness of events 2 or to circadian activity patterns 3 while a recent work shows that a combination of both effects is also a plausible scenario 4 however the value of the exponent a is still debated a stochastic priority queue model 6 allows to derive a by comparing two different rates the average rate l of messages arriving and the average rate m of processing messages if m l ie if messages arrive faster than they can be processed a 5 32 was found which is compatible with most empirical findings and simulation models 1 2 3 8 however in the opposite case m l ie if messages can be processed upon arrival a 5 52 was found together with an exponential correction term the latter regime also denoted as the highly attentive regime could be verified empirically so far only by using data about donations 7 so it is an interesting question to analyze other forms of online communication to see whether there is evidence for the second regime in this paper we analyze data about instant online communication in different chatting communities specifically internet relay chat irc channels where each channel covers a particular topic prior to the very common social networking sites of today irc channels provided a safe and independent way for users to share and discuss information outside traditional media different from other types of online communication such as blogs or fora where entries are posted at a given time decided by the writer irc chats are instantaneous in real time ie users read while the post is written and can react immediately this type of interaction requires much higher user activity in comparison to persistent communication eg in fora further it is more spontaneous often

introduction people are exposed to vast amounts of information through different social platforms individuals can collect and share information through these platforms at unprecedented speeds influencing both their lives 1 and decisionmaking 2 as such platforms can disseminate information faster than conventional websites 3 individuals generally use social media to stay in touch with friends and family while some post search and share information through it females generally use social media for information sharing in different situations compared to males 4 a problem with social media is the spreading of false or fabricated information that can harm others cause hysteria or make people disregard accurate information presented on various social media platforms 5 inaccurate or misinformation can evoke unwanted emotions such as confusion and anxiety which can subsequently motivate individuals to share incorrect information with others on social media 6 social media and pandemics comments on social media reflect peoples thoughts and interests 7 they are usually affected by news and content posted on social media particularly comments offer some insight into individuals perspectives as witnessed during the 2009 h1n1 pandemic when comments had a significant role in influencing peoples decisionmaking opinions and perspectives 7 diseases that are highly discussed in the media are perceived as more serious than ones with a low frequency of discussion 8 furthermore negative tweets are associated with higher stress and high levels of fear are associated with a greater frequency of negative tweets positive emotions however are associated with tweets reflecting happiness thus data and posts on social media can influence individuals wellbeing and social media platforms can help predict stress levels and emotional states 9 notably individuals attitudes toward social media are generally positive even in the case of medical issues 10 coronavirus disease 2019 is the latest pandemic that has disrupted the world on december 31 2019 this novel disease was first identified in wuhan hubei province china on january 10 2020 the world health organization issued technical guidelines advising countries on how to detect the disease and manage potential cases on march 11 covid19 was characterized as a pandemic 11 after covid19 started spreading around the globe many people used social media to share information some materials and posts were inaccurate however most information was reliable and practical especially when shared on popular social media 12 on the one hand social media had a vital role in managing communication and operations during the pandemic among university employees in the philippines 13 and helped to disseminate medical information much faster than what was possible 30 years ago 14 on the other hand academicians found that social media was employed as a platform for spreading conspiracy theories during the arab spring and the initial release of wikileaks in 2010 as well as in 2020 when conspiracy theorists on twitter linked the covid19 pandemic to the 5g cellular network 15 it was even suggested that the virus accidentally escaped or was even deliberately released from a chinese biological weapons laboratory this rumor was closely related to the 5g conspiracy theory according to another conspiracy theory the covid19 pandemic is a hoax and poses no significant threat other than economic damage caused by stayathome restrictions bill gates and his foundation were also placed center stage in conspiracy theories involving global vaccination and surveillance 16 many social media conspiracies are discussed on different platforms and messaging applications 15 the emotions expressed in social media differ according to the platforms purpose negative emotions appear more frequently due to the need for socialization and information sharing about events and updates conversely positive emotions are identified with entertainment and information related to products services ideas and inspirations 17 the expression of negative emotions has been rated appropriate for whatsapp followed by facebook twitter and instagram moreover the expression of positive emotions is more appropriate for whatsapp followed by instagram facebook and twitter 18 social media and information dissemination as the use of social media platforms rose people obtained information from more than one source however the sources are not always professional but do have a strong presence online accordingly such media can influence people by communicating messages 19 if used properly health communication can help protect public health through proper planning and education such forms of communication can maximize awareness and peoples adaptability to changing circumstances particularly when health plans are made from the perspective of a targeted group and are relevant to their needs 20 many people employ multiple messaging applications to communicate with family members and friends several applications permit and support crossapplication conversations enabling users to send and receive messages each messaging application fulfills a specific communication role for instance people choose a certain application according to their experience with it 21 whatsapp as a social media and messaging application whatsapp is a popular messaging platform for sharing information and keeping in touch with individuals and groups 22 it is an instant messaging application available on smartphones and employs the internet for communication allowing users to send images videos and audio media in addition to their location 23 while maintaining privacy 24 whatsapp accounts for a large proportion of typical daily smartphone use 25 many people believe it is an appropriate platform to express feelings and emotions 18 hence whatsapp helps shape decisionmaking improves communication and allows data to be sent to others 24 especially essential information that can help resolve daily life issues 26 females use whatsapp more than males and younger people tend to use it more than older ones whatsapp is apparently employed more than other messaging applications and social media such as facebook 25 whatsapp helps deepen friendships it allows multiple participants to be added to a group thus supporting a collective experience 27 according to several journalists whatsapp is a fast way of circulating information ordinary citizens report incidents and news to the media before any reporter a partnership has developed between ordinary people and media channels for instance citizens may record a video of an event on the spot and send it to different media channels using whatsapp therefore it is a way of exchanging information and news immediately among groups 28 pandemics and covid19 throughout history infectious diseases have resulted in the demise of countless humans peoples perception of and response to such risks and threats affect their decisionmaking during epidemics and pandemics 29 during the sars epidemic people in infected areas mostly avoided public transport which was perceived hazardous large gatherings of people at restaurants entertainment facilities hospitals and stores were also regarded as risky though regional variations were evident asian respondents reported that they were less likely to avoid restaurants and theaters and more likely to avoid doctor visits european respondents indicated that stores and hospitals were riskier places and should be avoided 30 cognitive variables during the swine flu pandemic generally showed low social sensitivity however a few key threat representations helped predict behavioral change such as perceived control understanding and fear of disease thus public information about infectious diseases is necessary to tackle inaccurate beliefs and help prevent diseases from spreading 31 during the h1n1 pandemic the content on twitter observably changed over time the publics attitude and behavior altered during the pandemic and public concern and precautionary behavior increased when the threat of the outbreak grew and decreased when the perceived risk declined personal accounts of h1n1 increased with time and the number of humorous comments fell besides a large amount of misinformation was not even detected 32 some measures have been adopted by various countries and organizations during epidemics and pandemics to curb the spread of diseases examples include school closures during the 1918 1957 and 1968 pandemics in the united states france hong kong and some australian cities which had some effect on the outbreak rate among children 33 implementing social distancing in mexico during the h1n1 pandemic caused the outbreak to pause but it did not stop the disease completely between waves 34 social distancing is the practice of increasing the space between people by about two meters or more to decrease the chance of a disease spreading in addition to working remotely and avoiding public transport social distancing is one of the main measures recommended to decrease the spread of covid19 35 governments in most countries closed schools and educational institutions temporarily as a precautionary measure to prevent covid19 from spreading 36 school closure likely reduces influenza transmission during outbreaks 37 united nations international childrens emergency fund urges schools to provide children with vital information on how to protect themselves and their families against covid19 the international federation of red cross and red crescent societies unicef and the world health organization issue guidance on protecting children and supporting safe school operations 38 during the covid19 pandemic many people relied on social media and social messaging to acquire information and keep abreast with changes twitter posts allowed users to read about inspiring stories global efforts on fighting covid19 and ideas and humorous ways of approaching medical quarantine 5 except for twitter peoples activities on social media during emergencies and lifechanging situations have generally been underresearched furthermore twitter is more accessible for research purposes than other social media and messaging platforms 4 whether accurate and reliable or incorrect and undependable news and information spreading on social media and messaging platforms is dependent on the group dynamics of those engaged with the topic 13 the present study this study evaluates the messages of a whatsapp group of friends in saudi arabia concerning the covid19 pandemic to capture their attitudes emotions and perception with no reservations this aspect is not possible on other social media because most other social media applications are open to the general public therefore individuals interactions might not be as transparent as on whatsapp moreover we did not find a study investigating the emotions and attitudes of individuals on a private social media application such as whatsapp this research answers the following question do whatsapp messages and posts influence users perceptions emotions and attitudes this study also examined the use of whatsapp during the pandemic whatsapp is the main social application used for communication among friends and family members in saudi arabia and is more popular than twitter facebook instagram and other social applications 39 methods this research combines a quantitative exploratory study and qualitative content analysis of a sample of a whatsapp groups interaction messaging during the covid19 pandemic in saudi arabia quantitative study this quantitative exploratory study intends to determine the utilization of whatsapp as a social communication and messaging application during the covid19 pandemic in saudi arabia tools a questionnaire was developed to obtain relevant information to better understand whatsapp utilization it constituted 24 questions among which four questions obtained demographic data 13 questions had a fourpoint likertscale answer five questions had a threepoint likertscale answer and two questions permitted the participants to choose more than one answer the survey was available as a google drive link on whatsapp instagram twitter sms and email the questionnaire was sent to eight university academics with the face validity form so that its face validity could be tested overall six members of our expert panel agreed that the questionnaire is valid at 90 according to its wording clarity and relation to the study however two of our experts suggested some changes to the wording of some questions which was taken into consideration while finalizing the questionnaire procedures the questionnaire was available as a google drive link on whatsapp instagram twitter and sms and was also sent as an email individuals that were interested to participate answered the questionnaire and were also asked to forward it to family and friends if interested results with regards to the use of different social apps where participants were allowed to select more than one app the proportions of users were as follows whatsapp 93 of respondents snapchat 71 twitter 58 instagram 53 facebook 15 and tiktok 9 thus whatsapp was used more than any other application the survey findings are summarized in tables 2 and3 participants were asked if they had downloaded the saudi ministry of health application on their mobiles notably 472 downloaded the appointment application 406 downloaded the health application 4 downloaded the health for doctors application and 395 did not download or follow any ministry of health applications during the pandemic some respondents however indicated that they downloaded or followed other health applications such as asefni sehaty zeyara nabd a who app and the ministry of healths twitter account and sms we asked participants about moments when they began feeling anxious or worried about covid19 the highest proportion was 20 witnessed after the announcement regarding the entry of infected people into saudi arabia subsequently this news led to the closure of schools and mosques marking the beginning of the lockdown the lowest percentages were seen when covid19 was first announced in january and when it spread to other countries such as italy and spain qualitative study this qualitative study aimed to determine how a whatsapp group of friends interacted after the covid19 outbreak in terms of their attitudes emotions and perceptions data collection we assessed posts and messages of a whatsapp group the group consisted of 12 saudi women aged 4952 years all university graduates in particular 10 participants had children studying in schools or universities in saudi arabia or 2373 other countries they had known one another since school this group was chosen because the members interacted with each other on whatsapp daily and felt comfortable discussing everything among themselves including covid19 and everything related to it with no reservations all 12 of the participants gave their consent to participate and for their whatsapp communications to be analyzed for this study data analyses and results a qualitative approach was followed to categorize the data obtained from our participants whereby all messages were classified according to the type of message sentiments and prayers and prevention measures for covid19 during the study time frame we examined and categorized all messages and posts in the whatsapp group about covid19 since the first message appeared in their messaging history after analyzing the groups messages and posts a pathway of how the communications affected emotions attitudes and perceptions related to covid19 was identified initially all the posts shared from january 28 contained general information concerning the new disease and situation in wuhan the comments were mostly about doctors reporting the most affected groups and the group was generally not happy with the situation a month later on february 24 one post implied that the coronavirus was like a new plague however the number of infected people in other countries was still small the umrah to makkah was halted by saudi authorities to protect against the virus however most group comments denied any immediate danger the first rumor appeared in the group around the end of february it was a post on social media about the commencement of schools final exams being held earlier than usual because of the virus the following day the rumor was discredited and all group members agreed to rely on information from original sites not posts from social media on march 2 the announcement of the first case of infection in saudi arabia together with the closing of the central main part of the great mosque in makkah was discussed among the group members overall three emotions were noticeable hope was evident through comments and posts about the virus and infected people with positive thoughts and prayers being relayed for the 2374 infected sadness was also evident in the remarks and discussions because of the closure of the great mosque in makkah lastly pride was observable in relation to the governments intervention to protect the people on march 6 the closure of schools and universities generated anger infected people had entered the country without informing immigration officers about countries they had visited before entering saudi arabia the change in emotion was due to the sadness caused by the virus which was clear in the groups comments about schools closure this move was considered a major change indicating the danger the virus represented with the initiation of online learning most of the mothers in the group were not happy with the new circumstances because they had to spend the whole day teaching their children around midmarch anxiety became prominent in the comments as the number of infected people rose the members started discussing the importance of being cautious about everything related to the virus and how to avoid it for the first time anger became a common theme in their remarks as some people were not following the guidelines issued by the ministry of health new posts appeared about making sanitizers and producing health guidelines in different languages prayers started to increase in messages and notes especially after the friday prayers were halted in mosques posts about lockdown around the country started to trend and panic was widespread many members were purchasing food and stocking their kitchens the government announcements however reassured the people that food markets would not close promising some relief weeks after the school closure children and their parents began feeling bored hence posts about group games exercises and activities at home appeared in large numbers and comments about daily goingson were discussed by the second week of april a lockdown was implemented in riyadh sadness and anxiety became very clear in the comments through the usage of tear and broken heart emojis by midmay some posts asked for the lockdown to be eased the comments reflected the fear generated by the virus the remarks also suggested that some people were not adhering to precautionary measures nevertheless some group members expressed hope that life would return to normal type of messages we identified 2220 messages and posts about covid19 from january 28 to june 27 2020 in the whatsapp group specifically 516 were messages and discussions among group members and 275 were posts from other social media platforms and unknown sites humor accounted for 5 and rumors accounted for 1 of the total number of messages the social media posts shared within the group were mostly from twitter followed by instagram notably facebook posts only accounted for 25 sentiments and prayers among messages sent by the whatsapp group members reflecting sentiments and prayers prayers had the highest proportion fear was noticeable in 1846 of posts followed by sadness anger caution hope happiness and stress the lowest sentiment was pride as seen in figure 3 these findings reveal that the proportions of fear and prayers were close possibly indicating that fear led to prayers in the group most of the messages indicating fear occurred when the number of infected people and deaths increased that emotion was followed by sadness because of the suffering the disease had caused there was anger because some people were not following instructions on how to protect against the virus and respect quarantine rules and the lockdown prevention measures messages and posts regarding prevention measures against covid19 started in the group on february 26 the first post was concerned with how pilgrims from infected countries would be denied entry into saudi arabia for umrah on february 27 the first post appeared about protection against the virus we found that 80 posts were about prevention measures applied by the government and roles and regulations on social distancing hygiene hand sanitizer utilization and wearing masks in 35 messages the comments presented views on the prevention measures implemented by the government and how they would affect the members lives comments and posts sent in the whatsapp group during the 38 days from february 26 to april 4 were regarding preventive measures and were taken from official websites and different social media channels all the posts and comments stopped around the beginning of april that could be because interest in protecting against a disease usually starts when major related events occur close to home in the groups case it was around the time that umrah in makkah was not allowed which underlined the danger and importance of such measures discussion we studied the use of whatsapp during the covid19 pandemic in saudi arabia and its effect on the attitudes and emotions of a whatsapp group consisting of childhood friends the extent to which whatsapp was used was also evaluated we found 40 while ensuring high quality and improving communications capability this platform helps its users to share their thoughts and feelings with individuals and within different groups 41 contrarily other social media are usually used for information collection and selfexpression 40 this study found that most participants employed whatsapp as the main platform of communication with family and friends they shared information about important topics in tandem with images and posts from different social and web platforms this outcome is consistent with those of alsanie 39 and azeema and nazuk 28 who state that whatsapp is not used only for chatting purposes but also for professional practices we found that a high proportion of participants resent information about covid19 to their whatsapp groups in particular 45 of the participants messages were posts taken from different social media platforms this result is in line with kant 23 who observed that whatsapp users sent images and posts from various social media platforms emotions and attitudes evident in the whatsapp group chats signified a dismissal of the disease after the candidates first received information about it this ignorance resulted in rumors regarding the effect the disease might have on the members lives especially regarding schools and examinations however other rumors and conspiracy theories about covid19 and the reality behind the pandemic such as the relationship between the disease and the 5g cellular network or the possibility of it being a biological weapon did not appear in the shared posts or in the discussions this result is at odds with ahmed et al 15 who found that conspiracies were discussed on different social platforms including whatsapp the discrepancy between the results could be due to differences between the participants characteristics and interests we found that the attitude towards the disease at the beginning of the pandemic was not fear or panic instead the prevalent attitude was denial because the event was presumably considered distant this behavior is usually exhibited during pandemics and is known as optimism bias the problem here is that it can lead people to underestimate a situation and ignore public health warnings 29 when covid19 reached saudi arabia emotions were conveyed through comments and posts shared by the group members changes began occurring around the country with the closing of schools workplaces and mosques accordingly sadness hope pride and anger became evident in the comments the closer the disease the more prominent the emotions and all posts and discussions were primarily around the effect of the pandemic this result concurs with jonung and roeger 42 who state that psychological effects begin to show when key changes occur and precautionary measures are adopted in a community posts and remarks concerning disease prevention began appearing along with the need to contain and ideally prevent the disease 31 overall the emotions and changing attitudes were clear with every post sent by the group members thus posts and discussions among people affect their perceptions attitudes and emotions when the posts addressed government prevention measures for covid19 and people started following those guidelines pride became evident conversely when posts revealed that groups of people were disregarding social distancing and precautionary measures anger became clear in the comments figure 5 indicates our interpretation of the pathway of communications effect on emotions and attitudes where posts and events are presented in triangles and emotions and attitudes are depicted through oval shapes this finding is in agreement with lin et al 17 who state that social media users are impacted by what they read on social media it also concurs with raude and setbon 31 who found that the publics attitude and behavior changed over time with social media posts during the h1n1 pandemic this finding could be because the information can be shared faster on social media than via any other conventional mechanism 3 information about covid19 appeared widely on social media many people received such information through whatsapp as shown in our results over 50 of our participants indicated that they obtained the latest updates regarding covid19 from whatsapp social media information can be false or fabricated 5 most of our participants stated that they confirmed the validity of the information received before resending it we observed that the same behavior was detected in our whatsapp group in their group statements members would add that they ensured the accuracy of the information they were sharing if they failed to confirm a point they would be clear that they had just resent the information without validating it conclusions overall our results show that as a social communication and chatting platform whatsapp affects its users attitudes perceptions and behavior just as much as any other social media or perhaps even more posts and comments shared on whatsapp reflected different emotions ranging from fear anger and sadness to hope happiness and pride they also included prayers and cautious behaviors were advocated notably the main emotion observed was fear our finding agrees with those of bavel et al 29 who also determined that the central emotion during the pandemic was fear which generated a certain defensive response however in our study fear led to prayers which reportedly increased during covid19 in many countries and faiths 43 emotions perceptions attitudes and behaviors indicated by our participants were influenced by what they had been reading and hearing on whatsapp and perhaps on other social media platforms practical and theoretical implications our findings could make important practical contributions to parents teachers social media managers and any individual using whatsapp because the results showed that interacting on whatsapp during the pandemic impacted emotions and attitudes therefore whatsapp and other social media could be utilized to help people during crises and hard times in the future each social media platform has a different use and a different way of interacting with its users where the users might not know each other in person such as on twitter and youtube nor would they be able to amass hundreds of followers on whatsapp the interaction between group members could be more personal hence information dissemination and discussion could be different from other social media platforms and more studies should look at whatsapp as a tool affecting behavior in different situations this research had several limitations most of our survey respondents were living in cities therefore the results reflect behaviors predominant in only cities and the patterns could differ between villages towns and cities future research should address how chatting on social media platforms affects users emotions lives and wellbeing such platforms are personal and people there are open and their communications are more transparent than on other platforms whatsapp as social media platform appears to affect emotions and attitudes during the first wave of covid19 it could also affect peoples behavior under different circumstances therefore social media is an important tool to study and explore ethical approval the institutional review board of king saud university approved this study participants gave their consent and the principles specified in the declaration of helsinki were followed disclosure the author reports no conflicts of interest in this work

background social media is an integral part of daily life as people are exposed to considerable amounts of information via social media in particular whatsapp is a messaging application used for sharing information and keeping in touch with individuals and groups it is a platform considered appropriate for expressing emotions purpose this study analyzed a whatsapp group of friends in saudi arabia and their messages regarding the coronavirus disease 2019 covid19 pandemic during the first wave of infections to capture their attitudes emotions and perceptions related to the pandemic we also investigated whatsapp usage during covid19 methods and participants a quantitative exploratory study and qualitative content analysis of a sample of whatsapp group interactions during the pandemic in saudi arabia were combined results we found that whatsapp was used more frequently than other social media platforms for communication with family and friends moreover denial was the first behavior evident at the beginning of the pandemic followed by hope sadness and anxiety and then panic fear and happiness conclusion whatsapp affects its users attitudes perceptions and behavior just as much as any other social media posts and comments shared on whatsapp reflected different emotions ranging from fear anger and sadness to hope happiness and pride

when an academic culture based on selfenhancement values undermines female students sense of belonging selfefficacy and academic choices the higher education system in the western countries is becoming increasingly selective creating a negative social interdependence dynamic and thus an academic culture emphasizing selfenhancement values we argue that depicting academic success as being linked to these values may have a deleterious effect on womens academic experience we lay the ground for this proposal by looking first at more nuanced indicators on gender inequalities in the western higher education system and at how past research may be limited in fully addressing these dynamics gender in higher education from general tendencies to more nuanced indicators women today represent the majority of students in higher education in the western countries however despite their higher enrolment percentages which may paint a positive preliminary picture regarding womens experience in the academic system particular indicators come into play to nuance this view one of the most documented indicators regarding the gender issue in higher education is the variable of academic choices generally in reference to the gender dynamics in stem fields in france as well as the majority of european union countries women are still underrepresented in the fields of sciences technology engineering and mathematics however even when women enroll and persist in these fields other features of the higher education environment may negatively interfere with their academic path for instance a study conducted in the united kingdom on a population of chemistry doctoral students revealed that womens interest in pursuing an academic career in the field decreased significantly during their doctoral studies in part because of the competitive culture within the research teams while in the first year 72 of women and 61 of men expressed their interest in pursuing an academic career by the third year the percentage decreased to 37 among women compared to 59 among men moreover there is often a smaller percentage of women than men among doctoral graduates even in domains in which they are in the majority at the undergraduate level for example according to a national french report 62 of the bachelors degree students enrolled in economics and administration were women however they represented only 42 of the students enrolled in the phd programs in the same field research has also revealed that women experience higher belonging uncertainty including in fields where they are not targeted by a negative stereotype these findings which are illustrative rather than exhaustive bring into question the idea that because they represent the majority of students women would have an utterly positive psychological experience in higher education previous research addressing womens poorer academic experience in higher education has focused on two main explanations social identity threat and the goals congruity hypothesis the former occurs when women fear that they may be devalued in an academic setting because of their gender the latter proposes that gendered endorsement of social goals leads to differentiated career paths with women less likely to study in the most lucrative and prestigious stem fields it is worth noting the more recent approach of leslie and colleagues that generalizes the deleterious effect of gender stereotypes beyond the stem versus nonstem framework their findings show that the percentage of women in a field of study may be predicted by the shared beliefs that success in the field requires brilliance a feature stereotypically associated more with men in the current research we aim to go beyond these approaches arguing that regardless of whether an academic setting is more or less congruent with womens goals or more or less targeted by negative stereotypes the cultural marks associated with academic success in the increasingly selective realm of higher education may also negatively affect womens academic experience a culture of selection in higher education many western european countries with minimal university entry requirements have large first year enrollment and limit masters and doctoral students to those deemed competent or having merit this selection process creates a struggle to be perceived as competent increasing students willingness to demonstrate their own competences relative to others in the same vein stephens and colleagues illustrated that western higher educational institutions focus primarily on norms of independence the cultural frame created by these selection dynamics is theorized in schwartzs model of values as the selfenhancement values selfenhancement corresponds to emphasizing competence in terms of prevailing social standards and the attainment of a dominant position within a social system on the opposite side of the cultural spectrum emphasizing the promotion of supportive social relations are the selftranscendence values this psychological opposition is well illustrated in the context of higher education a low level of concern for others often going as far as trying to impede others progress could be reasonably perceived as increasing the chances of success for oneself for example toma and butera showed that competition led group members to withhold unshared information in a decisionmaking task to sum up we argue that an academic culture that emphasizes selfenhancement values and deemphasizes selftranscendence values has become a pervasive feature of the current western academic system regardless of whether a particular field is a stem nonstem or brilliancefocused field because women endorse selfenhancement values less and selftranscendence values more than men do they may have a more challenging academic experience notably in terms of belonging uncertainty decreased academic selfefficacy with downstream consequences on womens academic choices sense of belonging academic selfefficacy and academic choices a sense of belonging in a given academic setting captures the extent to which students feel accepted included and supported by others students who experience a sense of belonging in educational environments are more engaged in classroom activities more motivated and report increased academic selfefficacy academic selfefficacy captures students belief that they are capable enough to master academic tasks and obtain successful results thus in the academic contexts in which women are less certain that they belong they may consequently feel less academic selfefficacy furthermore research has shown that academic selfefficacy in an educational field predicts students course choices however so far no research has tested such causal paths between these three psychological mechanisms within the same study thus the second goal of the present research is to examine within the same study how an academic culture promoting selfenhancement values may affect womens sense of belonging selfefficacy and course choices in both stem and nonstem academic settings overview of the research past literature suggested that the culture often promoted in the stem as well as brilliancefocused fields emphasizes selfenhancement values however it remains unclear whether an individualistic and competitive culture would still have a negative effect outside a stem or brilliancefocused type of setting indeed in these settings selfenhancement values are embedded in an already threatening environment with women being negatively stereotyped therefore the goal of the present research is to isolate the effect of values alone on womens academic experience first within a stem field but in a course not negatively stereotyped for women and second within a nonstem field in a course framed as highly relevant and useful we argue that depicting selfenhancement values as strongly linked to success in a given academic setting might undermine female students expected sense of belonging which would affect their anticipated selfefficacy and ultimately would decrease the likelihood of integrating into the given academic setting even if it is presented as highly relevant for their career in contrast due to the intrinsic nature of selftranscendence values which foster a feeling of acceptance and integration for all students both female and male students should report relatively high levels of sense of belonging academic selfefficacy and interest in pursuing the presented academic opportunity in an academic culture depicting success in terms of selftranscendence values such a prediction mirrors the documented findings of mens positive experience in feminine occupations thus we hypothesized that assigning high success to selfenhancement values would impair female students but not male students sense of belonging academic selfefficacy and academic choices studies 1 and 2 tested this hypothesis on a population of engineering students we considered that our hypothesis would receive stronger support if validated among women who had chosen a stem field of study considered as especially prestigious and demanding in the french higher education system hence embracing a career perceived as more favorable to selfenhancement than to selftranscendence values indeed this will demonstrate that the negative effect of selfenhancement values remains strong even among women who chose such an orientation we employed an experimental paradigm designed to minimize for women the potential social identity threat associated with the setting by offering engineering students the opportunity to attend a psychology course moreover in addition to lacking threatening stemrelated content psychology is not perceived as a field in which brilliance is the primary requirement for success in order to make the decision to participate to the course more consequential and procedure and materials at the end of a regular class the participants were told that their engineering school collaborated with the psychology department and that we were interested in their opinions on the potential implementation of a new psychology course the following academic year after the coursedescription participants either read that the students who succeed brilliantly in this course like being the ones making decisions leading others showing their competence and outperforming others or that the students who succeed brilliantly in this course think it is important that all persons be treated equally and like helping other students and listening to other peoples different opinions even if they do not agree to ensure that the participants read and understood the text they had to write down four adjectives that in their opinion characterized students who succeeded in this course next they completed the 7item sense of belonging scale and the 7item academic selfefficacy scale finally the participants reported the likelihood of enrolling in this class the following academic year results and discussion manipulation check three blind judges estimated the extent to which each series of adjectives provided by the participants referred to selfenhancement values and selftranscendence values the cronbachs alpha coefficient showed good interrater reliability for both selftranscendence and selfenhancement ratings therefore the three overview of the analyses we conducted regression analyses to test our hypotheses the regression model contained three predictors condition gender and condition x gender sense of belonging regressing the sense of belonging scores on the predictors revealed a significant effect of condition b 021 95 ci 037 005 f 660 p 012 ɳp² 06 when led to believe that success in the course was achieved through selfenhancement values the participants expected a lower sense of belonging than when led to believe that succeeding involved the endorsement of selftranscendence values the main effect of gender was not significant b 010 95 ci 006 026 f 140 p 239 ɳp² 01 more importantly the effect of condition was qualified by a significant condition x gender interaction effect b 019 95 ci 003 035 f 537 p 022 ɳp² 05 analyses of simple effects indicated that the women anticipated a significantly greater sense of belonging in the selftranscendence condition than in the selfenhancement condition b 040 95 ci 066 014 f 954 p 003 ɳp² 08 whereas the men anticipated approximately the same sense of belonging across the two conditions f 1 p 838 ns in the selfenhancement values condition the women expected a significantly lesser sense of belonging than male students b 029 95 ci 005 052 f 580 p 018 ɳp² 05 whereas in the selftranscendence values condition female and male students did not significantly differ regarding their anticipated sense of belonging f 1 p 410 ns academic selfefficacy regressing the academic selfefficacy scores on the predictors revealed that neither the main effect of condition nor the main effect of gender was significant 159 p 209 for gender although showing the expected meanspattern the condition x gender interaction effect did not reach significance b 020 95 ci 004 045 f 277 p 099 ɳp² 03 likelihood of enrolling in the course regressing the likelihood of enrolling scores on the predictors did not reveal any significant main or interaction effect we found that in an experimentally created academic context linking success to the endorsement of selfenhancement values undermined female students but not male students sense of belonging creating a significant gender disparity the effects expected on selfefficacy and likelihood of enrolling were not significant one plausible explanation might be that the students relatively busy timetable in engineering school lowered the general probability of choosing to attend a course that was neither essential nor mandatory for their training program furthermore as we only had access to the students who attended the class that day our sample sizes were quite small to offset these limitations we replicated study 1 with the following methodological improvements first we used apriori power analyses to determine the number of participants we needed to make sure we ran a sufficiently powered study second we included in the description of the training more elements likely to appeal to engineering students since this modification in the content may cause the course to be seen as a male domain that may be threatening for women we decided to assess students perception of the course in terms of gender relevance third because the oneitem scale that we used to estimate the likelihood of enrolling in the course was quite limited in capturing participants overall interest in the course we improved the scale by including three more items study 2 method participants we conducted first a power analysis using g power 3 to determine how many participants we needed to achieve 80 power to detect a small to medium effect this analysis suggested that we needed 2 the resultspattern does not change when controlling for the study setting likely 10 very likely α 93 3 finally the participants rated on a 7point scale whether the proposed training was intended more for women for men or both results and discussion manipulation check two blind judges evaluated the adjective series three participants were excluded because their adjectives were unrelated to the actual description of the training the interrater agreement was satisfactory for both selftranscendence and selfenhancement ratings supporting the efficacy of our manipulation the adjectives provided in the selfenhancement values condition were considered to refer to selfenhancement values to a greater extent f 7615 p 001 and to selftranscendence values to a lesser extent f 13452 p 001 than those provided in the selftranscendence values condition perception of the training a frequency analysis of this variable revealed that the vast majority of participants namely 896 of the total sample considered that the training was intended for both men and women while 78 conveyed a rather gender neutral evaluation by choosing the responses 3 and 5 on the scale4 overview of the analyses as in study 1 we contrastcoded our independent variables because students age correlated with condition standardizedage and its interactions with the independent variables were included in the final model 5 the regression model contained seven predictors gender condition condition x gender age and the three interactions with age sense of belonging regressing the sense of belonging scores on the predictors revealed a significant effect of condition b 024 95 ci 034 014 f 2371 p 001 ɳp² 10 when led to believe that success in the course was achieved through selfenhancement values the participants expected a lower sense of belonging than when led to believe that succeeding involved the endorsement of selftranscendence values the main effect of gender was not significant b 005 95 ci 005 015 f 111 p 292 ɳp² 01 as expected we obtained a significant condition x gender interaction effect b 012 95 ci 002 022 f 571 p 018 ɳp² 03 analyses of simple effects indicated that the female students anticipated a significantly greater sense of belonging in the selftranscendence condition than in the selfenhancement condition b 036 95 ci 050 022 f 2479 p 001 ɳp² 10 the difference was not significant for the male students b 012 95 ci 027 001 f 328 p 071 ɳp² 01 furthermore in the selfenhancement values condition women expected a significantly lower sense of belonging than men did b 017 95 ci 003 031 f 563 p 019 ɳp² 03 whereas in the selftranscendence values condition female and male students did not significantly differ regarding their anticipated sense of belonging f 1 p 333 ns we also obtained a significant interaction between age and condition b 015 95 ci 027 004 f 654 p 011 ɳp² 03 in the selfenhancement condition the older the participants the lower their expected sense of belonging b 022 95 ci 041 004 f 561 p 019 ɳp² 03 in the selftranscendence condition age was unrelated to sense of belonging academic selfefficacy regressing the academic selfefficacy scores on the predictors revealed main effects of condition and gender when led to believe that success in the course was achieved through selfenhancement values the participants anticipated lower academic selfefficacy than when led to believe that succeeding involved the endorsement of selftranscendence values b 018 95 ci 032 004 f 679 p 010 ɳp² 03 overall the male students anticipated higher academic selfefficacy than the female students b 014 95 ci 0004 028 f 409 p 044 ɳp² 02 the condition x gender interaction effect was significant b 021 95 ci 007 034 f 899 p 003 ɳp² 04 analyses of the simple effects indicated that the female students anticipated higher academic selfefficacy in the selftranscendence condition than in the selfenhancement condition b 039 95 ci 058 019 f 1479 p 001 ɳp² 06 the male students anticipated comparably the same academic selfefficacy across the two conditions moreover in the selfenhancement values condition the women expected lower academic selfefficacy than men did b 035 95 ci 015 054 f 1195 p 001 ɳp² 05 whereas in the selftranscendence values condition female and male students did not significantly differ regarding their expected academic selfefficacy f 1 p 479 ns finally although the interaction between age and condition was significant b 019 95 ci 035 002 f 514 p 024 ɳp² 02 the simple effects of age did not reach significance likelihood of enrolling in the course regressing the likelihood of enrolling scores on the predictors revealed a significant effect of condition b 054 95 ci 083 025 f 1328 p 001 ɳp² 06 when led to believe that success in the course was achieved through selfenhancement values the participants reported a lower interest in the course than when led to believe that succeeding involved the endorsement of selftranscendence values the main effect of gender was not significant f 1 p 531 ns we obtained a significant condition x gender interaction effect b 048 95 ci 019 077 f 1078 p 001 ɳp² 05 analyses of simple effects indicated that the female students reported a greater interest in the course in the selftranscendence condition than in the selfenhancement condition b 102 95 ci 144 0 mediation analyses to test the hypothesized mediated moderation model we used the process macro for spss in which we entered the interaction term between condition x gender as the x variable and the main effects of gender and condition in the covariates window age and its interactions with the independent variables were also included as covariates the interaction effects of condition x gender on likelihood of enrolling and sense of belonging have already been established as significant the effect of sense of belonging on academic selfefficacy when controlling the condition x gender interaction effect was also significant b 061 95 ci 045 078 t 729 p 001 finally the effect of academic selfefficacy on likelihood of enrolling when controlling the effects of sense of belonging and condition x gender interaction was significant b 051 95 ci 025 077 t 391 p 001 whereas the interaction effect between condition x gender on likelihood of enrolling was not b 023 95 ci 002 047 t 183 p 068 moreover the indirect effect of condition x gender on likelihood of enrolling through the sense of belonging and academic selfefficacy in the sequence was significant b 004 95 ci 001 009 taken together studies 1 and 2 consistently demonstrated that depicting selfenhancement values as strongly linked to success undermined female students but not male students sense of belonging study 2 went further in showing that such an association also undermined female students academic selfefficacy and interest in the course importantly the fact that the course proposed to the participants was a psychology course a field that is not negatively stereotyped for women and which was not perceived as a male domain allowed for an independent test of the effect of values finally we obtained an interesting result involving students age in an academic culture depicting selfenhancement values as highly linked to success the older the students the lower their anticipated sense of belonging and their interest in the course this may be explained by the fact that the older the students the more they have been exposed to such a culture generating more avoidance tendencies although this effect applies to both male and female students it does so in an additive manner for women only because independent of age they are affected more by the selfenhancement culture compared to men we argued that similar selection processes should apply to all fields of study thus even a social field of study could develop a culture of achievement based on selfenhancement values and thus create a challenging academic context for female students therefore the goal of study 3 was to test the generalizability of the findings among psychology students and to highlight further the academic relevance of the findings moreover the results of studies 1 and 2 illustrated that as expected male students were unaffected by whether the achievement culture in the course emphasized selftranscendence or selfenhancement values thus we conducted study 3 on female psychology students and framed the psychology course as highly important for their career study 3 method participants based on a medium effect size as suggested by the effect sizes obtained in study 2 for women a g power 3 analysis indicated that we needed at least 93 participants to achieve 80 power ninetyseven first and second year female psychology students completed the study procedure and materials we used the same experimental paradigm and framed the psychology course as highly relevant for todays job market next students completed the sense of belonging scale academic selfefficacy scale and estimated their likelihood of enrolling in this class the following academic year in order to reinforce the perception of an actual academic choice they were about to make the students were asked to report their name and academic identification number results and discussion manipulation check three blind judges evaluated the four adjective series with course was achieved through selfenhancement values the participants were less likely to enroll in the course than when led to believe that succeeding implied endorsing selftranscendence values b 102 95 ci 150 056 f 1878 p 001 ɳp² 17 mediation analyses what model best captures the path from condition to likelihood of enrolling we hypothesized that that a culture of achievement based on selfenhancement values ultimately affects female students academic choices through its effect on students anticipated sense of belonging and academic selfefficacy however given our cross sectional data we could not exclude the alternative that the path from condition to likelihood of enrolling for the course flows through anticipated academic selfefficacy and expected sense of belonging thus in order to assess which of the two models better fits our data we conducted path analyses using a maximum likelihood estimator in r to test our hypothesis we ran a model with estimated paths from condition to sense of belonging from sense of belonging to academic selfefficacy and from academic selfefficacy to likelihood of enrolling in the course moreover to show full mediation we constrained the direct path from condition to likelihood of enrolling in the course to zero additionally to depict full meditation of the effect of condition on academic selfefficacy through sense of belonging we also constrained the direct path from condition to academic selfefficacy to zero based on previous studies documenting a direct effect of sense of belonging on academic choices we allowed for the direct path from sense of belonging to likelihood of enrolling to be estimated supporting our hypothesis this model showed good fit to the data χ 2 409 p 130 cfi 99 rmsea 10 90 ci 00 25 6 and srmr 05 to test the conceptual alternative model we shifted the place of sense of belonging with academic selfefficacy as in model 1 to reflect full mediation the direct path from condition to likelihood of enrolling was set to zero moreover to mirror model 1 we set the direct path from condition to sense of belonging to zero while allowing for the direct path from academic selfefficacy to likelihood of enrolling to be estimated 7 model 2 showed poor fit to the data with a statistically significant χ 2 test χ 2 766 p 022 these complementary sets of analyses support the directionality of our hypothesized model depicting selfenhancement values as strongly linked to success undermined female students sense of belonging academic selfefficacy and corresponding choice regarding enrolling in the course as the course was framed as a clearly useful and relevant opportunity for their future career this result effectively illustrates the dynamic through which even in a nonstem field of study women opt out of academic possibilities with a potentially decisive impact on their professional career when they perceive that they have to endorse selfenhancement values to succeed 6 it is important to note that the rmsea tends to be substantially elevated for correctly specified models with small degree of freedom in fact the authors recommend completely avoiding computing the rmsea when model dfs are small and particularly when the χ 2 test is not statistically significant since in such a case we know that the model relatively closely reproduces the data 7 given that in the alternative model we did not have a specific prediction about the degree of mediation for the effect of condition on sense of belonging through academic selfefficacy we also ran model 2b in which we included a direct path from condition to sense of belonging model 2b also showed relatively poor fit to the data χ 2 298 p 084 general discussion womens academic attainment in higher education is qualified by a certain paradox despite the fact that a higher proportion of women than men attend university womens psychological experience in various academic contexts is qualified by decreased sense of belonging and academic selfefficacy even in nonstem settings contradicting interpretations in terms of social identify threat only we proposed that a possible explanation may be located at a cultural level namely in the emergence within an increasingly selective higher education system of an achievement culture based on selfenhancement values because of gender differences in the endorsement of selfenhancement values we expected that an academic setting depicting success in terms of selfenhancement values would diminish female students sense of belonging academic selfefficacy and interest in pursuing the given academic course indeed we showed that independent of fields stem or nonstem an academic culture depicting selfenhancement values as highly linked to success had a negative impact on female students psychological academic experience through sense of belonging selfefficacy and academic choices this is important because even a social field of study in which the specific goals afforded by the future career may be close to selftranscendence values could still develop a culture of achievement based on selfenhancement values this may be the case because similar selection processes apply to all fields of study stem or social sciences moreover by presenting female engineering students with a course that does not pose a particular threat to their gender identity we assured that the effect is due to the valuemismatch thus our findings nicely disentangled the effect of values from the effect of social identity threat which are relatively intertwined in the literature furthermore we extended the goals congruency hypothesis by highlighting a complementary academic dynamic in which the concept of values is essential but which is orthogonal to the students primary choices for specific fields of study in other words both students who chose either a stemrelated or a femaledominated field of study may be confronted during their studies with a culture of success emphasizing selfenhancement values understanding how students navigate this climate is of particular importance thus an additional contribution of the present results is to depict the psychological mechanism underlying students academic choices based on the literature we construed a mediational process engaging as key variables sense of belonging and academic selfefficacy although the crosssectional nature of our data demands caution the various statistical techniques employed support the idea of sense of belonging affecting academic selfefficacy which ultimately shapes students interest in different academic courses the effect on selfefficacy which was modeled as fully mediated by sense of belonging is particularly interesting since it reveals that womens belief in their capacity to master academic tasks and obtain successful results is affected by cultural features of the setting unrelated to the actual content of the course limitations and perspectives in the current research we argue that selfenhancement values are associated with a high level of academic success notably because of the selection function inherent in the functioning of the higher education system however we have not fully addressed the direct causal relationship between the selection practices of the university and the perception of the academic culture as being based on selfenhancement values for instance showing that the link between selfenhancement values and academic success is stronger when the type of evaluation in the course is based on relative performance as opposed to personal improvement or in fields practicing numerus clausus would nicely test this relationship despite these limitations our findings have significant practical implications in particular given the selection processes that take place in most european academic systems all throughout the undergraduate level an academic culture in which selfenhancement values are emphasized is rather common even in a nonstem field of study for example the fact that a program is highly competitive is often presented as an argument to support its quality such messages imply a display of selfenhancement values and as suggested by our findings could prevent female students from taking full advantage of their academic opportunities even in a field stereotypically in accordance with their predominant values and goals this is particularly important because it suggests that all things being equal women may have a more challenging academic experience even if they perform as well as their male counterparts womens generally good performance in college may minimize and even conceal their more subjective experience in terms of sense of belonging or selfefficacy with significant downstream consequences for their academic choices during their academic years finally in the spirit of selftranscendence values higher educational institutions could certainly gain from implementing collaborative projects framed with a prosocial purpose for example the opportunity of working together toward common ends was found to increase motivation for challenging tasks as well as greater interest in and enjoyment of the task our results suggest that such collaborative projects might also provide all students with a more positive academic experience satisfying interrater agreement for both selftranscendence and selfenhancement ratings confirming that our manipulation worked the adjectives provided in the selfenhancement values condition the participants anticipated a lower level of academic selfefficacy than when led to believe that succeeding implied endorsing selftranscendence values b 039 95 ci 060 017 f 1260 p 001 ɳp² 12 likelihood of enrolling in the course regressing the scores of likelihood of enrolling in the course on condition revealed that when led to believe that success in the

although overall women are better represented in higher education than men womens psychological experience in various academic contexts is qualified by a decreased sense of belonging and academic selfefficacy including in fields where they are not targeted by a negative stereotype to clarify this phenomenon we develop the hypothesis of a mismatch between female students values and the values associated with success in the increasingly selective realm of higher education we argue that whatever the fields of study these values are selfenhancement values competitiveness selfaffirmation dominance three studies showed that when success was depicted in terms of selfenhancement values womenbut not menexpressed a lower sense of belonging had lower selfefficacy and were less likely to pursue a given academic opportunity both in stem and nonstem fields of study these effects did not appear in an academic context depicting success as being rooted in selftranscendence values helpfulness cooperation benevolence

background there is no shortage of media coverage following disasters and no shortage of criticisms of the media coverage following disasters it is a familiar pattern the first media wave reporting on the event the second wave of clarifications and professional opinions then the third a stream of splashy sensationalist pieces that play towards a hungry audiences desire for more information it all becomes so big and blurry this is my memory of the media coverage of the 2011 earthquake tsunami and nuclear plant explosion in fukushima japan and my only concept of fukushima prior to visiting for research news stories of contaminated fish mutated plants terrified and irradiated evacuees there was no sense of personal narrative people lost control of their own stories the same is true in the academic literature 8 years later ethnographic studies of the great east japan earthquake are extremely few during my time at fukushima medical university my hope was to hear the experiences of students who were there when it happened as half of my stay in fukushima overlapped with the universitys exam period i imagined that students would be reluctant to speak with me for fear of compromising their studying and that the interviews i did manage to schedule would be very brief however the students were more than eager to share both their time and their stories while i initially came to fmu to pursue questions of ethics in postdisaster research i quickly found that the participants were more passionate about other topics related to the great east japan earthquake and i was excited for the discussions to shift therefore a new research focus emerged and i simply began asking participants what was it like this inductive and discoverybased approach allowed me to reframe and refine the objectives for this study while there continues to be extensive news coverage and quantitative studies on fuksuhima prefectures recovery there remains a paucity of scientific literature on individual narratives during and following the geje a holistic understanding of such an impactful event requires investigations from both qualitative and quantitative perspectives through openended interviews this study aims to illuminate individual stories of medical students at fmu who lived in the prefecture at the time here we utilize a qualitative approach based in ethnography to delve into their complex lived experiences explore their responsive belief systems and coping strategies as a result of the earthquake and lastly provide a space in which survivors can control the narrative in academic research in the afternoon of march 11 th 2011 a magnitude 90 earthquake off the coast of japans tōhoku region induced a major tsunami this earthquake the great east japan earthquake was the most powerful ever recorded in japan and the fourth most powerful recorded worldwide 1 the resulting 68 m tsunami hit areas of iwate prefecture miyagi prefecture and fukushima prefecture causing enormous loss of life as well as tremendous destruction of buildings roads and railways as of december 10 2019 the national police agency of japan has declared 6157 injured 2529 missing and 15899 dead 2 as it reached the fukushima daiichi nuclear power plant in ōkuma fukushima prefecture the tsunami swept over the plants seawall flooding the lower grounds and knocking out the emergency generators which were required to cool the reactors in the absence of cooling 3 of the plants 4 units went into nuclear meltdown resulting in three hydrogen explosions which released radioactive material 3 in the days following the accident radiation released into the atmosphere lead the government to declare an evacuation zone around the plant which grew to reach a 20km radius 4 an estimated 154000 residents evacuated from the towns surrounding the plant to avoid contamination and relocated throughout japan principally in the central and western areas of fukushima prefecture 1 there were significant challenges in evacuating patients from hospitals and nursing homes the deaths of 51 seriously ill patients eg terminally ill suffering from dementia requiring dialysis andor immobile were attributed to insufficient transportation inadequate medical facilities lack of accompaniment by medical staff improper heating inappropriate seating for patients with limited mobility and extremely prolonged travel due to the tsunamis destruction of roads and bridges 5 as of 27 february 2017 the fukushima prefecture government identified 2129 disasterrelated deaths 6 this figure does not distinguish between the deaths of people displaced by the nuclear disaster compared to those displaced by the earthquake or tsunami but media analysis suggests that 1368 of these deaths are attributable to the nuclear evacuation 7 while today the evacuation zone is gradually shrinking and some residents are returning to their homes for the first time in 8 years many still remain in temporary housing or else have decided not to go back despite ongoing fear regarding the potential health effects of the disaster studies have shown no increase in miscarriages stillbirths developmental disorders in babies born after the accident nor have they found a link between the nuclear disaster and incidence of thyroid cancer within fukushima prefecture 8 however the results of a largescale mental health and lifestyle survey conducted throughout the prefecture by fukushima medical university indicated posttraumatic psychological distress among residents of fukushima prefecture both in evacuees and nonevacuees as well as increased rates of obesity binge drinking and alcohol use disorder depression and suicide the rate of psychological distress was noted to be particularly high in children and adolescents compared to the background population 9 these effects are more prevalent among evacuees who face radiation stigma stigma due to the fear that these individuals may contaminate others or that they might bear children with severe birth defects due to potential exposure 10 methods context in the academic literature written in english the events of march 2011 are referred to collectively as the tōhoku disaster the fukushima disaster or the triple disaster or else as variations on 311 11 however in order to be consistent accurate and respectful i will to refer to the earthquaketsunami the subsequent incident at the power plant and the repercussions of all three components of the event in the same way that the research participants referred to them the great east japan earthquake or simply the earthquake the icahn school of medicine at mount sinai and fukushima medical university have enjoyed a partnership since 2012 each spring two thirdyear students from fukushima medical university come to the icahn school of medicine to study endocrinology and each summer two students from the icahn school of medicine conduct research at fukushima medical university a major goal of this partnership is crosscultural exchange students from each school have the opportunity to learn about the healthcare system current policy issues and the lifestyle of medical students and doctors in their host country as i was a student at the icahn school of medicine at the time of the study this existing relationship paved the way for my participant recruitment study population and recruitment interview participants were limited to students enrolled at fukushima medical university who lived in fukushima prefecture at the time of the great east japan earthquake medical school provides students with a medical degree and general medicine education with which students will go on to specialize in residency medical education in japan lasts 6 years and begins after high school as a result most students are generally somewhere between 18 to 24 years of age in a student body of 792 students as of may 1 st 2019 only 32 came from fukushima prefecture 12 exponential nondiscriminative snowball sampling where each participant recruited could provide one or more referrals was the main method of participant recruitment initially participants were invited to participate via announcements made at the beginning of classes for year 1 to 6 students as well as through class group chats in the line mobile messenger app two reminders spaced two weeks apart were sent in the class group chats the first wave of recruitment garnered 5 participants these participants then provided recommendations for other students to attempt to recruit garnering an additional 3 participants in the second wave of recruitment concurrently throughout both waves of recruitment members of a disaster medicine interest group called fukushima will reached out to their club members this garnered 2 participants of the initial group of 253 students 10 students agreed to engage in interviews there were no limits on the number of participants for the study the natural endpoint for participation coincided with the conclusion of the exchange program participants were in years 15 no 6 th year students from fukushima prefecture were available to interview due to demanding curricular requirements during the summer months interviews interviews were conducted from june to august 2019 interviews were openended and an interview guide was used the interview guide was developed by the authors including two physicians two medical students two japanese medical students at fmu and a japanese faculty member at fmu the interview guide was updated throughout the study as needed the goal of the open format was to encourage the participants to reveal and discuss what they wanted to reveal and discuss rather than what the researchers wanted interviews took place in study rooms and classrooms on fmus campus informed consent to participate was obtained both in english and japanese at the start of the interview written consent for recording and publication was obtained as well all but one of these interviews was private unfortunately a private room could not be reserved for participant 2 and there were other students in the study room at the start of the interview additionally participants 8 and 9 requested they be interviewed together and brought three friends with them who wanted to observe though the researcher verified many times prior to the start of the interview that this was alright with both participants they insisted that they would rather have their friends stay ultimately the researcher favored participants comfort over a sterile interview environment following consent participants were provided with the choice of conducting the interview in english or japanese the choice of language depended on both the participants comfort with speaking english and their desire to practice interpretation from japanese to english and vice versa was provided telephonically by a language access company pacific interpreters interpreters hired by the company have passed both language proficiency and interpreter readiness tests in english throughout the interviews the interpreter would convert from japanese to english or vice versa in real time interpreters would sometimes ask clarifying questions to either the english or japanese speaker to more accurately translate the meaning of the speakers words the researcher did not perceive a difficulty in understanding or being understood by any of the participants during one interview involving participants 8 and 9 an telephone interpreter through pacific interpreters was unavailable instead a friend observing who was fluent in english served as an interpreter for participant 8 of the 10 participants 5 conducted the interview in japanese via an interpreter and 5 conducted the interview in english interview times varied from approximately 30 min to over 3 h but the average session length was around 15 h all interviews were audio recorded and were later transcribed by a researcher only the english language portions including words spoken by the interviewer interpreter or participant were transcribed a second researcher listened to all the audio recordings along with the transcribed document to ensure no errors in transcription were made throughout this study interview participants are referred to by the order in which they interviewed for example the third participant to be interviewed is called participant 3 in an attempt to anonymize participants the researchers recognize the relative futility of this effort as anthropologist rebecca nelson points out in her wonderfully titled essay how can we hide participants identities when theyre on pinterest the ubiquity of social media and the necessarily specific identity markers of these interview participants allow curious readers to play detective making it difficult to respect the privacy and ethical commitments made to participants 13 therefore personal and identifying information is withheld from the text whenever possible all participants regardless of the language spoken are quoted in firstperson translators from pacific interpreters relayed the words of japanesespeaking participants directly with the exception of participant 8 who was interpreted in third person rather than first methodological approach data analysis and rigor the topics discussed in this text are the result of an inductive thematic analysis of the interview transcripts under the lens of ethnographic anthropology so chosen for the disciplines goal of exploring cultural experiences from the point of view of a studys subject rather than from the perspective of the researcher the researchers began the analysis while collecting the data the inductive thematic analysis process comprised the following steps familiarizing oneself with the data generating initial codes defining and naming interpretative codes for the entire data set into themes identifying patterns across all data to derive themes for the data set and lastly defining and naming themes as ml ck and ry were involved in all steps of the thematic analysis and served as reviewers this measure minimized the risk of a researchers individual bias personal preconceptions or positionality overly influencing the data analysis team meetings were organized frequently to share the research path and reframe objectives as needed credibility was obtained through prolonged engagement of all the researchers with the setting credibility was also assured by gathering rich data from the interviews transcribing the interviews verbatim and analyzing the data line by line findings three themes naturally emerged in the inductive analysis first that the events following the earthquake influenced not only these students decisions to become doctors but also the ways in which they hope to practice medicine in the future second that these students were motivated to share their experiences by a want to change fukushimas public image and lastly that the students viewed the opportunity to discuss their experiences through these interviews as healing both for themselves and for the future effect on future medical practice all of the interview participants attributed some part of their budding medical careers be it the medical specialties theyre interested in or their wish to study or practice in fukushima to their experiences following the earthquake for some of the students with whom i spoke the great earthquake acted as a catalyst of sorts in their decisions to pursue a career in medicine i think participant 1 observed what you did before you were medical student maybe makes you what you are today indeed of the 10 students interviewed 6 cited their experiences following the geje as a motivating factor in applying to medical school qualitative evidence supports this trend a 2015 survey of fmu medical students who had engaged in recovery volunteer work showed that these student volunteers displayed a statistically significant increase in desire to become a physician compared to nonvolunteers authors anderson et al acknowledge that in the years that elapsed between the earthquake and the survey volunteers and nonvolunteers alike certainly had other experiences that influenced their professional goals 14 however some of the students interviewed for this study explicitly connected the earthquake to their chosen career paths some such as participant 1 expressed an interest in medicine prior to the earthquake but noted that this interest was heightened by the disaster participant 1 explained …after the earthquake partly because my fathers job is doctor i thought that medical is essential for daily life i thought about it stronger than before the earthquake thats why i thought that i want to be a doctor participant 5 similarly reported a strengthening of their preexisting interest in medicine by the earthquake they explained i learned through this experience of the earthquake that one of the most important things is helping people thats the biggest thing i learned through the disaster i think its connected to what i want to do in the future other student interview participants viewed their experiences following the earthquake as essential in their choice of career participant 8 is one such example though participant 8 had worked in healthcare prior to the earthquake as a nursing home aide they decided to apply to medical school after coming into contact with evacuees from the exclusion zone including the displaced residents of another nursing home in namie a town directly downwind of the fukushima daiichi nuclear power plant participant 8 explains as a fellow citizen of fukushima prefecture participant 8 was always thinking about the…evacuation zone the people in the evacuation zone he want ed to do something for them but he had a daily life and work…so he couldnt do enough for them participant 2 was the most emphatic in describing the earthquakes role in her choice of career she recounted before the earthquake happened i didnt know what i wanted to do in the future i had no goal or dream but then id seen so many friends die and i went through that experience and that made me want to save lives she went as far as to say i think that if i didnt experience the accident theres no way i would have gone into medicine the aftermath of the great earthquake affected not only her decision to pursue medicine but also her priorities as a future healthcare practitioner after the earthquake she and her friends experienced several years of flashbacks and panic episodes triggered by images and videos of the disaster but what saved us she said was school counselors doctors and mental health professionals so i want to be a doctor who can help not just medically but mental health as well not just physical health but mental health as well thats really important this emphasis on an integrated approach to medicine particularly for children and adolescents was shared by several of the participating students participant 1 who is not at present planning on going into psychiatry expressed the importance of incorporating psychiatry into his future medical practice its important thing to have psychiatric mind psychiatric comprehension skills how to feel sympathy how to open patients minds how to icebreak i think especially for child like adolescent age…i think its kind of like 100 skill of a doctor its essential to me psychiatry is important to every medical field…i strongly think so because i can emphasize on peoples depression and peoples negative minds especially in people who struggle in harder situations like attacked by not only nature disaster but also violence maybe i can feel sympathy with them i want to be a different doctor participant 1 describes most doctors as being 100 medical mind his shorthand for a scientific approach to the exclusion of the personal but he describes himself as being less medical than his classmates at only 90 medical mind a trait he attributes to living in fukushima after the earthquake it is this trait that he hopes to use to become a different doctor majority of my classmates i think…are kind of like more concentrated on their medical things more than me they tend to avoid to talk with ordinary people who arent in medicine …students totally forget about the normal mind because of the exposed by the medical things but to have sympathy with normal people maybe we have to still have a kind of normal mind about like everything so i dont think 100 medical mind is a good thing participant 9 describes a similar mindset that they attribute to their experiences as a postdisaster recovery volunteer in iwaki the site of the earthquakes epicenter of those displaced by the earthquake participant 9 states its very important to do healthcare for them its also very important to chat with them to talk with evacuees about a lot of things for example their families their hobbies and so on while doing treatment while he states the tōhoku earthquake did not influence his decision to pursue medicine he says it did change his field of interest from surgery to family medicine 15 he explained when i first wanted to be a doctor i thought its cool to become a surgeon very cool but after the big earthquake my feeling changed because a lot of people were affected by a lot of hardship if i become a surgeon i will help one person per day but if i become a home doctor i will treat many people all of the students with whom i spoke described a relationship between their medical field of interest and their experiences living in fukushima following the earthquake while none of these students will have to decide until after they graduate from medical school their current thoughts on specialties reveal the lasting impact of the earthquake participant 7 is currently doing research in lifestyle medicine and preventative care which she says also includes what to do after a nuclear incident so i guess im ending up studying life after the nuclear accident because i think its important to know how to prevent risks of being sick after that as a specialty shes interested in psychiatry because you have to know how the disaster affects the mind participant 9 is interested in family medicine for the same reason as his friend participant 8 participant 4 is considering pediatric psychiatry inspired by loved ones who struggled with their mental health following the earthquake i want them to know that they dont need to be ashamed she declared participant 3 described a similarly personal motivation for his field of interest due to space constraints his was the only interview conducted in public and though nervous about his level of proficiency he requested we switch our conversation to english for this portion of our discussion his friends none of whom spoke english were sitting at another table on the other side of the room and he glanced at them before sharing after the disaster i saw sick people who couldnt be treated properly so i thought you know i want to provide proper care for sick people… my mother… had cancer and the time is just when the earthquake happened so when the earthquake happened lots of doctors went away to other prefectures so fukushima prefecture had little doctors sothere were no people she couldnt get treatment… and later she was gone she died this difficult experience was the impetus for participant 3s interest in a career in regenerative medicine he explained because of this disaster we had less doctors so patients couldnt be treated properly like my mother so the development of new technology would help patients treat themselves by themselves for themselves several participants also expressed a desire to stay in fukushima to practice medicine once they graduate out of a want to help heal their prefecture while this is not unique to these participants 56 of fukushima medical universitys last 5 graduating classes have stayed in the prefecture after graduation for their medical internships 12 the students interviewed specifically cited a wish to help their home communities recover participant 2 says she wants to pursue internal medicine since i want to go back and help the locals participants 8 and 9 are both hoping to become homevisit family doctors because fukushima needs home doctors fifthyear student participant 6 felt that the earthquake so transformed his plans in practicing medicine that he confided i think that 311 is good experience for my life he went on the earthquake was the trigger of my studying radiation and now i want to know more about fukushima if there were no disaster i would want to go to some big city but there was a disaster so now i want to help fukushima it was a great experience for me but someone who had big damage by the disaster would think that its an imprudent point of view righting fukushimas public image this desire to help fukushima heal extends beyond the literal many individuals i spoke with in fukushima both in the context of interview and out lamented the fear that many outside of the prefecture feel towards fukushima as participant 2 put it …people especially overseas around the world they think that fukushima is a very dangerous place to live still and that everyone who lives in fukushima is sick but thats not true ideas like that they should be fixed i have encountered this line of thinking myself both in the united states and in japan in planning my visit to fukushima friends including my classmates in medical school asked me if it was safe to be there a bartender in osaka confided that she would never visit fukushima and that her friends from korea have even asked her if visiting tokyo is safe given its proximity to fukushima a few weeks into my stay in looking for the address of a shop in downtown fukushima called daisy bell i made the mistake of running a google search for fukushima daisy instead of the address i had hoped for my search returned articles with titles such as these mutant daisies near japans nuclear disaster site are freaking everyone out 16 flanked by images of a group of daisies that appear elongated like several flowers merged together they came to the internet via twitter user sankaido who uploaded them in may 2015 with the caption the atmospheric dose is 05 μsvh at 1 m above the ground 17 which lead many viewers to assume that the mutations displayed in the photograph were caused by nuclear radiation from the fukushima daiichi nuclear power plant in reality such mutations occur naturally worldwide without the influence of radiation 18 these images accompanied by the claim that the flowers shown had nuclear birth defects were used in a 2016 study by the stanford history education group to investigate the ability of usonian high school and college students to evaluate the credibility of information that exists on the internet 19 according to study codirector sarah mcgrew most students the vast majoritynoticed none of those problems 18 eighty percent of fig 2 viral photo of fascination mutation in daisies twitt er com san kaido status 60351 33719 34130 176 used with permission from twitter user sankaido high school students accepted the picture as proof of the continued effects of radiation in fukushima 19 the publics fixation on fukushima as the ultimate meme of nuclear power 20 is still going strong fed by an eager media in april 2018 british tabloid newspaper the sun ran a story with the outrageously dramatic headline japan covering up fukushima nuclear dangerzone radiation levels and blackmailing evacuees to return to radiated areas swarming with radioactive pigs and monkeys 21 in july of that same year netflix aired its original docuseries dark tourist which follows journalist david farrier as he visits in the words of the shows netflix official site unusual and often macabre tourism spots around the world 22 episode 2 japan begins by following farrier on an organized bus tour in an unspecified location near the fukushima daiichi nuclear plant as farrier wonders in the narration is it even safe to be here he and his fellow nuclear tourists are then shown in tomioka anxiously watching the numbers on their geiger counters rise and a woman comments oh my god the level of radiation thats higher than around chernobyl where no ones allowed to go the group later has lunch in namie where ferrier says of the food it may be radioactive but its delicious 23 while it is not within the scope of this research to disprove the false rumors on the safety or lack thereof of fukushima its important to point out that the high radiation levels observed by farrier and his fellow tourists reflect the exposure they would have received in an hour and that the threshold for sickness against which they compared their readings is the amount of continuous exposure needed per hour to cause damage over the course of a year in fact farrier likely received more radiation flying from japan to the united states to film his next episode than he did on his tour in fukushima 24 the fukushima prefectural government and the reconstruction agency are upset by more than farriers cavalier attitude towards the tōhoku earthquake they reported considering legal action due to concerns that the video could fuel unreasonable fears related to the march 2011 disaster 25 the episode has certainly had an impact on the nuclear tourism community despite the governments efforts an estimated 100000 foreign visited fukushima in the year following the shows release many attracted by the opportunity to see what farrier called a nuclear wasteland 2326 in reality its not and the fukushima prefectural government has been working hard to disabuse this notion however the widereaching impacts of the sensationalism and misinformation following the earthquake have been so severe that some have dubbed the socalled harmful rumors the fourth disaster of the triple disaster 27 the widespread view of fukushima as dangerous its food as radioactive and its people as sick or even mutated is familiar to the interview participants rumor itself participant 8 said is a very evil thing especially when there are a lot of vulnerable people in fukushima tabloid and gossip media he argued were equally evil participant 7 was in agreement she observed a lot of people outside fukushima have fears about radiation and i think those fears exaggerated and became rumors all over the place there was so much information after the nuclear accident the media picked up so many stories but i dont think many people visit the government site to verify information but i dont know im sure some people went to the government site to get information but there was just so much information on the media and this is where many people went for their information…people inside of fukushima they tried to find out what really happened but people outside of fukushima once you go outside of fukushima theyre just not interested in seriously learning the truth so they still go by biases about fukushima once you go outside of fukushima a lot of people have those biased ideas but i cant blame them because they dont get much information as an evacuee from minamisōma participant 7 is passionate on the topic of misinformation on fukushima since the earthquake she has heard these claims from peers and adults alike she shared after the incident people were so stupid sometimes saying things like people from fukushima they have runny noses all the time or they dont live that long or you shouldnt get married to women from fukushima i heard all kinds of terrible ignorant comments as a teenager i was so shocked to hear that so thats why im interested in medicine now because i was so shocked to hear those rumors from people before i went to college i went to a prep school outside of fukushima and students and teachers at the prep school those people would tell me their biased ideas like that were all sick or that we all have cancer that we all have tumors i was so shocked to hear this even the teachers said that to me…you know when i heard that i defended fukushima you know saying its not like that i kept telling them that but after a while i just started ignoring those people and their words no matter what i was going to say they would never change their minds those biased ideas were already in there already so i just stopped correcting people like that however many of the student participants felt that by sharing their experiences through these interviews with foreign researchers they had the chance as participant 4 put it to tell everyone the right situation of fukushima participant 3 declared prejudice about fukushima i want to clear it…any wrong information such as the idea that fukushima people cannot live because of the radiation thats not true thats not correct also the idea that fukushima produce is not edible thats not true…when the incident occurred there was a lot of news going around which discriminated against fukushima and i dont want that…theres still a lot of prejudice about fukushima going around so by speaking out i hope i can clear some of it up this is important to me…thats the reality and i want people to know about it participant 6 also implored me to tell people in my home country about the reality of fukushimas situation he sees the earthquake as an essential time in his life and in the lives of other individuals from fukushima and even called the incident our disaster several times throughout the interview despite his wish for fukushima to move forward he feels this cannot be accomplished until the misconceptions have been cleared he explained i dont want to keep in the past in bad things i want to go ahead to forget about that disaster but we have some impacts still from this disaster so it is part of our part of my life it is part of myself it is part of my identity so to educate people is a good thing…i think that the information about this disaster the information in foreign countries its not exact as in japan so some foreign students come to fukushima and study about it and go back to their home country and spread the exact information its very important thing he experienced this importance firsthand in 2018 as an exchange student in belarus like its partnership with the icahn school of medicine at mount sinai fukushima medical university has an academic cooperation with belarusian state medical university and gomel medical university facilitated by nagasaki universitys atomic bomb disease institute 2829 part of belarus is still included in the chernobyl exclusion zone following the chernobyl disaster of 1986 and as nagasaki universitys international collaborative research coordinator wrote there has been active attitude in japan toward learning lessons of chernobyl accident aftermath and countermeasures since the fukushima nuclear power plant accident 29 though participant 6s curriculum focused on studying military medicine shadowing thyroid surgeries and practicing effective patient communication what left the most lasting impression on him was how his concept of chernobyl changed 30 in our interview he described before we visited there i thought chernobyl is very terrible destroyed but it is not exact information chernobyl is not terrible condition and my understanding changed after i visit there so i have good image about belarus and about chernobyl for foreign students to come to fukushima and go back to their home country helps them they can have exact information they can have a similar experience as i had in belarus he like other participants believes that international collaboration allows for increased opportunity to set the record straight when it comes to fukushima participant 4 had a similar experience as participant 6 though as a host rather than as a guest in high school she took part in a workshop in which fukushima students partnered with french students as they toured through the prefecture in an effort to show what participant 4 calls the right thing to the visiting students she elaborated people should just know the right thing i know the right thing because i live in fukushima i want to tell the world the right thing because i know the right thing…i thought i could tell them the french students the right things of fukushima the right things instead of harmful rumors about farmers and i could show them the nice sightseeing places of fukushima and the delicious food of fukushima participant 4 explained that she felt she had and still has a responsibility as a fukushima resident to represent her prefecture and to ensure that others have an accurate understanding of the place that she calls home she expressed a wish to replace the damaging inaccurate ideas i may have received with positive ones and called this wish her duty she said that earthquake was big turning point of my life and my high school teacher said that in the future we are going to be asked about 311 and the accident at daiichi so we need to know the right situation of fukushima and we have duty we need to tell people around fukushima around japan we have a duty so i realized that i have to know the situation of fukushima the right situation of fukushima do you know the bad rumors the bad rumors about fukushima we the people who live in fukushima have to tell others the right things about fukushima i think however not all those from fukushima prefecture are as clear as participant 4 as to the right things about fukushima participant 8 explained we dont know which was rumor and which is truth even the people the local people we dont know that he noted that the medias platform has been enhanced by a continued lack of trust in the government of his fellow fukushima residents he said they cant trust the governments statement…they couldnt think that they should believe all the information from the government when i asked participants 8 and 9 where they believe the mistrust of the government comes from they discussed in japanese for a moment and laughed before offering the government said that the nuclear plant was safe but it wasnt distrust of the government in fukushima following the earthquake has been well documented the washington post describes a culture of coverups and denials that contributed to the nuclear accident and continues to dog japans efforts to restart its nuclear industry referring to the tokyo electric power company s attempt to deny that the nuclear disaster had occurred for months after the accident 27 subsequently tepcos president naomi hirose apologized for the lack of disclosure admitting i would say it was a coverup 31 in january 2019 a member of tepcos external advisory committee said at a news conference if tepco does not improve their communication it will be very difficult for them to regain the public trust 27 due to this local wariness of government information participant 8 expressed that unlike many of the other participants his top priority was not to educate not the whole world or all japanese peoples minds but the people around him he was adamant on this point insisting several times that he wants to enact change in a small way rather than on a large scale his friend translated he has a strong feeling about caring for the people in his community he has feelings for his community but his community is not so big he doesnt want to change public opinion or something he just wants to change his people everyone has to care for their own for some students the desire for individuals outside of the prefecture to know the right situation of fukushima stemmed from as participant 3 phrased it a want to be treated like everybody just like anyone not anything special were just like anyone i want to be treated the same equal participant 7 remembers expressing this wish as well and described being treated differently than her classmates as a high school student she noticed that her teacher was projecting his idea of an evacuee on her rather than recognizing her true feelings she recounts my teacher treated me like an evacuee he felt so sorry for the kids like me in his class as a kid moving to my grandparents house moving to the city i was excited but the teacher didnt understand how i was feeling i think the teacher pitied me he didnt treat me like a regular student and when i was 14 i just wanted to be like everybody else teenage life by itself is confusing but with the accident affecting that time of my life it was all much more complicated however the motivating factor expressed most often by participants was their love of fukushima participant 5s tothepoint explanation summarizes the thoughts of many of the students she shared in general if you see the news you know that people are kind of horrified about the lasting effects of the nuclear accident but you know i have to tell them those effects are not as bad as they think…a lot of people are living here in fukushima and i dont want to present that image of fukushima because i love it here participant 4 was of the same mind she believes that many residents of fukushima such as herself want to rectify the negative image of their prefecture because they love fukushima and repeated i want everyone to know the situation of fukushima this was the sixth time in our conversation that shed said this she then laughed and said of her goal always the same research as healing for the participating students at fukushima medical university these interviews appeared to serve multiple purposes the students were clearly motivated to speak with me by a passion to change the public opinion of their prefecture and some hoped to practice their english or else to learn more about north american medical education but most students also said that they wished for their interviews to be healing both to themselves and to potential future survivors of similar disasters participant 7 said that because of the earthquake everyone knows fukushima and that the prefecture is famous now i know its because of the nuclear accident she said but i think we can somehow use it for good for both her fellow fukushima residents and for the future as participant 1 said the interview helped to evaporate some negative feelings and he declared i think it was a good thing for me to be interviewed participant 1 felt that this was an ideal time to discuss his experiences he said that while there was plenty of opportunity and encouragement to talk about his thoughts and feelings in the months following the earthquake that has since died down and at present he feels such activities to be inadmissible of the interview he said its good for me to share the emotions and um actually actually three years four years after the earthquake the kind of atmosphere changed soon after the earthquake everybody thought okay we have to share the information and share the emotions because of the struggle with the earthquake but…years after the earthquake majority people thought that we mustnt share the emotions we mustnt speak about the earthquake the main atmosphere shows that were already finished with the earthquake so i think its kind of taboo to reopen old wounds and for me its only my family to share my emotions about the earthquake about evacuation…and i think that it was a precious experience and good experience for me to share emotions not only with my family and relatives but also with other people participant 3 also felt that he no longer had occasions to discuss his feelings his most memorable experience of the day of the earthquake was leaving school in a bus and looking out the window to see snow at the same time as thunder of that sight he said that was something i will never forget he went on i was with my classmates when this happened so once and awhile we used to talk about it the five years after the incident wed meet up and talk about it but not anymore participant 7 agreed that she is now in a position to benefit from an interview for different reasons than participants 1 and 3 she explained that she decided to volunteer for an interview because i think its a good time for me to look back at my past at what happened during 311 though in our conversation she recounted difficult memories her tone was determined even hopeful she explained i was so afraid of doing an interview or a survey before when i was young i was afraid to remember my experiences the bad things that happened like participants 1 and 3 she found that talking about her experiences was a crucial part of her recovery participant 8 also found discussion helpful calling the interview a rare situation in that it offered him a chance to reflect while moving forward he and participant 9 discussed in japanese for a moment before participant 9 relayed these interviews made me rethink about the disaster reflect think back remember my situation and know what other people have to say and combine these things to give me new ideas and so on participant 8 agreed and his friend translated the following participant 8 thinks that he feels like he was healed by talking about his experience…he feels very ashamed that he almost forgot about his experience with the disaster and this is a very good opportunity to remember about the experience what it was like… these interviews give us the chance to think about the earthquake not forgetting is very important i think its not a good experience but something good can come because of it this something that he and his fellow interviewees hope will come of their experiences following the earthquake is a healing in two directions internally and externally the internal healing appears to come from the interview itself while the external healing will come from what they hope will be done with their words as participants 8 and 9s friend translated they dont want the memories of the tragedy to decay they want people to remember the memories of tragedy…and they want to continue the memory for the future participants 8 9 and 1 are all members of the universitys student group fukushima will a club participant 1 defined via message devoted to studying disasters and related issues as well as radiationradiation education in fukushima though capitalized the name is not an acronym participant 1 says that the emphatic will refers to the strong mind of the organization their determination to keep fresh the situation of the earthquake peoples mind the difficulties their hope is that by helping to spread the stories of what the residents of fukushima went through survivors of future disasters wont feel as lost as they did this goal is not unique to members of fukushima will many participants described a hope that their words would improve conditions for survivors of future disasters as participant 7 said i hope this kind of disaster never happens again but in case it does i want to let everyone know as a good example what happened here participant 8 expressed a nearly identical sentiment saying there are a lot of nuclear power plants around the world so accidents will happen again in other countries so people will need to have the right things to treat those accidents people from fukushima had a very interesting unique experience so these things should be taken to other people participant 5 also highlighted the uniqueness of the experiences of those after the earthquake in particular participant 2 hopes that by sharing his experiences he can offer more insight into the psychological effects of such a disaster in addition to his want to help fukushima get better help people get better he stressed the need for increased attention to mental health in the aftermath of similar events as a reason for his participation in the interview he explained i wanted people who never had an experience like this to know about the mental health issues that me and my friends had due to the earthquake the tsunami and the power plant disaster it shouldnt be forgotten and i dont want people to forget…i want them to know other people in the world i want them to know what we experienced…i want people to understand when theres a nuclear accident an atomic power accident with a natural disaster like an earthquake that the damage that causes to peoples mental health that lasts many many years it needs to be dealt with the sharing of these postdisaster stories does more than provide an opportunity for healing or memorialize history for the future or lead to improved medicine as participant 9 put it the experiences of these participants are deeply personal a part of these students lives therefore to tell their stories is to create their legacies in a quietly determined voice participant 8 once a teacher now one of the oldest students in his firstyear class told me and his friends why he decided to talk about what he went through i may not do big things achieve big things in my life but if i can tell about my experiences to other people maybe they those people will help other people with hardships these people who have had hardships they might themselves have a high achievement and that will give us the legacy of their achievement so knowing is very important and conveying my feelings and my knowledge is very important…and people who are from other countries and other prefectures if i give them some of the truth maybe they will do things to help the refugees they can do good things with that truth discussion and conclusions at present fukushima is a prefecture of dualities at once it is both injured and recovering mourning and moving forward unified with the government and distrustful of it the geje has a similarly complex significance for this studys interview participants for most if not all of these students the event was careerdefining it opened doors not only to areas of study within the field of medicine but for some to medicine as the field of pursuit at the same time the lasting burdening effects of the earthquake endure trauma loss of life and destruction of property stigma and yet even these consequences act as galvanizing agents these students stand eager motivated and poised to make change in this current study through interviews and inductive thematic analysis we explored the individual stories of medical students at fmu who lived in fukushima during the time of the great east japan earthquake to our knowledge this is one of the first studies to not only use a qualitative approach to detail common themes in the personal narratives of evacuees of the earthquake but also to provide a space wherein evacuees can control the narrative of the geje in academic literature this study further colors our understanding of the disasters impact on the behavioral societal cultural and political aspects of the lives of residents of fukushima our study has several strengths the qualitative and ethnographic framework adopted for this study allows for a complex and nuanced investigation of the impact of a largescale disaster this approach lent itself well to broadening comparative contextual and crosscultural perspectives on the geje furthermore the focus on personal narratives and the common threads throughout these narratives adds a humanistic layer to current academic research on the topic by placing these narratives at the forefront participants were empowered to contribute to local and worldwide perceptions of fukushima following the earthquake there are a few limitations to our study firstly our study population exclusively included medical students a group not necessarily representative of all those affected by the earthquake the themes discovered in this study may not be generalizable to the entirety of the evacuee population secondly as with most ethnographic studies the richness of the data depends on both the rapport of the researcher with the subjects and the openness and honesty of the subjects though the researcher felt that good rapport was established through close contact with participants and their friends prior to during and following the interview this is difficult to fully ascertain interviews were conducted in private and anonymity was stressed at the beginning of the encounters to increase the likelihood of participants being open and honest more chances must be given to residents of fukushima prefecture both current and displaced to provide insight into their experiences following the great east japan earthquake and the associated tsunami and nuclear incident further ethnographic research should be conducted to expand upon the themes approached in this research and to explore the wealth of other stories not touched here additionally longitudinal studies of medical students from fukushima prefecture would permit more rigorous data on the impact of the earthquake on career path finally crosscultural studies between survivors of nuclear accidents would allow for not only the healing described by the participants but for the chance to pass on a unique expertise for potential future survivors as the interview participants noted themselves these stories are their legacy authors contributions as ml ck and ry devised and designed the project as performed ethnographic interviews with help from ml ck sw and ry performed technical coordination as analyzed the data and wrote the manuscript with input from all authors as and ml revised the manuscript according to reviewer comments the author read and approved the final manuscript • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from competing interests on behalf of all authors the corresponding author states that there are no competing interests

background the great east japan earthquake and the resulting tsunami and nuclear disaster on march 11 2011 have had a profound and lasting effect on residents of japans fukushima prefecture particularly among evacuees while there continues to be extensive news coverage and academic study of fukushima prefectures recovery there has been little exploration of individual narratives this study aims to illuminate some individual stories of medical students at fukushima medical university fmu who lived in the prefecture at the time of the earthquake methods a qualitative approach was taken in order to investigate individuals experiences with the goal of adding a personal dimension to quantitative studies on the subject 10 openended ethnographic interviews were conducted with medical students at fmu in years 15 who lived in fukushima prefecture at the time of the great east japan earthquake all interviews were audio recorded and transcribed transcriptions were reviewed using inductive thematic analysis under the lens of ethnographic anthropologythree major themes emerged from these interviews first that the events following the earthquake influenced not only these students decisions to pursue careers in medicine but the ways in which they hope to practice medicine in the future second that these students were motivated to share their experiences by a want to change fukushima prefectures public image and lastly that the students viewed the opportunity to discuss their experiences through these interviews as healing both for themselves and for the future conclusions while multiple factors undoubtably contributed these students medical education they cite the earthquake as essential to their approach to their medical careers additionally opportunities for the participants to discuss their experiences following the earthquake appear to be rare but valued as the students view their stories as their legacies the enduring burdening effects of the earthquake appear to have galvanized the participating students to act on behalf of their communities and their prefecture further qualitative studies in more generalizable populations are needed to improve and deepen our understanding of the societal cultural and personal impacts of the great east japan earthquake

introduction this research deals with the range of vulnerabilities induced by climate change in the coastal areas of bangladesh du e to the unique geophysical structure the coastal areas of bangladesh are extremely vulnerable due to climate change the severe impacts of climate change are evident on the life and livelihoods of all walks of people specially in the coastal areas of bangladesh poor and marginalized people are the worst victims in this case to be specific however due to this climate vulnerability the vulnerable communities of the coastal areas have developed their own adaptation practices based on their indigenous coping mechanisms to study the socioeconomic vulnerability of climate vulnerable coastal area is the key motivation as well as the objective of this study the main aim of this study is to carry out a vulnerability assessment of the selected coastal atrisk communities the lack of knowledge technological innovation exclusion of vulnerable social groups policy constrains and systematic analysis on climateinduced vulnerability livelihood disruption due to the frequency and intensity of disasters coping with the vulnerability of climate change with economic and social complexities the coastal population remain barriers to sustainable adaptation strategies leading towards social and economic collapse these distinctive characteristics make these coastal inhabitants more vulnerable in terms of social economic or financial physical demographic health and environmental domains also these sort of vulnerabilities lead them to become more susceptible to calamities distress disruption and increases tangible intangible loss nowadays climate change is perhaps the most widely discussed of all the recent global environmental crisisrelated topics and several welldocumented studies revealed that climate change creates an authentic link to natural disasters due to anthropogenic causes thats why little too intense alter in climatic the dhaka university journal of earth and environmental sciences vol 11 2022 corresponding author nushrat tashmin email doi variability affects the social and economic wellbeing of populations climate change has influence over various interconnected issues of the nations of the world such as environmental ecological socioeconomic sociopolitical and so on the ongoing threat of climate change imposes a severe impact on the lives and livelihood of coastal people such as physical infrastructure damage lower level of health status death of livestock loss of income physical injury raising migration pattern natural property damage and so on it is now well known to all of us that among other developing countries bangladesh is recognized as the most climatevulnerable country in the world the frequency and intensity of disasters such as floods cyclones droughts and landslides have changed due to the impacts of climate change moreover the coastal area of bangladesh is also facing the severe impacts of sealevel rise and salinity intrusion due to climate change over the last three consecutive decades bangladesh has experienced nearly 16 billion in gdp losses including property damage livelihood disruption communication destruction infrastructure collapse agricultural loss and over thousands of death tolls due to about 200 climaterelated disasters bangladesh has ranked 7th most vulnerable of the mostclimatevulnerablee counties in the world according to the ipcc 2021 report because of the flat topography and low adaptation capacity the coastal communities of bangladesh are highly exposed various natural disasters such as cyclone storm surges coastal flooding sea level rise and so on the coastal areas of the bangladesh are regarded as the frontline of climate change which are severely affected by increased flooding increased intensity of cyclones salinity intrusion and temperature extremes due to climate change the intensity and frequency of disasters increase and these climate induced disasters disrupt the social and economic wellbeing of populations specially in the coastal areas of bangladesh in this study the researchers have chosen 4 unions of a coastal upazila of southern bangladesh namely koyra upazila under the khulna district of bangladesh the coastal areas of bangladesh are affected by the impact of climate change and the koyra upazila is a remarkable disasterprone area where the impacts of these changes are notable and significant this upazila is being frequently affected by cyclones and storm surges this area was severely affected by the super cyclone sidr and aila moreover research shows that in koyra upazial salinity intrusion and waterlogging are the most common natural hazards in this area the people are vulnerable due to the repetition of disasters before overcoming the impacts of previous disasters gradually vulnerable people living here are losing their capacity of disaster management and being trapped by the cycle of poverty therefore this study focuses on the socioeconomic vulnerability of the climate vulnerable koyra upazila the objectives of this study are to explore the components and levels of vulnerability explain the vulnerability scenario and analyze the social perception of the climateinduced disasters of the selected coastal areas of southern bangladesh the present paper focuses on the socioeconomic vulnerability of the selected coastal study areas of bangladesh and socioeconomic impacts of climate induced disasters are also analyzed critically in this study background and significance of the study climateinduced extrem force people to alter the course of life most of the time and ultimately engage tem in diversified occupation patterns for maintaining their lives livelihoods the result of extreme weather events such as floods droughts cyclones and other weatherassociated phenomena affect the wellbeing of affected people through the destruction of physical human as well as social capital due to climate variability displacement is also a common phenomenon especially in coastal areas of bangladesh due to this sort of forced migration the coastal residents become economically vulnerable this is one of the most distinguished forms of vulnerability experienced by many households in this researchs selected study areas climate change leads to negative consequences on every sector of our surroundings especially people who live in coastal regions suffer an immense crisis the livelihood of the poor and marginalized people are disproportionately vulnerable in coastal bangladesh the multiple stressors related to climate change make the life of the people more vulnerable than the rest of the country moreover the study of vulnerability helps the authority to determine the actual condition of the communities and implement necessary plans for reducing the vulnerability in this study the socioeconomic vulnerability of the community people at risk is assessed through the socioeconomic vulnerability index using a composite indicator framework method according to ipcc the interrelationship between vulnerability and climate change depends on three components exposure sensitivity and adaptive capacity these dimensions are further divided into five domains physical social economic demographic and exposure to hazards in this present study the researchers used this sevi index to assess the socioeconomic vulnerability of the study area with a specific focus on the social perception of the climate induced disasters for the theoretical framework this study used the par model for developing the indicators for sevi the par model guided the researchers to determine the root causes and dynamic conditions of vulnerability the most familiar conceptual model of vulnerability to disasters includes the pressure and release model by wisner this model emphasized vulnerability at microunit level the par model shows the intersection of unsafe conditions and hazards which creates social vulnerability according to this model disasters occur when vulnerable people are affected by hazards the root causes of vulnerability are social economic and political conditions of community people the vulnerable communities live under constant pressure due to their limited access to livelihood education and healthcare resulting in poor income and unsafe healthcare status and living conditions to release this pressure the vulnerability components of risk should be addressed properly by the concerned authorities the study is about the assessment of socioeconomic vulnerability of the people living in coastal bangladesh this study not only focuses on the socioeconomic vulnerability but also it deals with social perception of the climate induced disasters of the selected coastal areas of bangladesh this indexbased assessment with social perception can be an integral part of the contingency planning of the disasterprone coastal areas of bangladesh through qualitative and quantitative approaches this study determines the changes of the holistic lifestyle of the community people at risk due to climate change this study shows that the frequent climate change induced disasters have always been detrimental to the local vulnerable coastal communities the socioeconomic vulnerability assessment is imperative for recognizing the impacts of climate induced disasters and formulating effective contingency plan the vulnerability analysis by using the sevi can be useful for assessing the coastal vulnerability of bangladesh and identifying the priority areas for implementation of actionoriented communitybased resilience planning for lessening the effects of climate change methodology selection of the study area this koyra upazila is highly fragile and vulnerable in terms of climate change induced disasters the available demographic sources reveal that about 133 million population may likely be homeless in the name of climate refugees as the victim of climate extremes in the southern coastal part of bangladesh by 2050 koyra is a coastal upazila under the khulna district of bangladesh it is about 100 km by road from khulna city and located at the border of sundarban mangrove forest in 2009 cyclone aila created a huge damage and loss in koyra and affected nearly a population of 152496 over there after this damage and loss the government of bangladesh and the relevant development partners regard this area as a priority for recovery and reconstruction the upazila is occupying an area of around 1800 km 2 this area belongs to the immature delta slope which his hardly above the sea level for this coastal location the koyra upazila is susceptible to different disasters such as cyclone flood storm surges salinity intrusion and water logging the damage and loss scenario after the super cyclones reveals that the community people living in the study area are the worst sufferer of socioeconomic vulnerable conditions the researchers selected four unions among the seven unions of koyra upazila for this study in this study the primary data reveal the underlying and overlying causes of vulnerability in the study area the data show the most vulnerable groups within these communities such as women minor groups lowincome households disable people oldage people displaced people etc the researchers have chosen the four unions and tried to figure out the factors which are responsible for emerging crises this study tried to reveal the socioeconomic vulnerability perspectives of the concerned unions under koyra upazila data collection this research focused on a mixedmetho strategy by combining both quantitative and qualitative data the researchers collected primary data conducting key informant interviews focused group discussions questionnaire survey and secondary data was collected through extensive literature review by conducting systemic data analysis the researchers tried to identify the socioeconomic vulnerability of the people of selected communities by using the vulnerability index moreover the researchers have also explored the adaptation strategies of the vulnerable frontline people by focusing on their livelihood patterns the researchers have followed the nonprobabilistic sampling method in this study to have detailed insights into the life and livelihood of the climate vulnerable people the researchers have selected 200 households on the basis of their climatevulnerable situation by conducting several fgds with community people the researchers have tried to collect data related to socioeconomic status of the households to have detailed insights of the community lives and livelihood the researchers have chosen some key informants from the selected study area with whom they maintained constant contact throughout out the fieldwork period moreover some experts from the selected field of research interest were chosen for their valuable advice and opinions data analysis after the data collection the data was analyzed systematically in spss and microsoft excel for quantification furthermore the qualitative data were analyzed thematically by chunking and coding the researchers determined the indicators for vulnerability indicators by following the par model to determine the domainwise vulnerability score the researchers summed up the findings and organized each value according to the indicators of the vulnerability index physical social economic demographic and exposure to natural hazards here the researchers took the score which varies between 0 to 1 where 0 means no vulnerability and 1 means extreme vulnerability in between 0 to 1 the researchers categorized the different levels of vulnerability including severe moderate partial and fully vulnerable the subcomponents of vulnerability were standardized again between 0 and 1 each subcomponent has an equal contribution to the sevi index a balanced weighted approach were used for calculating the sevi weighted index score k × the domainwise vulnerability score was then calculated by averaging the weighted score of all subcomponents for each domain category source sahana et al 2021 result the nature of climateinduced vulnerability in the study area for understanding and measuring the vulnerability of the selected coastal areas the researchers have used the pressure and release model in this research the researchers have taken the livelihood pattern as an important indication along with other indicators such as calorie intake life style income expenditure savings debt housing pattern literacy rate access to technology health condition social capital community participation dependency on relief and so on according to the par model the social economic and political situations make some people more vulnerable to natural disasters root causes dynamic pressures and unsafe conditions makes the vulnerable population more sensitive to natural hazards the figure 3 shows the rooted character of vulnerability of the people who have limited opportunity as well as limited access to resources figure 4 the social causation of disaster as per the par model the researchers have considered the vulnerability situation of the study area by combining two opposite forces the mechanism of the progression of vulnerability and the occurrence of a hazard the vulnerable situation of the community people is generated without the impacts of hazards initially then the occurrence of hazards creates stress in their life and complicates their situation in the selected unions of the koyra upazila the researchers have found that the climate induced disaster situations usually intensify the vulnerable situation of the community people this situation gets more intense for the households who faces political social and economic inequality researchers found that the underlying economic and social problems of lowincome households and socially marginalized groups affect livelihood opportunities and this situation gets worse during and after disasters moreover the climate change situation exacerbates the damage and loss and the situation of the community people becomes more vulnerable to have the insights about the vulnerability of the selected households of study areas the researchers considered community based disaster risk index and also took into account the number of dependent and independent variables based on sensitivity exposure and capacity in this study the index is comprised of relevant indicators which summarizes the overall climate vulnerability situation of the study area table 1 shows the domain wise vulnerability indicators and the associated general remarks on the findings the level of vulnerability of each indicator is presented here with and signs with these signs the researchers were able to present the overall vulnerability of the selected households rapidly the nature of vulnerability here is presented on the basis of the increase and decrease of the factors associated with the indicators financial or economic 1 number of employees per households 2 sate of insurance debt or loan availability of lands due to frequent climatic condition vulnerable coastal people loss their formal jobs and a vast majority of people are going under the poverty line social state of existing literacy rate 2 people attitude towards psychological trauma during disasters number of marginalized people 4 state of vulnerable people access to community decision making approach social capitals majority of people loss social capital and being marginalized due to economic instability the holistic peace and stability in society are largely disrupted also social status created one type of caste system which is one of the most emerging issues for social transition of population demographic population density 2 rate of migration towards urban area state of occupational pattern change large portion of vulnerable people are migrating towards urban area for managing their livelihoods exposure to natural hazard 1 not having shelter in cyclone centers 2 willing to go to cyclone shelters understanding national waring system 4 number of cyclones in last 10 years number of floods in last 10 years people usually go to shelters homes during cyclones not all of them are willing to go to cyclone shelters but the ratio of willingness has increased after aila vulnerability scenario in study area the results of the study shoes that most of the households of the study area are vulnerable the degree of exposure and sensitivity are high and low adaptive capacity contributes to the high level of vulnerability the physical economic social demographic and exposure to natural hazards domains have contributed to different degrees of vulnerability the selected households are found more exposed to coastal disasters and sensitive towards damages created by the disasters moreover the low level of adaptive capacity of these households makes them more vulnerable most of the sampled households of the study area affected by the asset loss and home damages the socioeconomic vulnerability situation exposes their low access to healthcare services less access to food and safe water limited livelihood facilities low economic condition and inadequate provision of infrastructure the domains of sevi are presented in table 2 the researchers have also presented the domain wise vulnerability scenario of the study area the researchers analyzed the areas of vulnerability in terms of exposure sensitivity and capacity and categorized the unions on the basis of the category of of vulnerability social perception about climate induced disasters the selected four unions are more disasterprone areas among other remaining unions of koyra upazila the residents of this area undergo a severe climate crisis the extreme weather events due to climate change pose a great challenge towards their lives and livelihoods during the field survey the researchers asked local responders about existing weather patterns and rank the event that they faced in the last five years based on the emic perception of the local respondents the disasters to which they are being exposed regularly are given below therefore almost a large section of the respondents said that cyclonic events make their vulnerable situation worse and these events are most responsible for civics distress and the researchers tried to figure out the recent devastating cyclone in concern unions in the following figure it is well apparent from social vulnerability analysis thatthe koyra upazila is much more fragile in terms of social perspective such as in terms of poverty rate availability number of healthcare institutions safe drinking water supply rate of literacy female participation on policy making perspective and so on the community members do have their own socioeconomic and religious factors in this case which shape up their own perception about the climateinduced disasters in their opinions the frequency of disasters has increased in the recent past years and their direct and indirect experience within these situations have formatted their experiences regarding risk perception households which have socioeconomic differences do perceive the disaster risk differently some prefer to migrate from their community to nearby cities to find better options to these households migration is an adaptation strategy however the households which are economically vulnerable are being trapped in their communities and cannot migrate due to their socioeconomic dynamics in addition to this the male and female victims consider their situation differently due to their gender specific exposure and ethos female respondents consider the disastrous situations to carry more risks because they are more exposed their domestic roles and actives rather than their male counterparts the respondents are less aware about the anthropogenic activities which leads the climate to change faster rather they perceive these disasters according to local values religious beliefs and cultural factors moreover the community members do poses traditional strong family and social community values and during and after disasters they do play the roles of volunteer for communal wellbeing as per the par model the socioeconomic situation of a community determines their adaptive capacity towards disasters the socioeconomic development shapes a communitys resilience capacity which sometimes depends on the nonstructural mitigation measures the social perception of a community provides us the overall mindset and social situation of local inhabitants this study provides both the socioeconomic vulnerability scenario and social perceptions of respondents about disasters from this perspective the policy makers and concerned authorities should take appropriate initiatives of awareness raising campaigns amid the community people this sort of initiative will reshape their social perception about every stage of disaster cycle and it will have a positive impact on their socioeconomic vulnerable situation discussion due to the unique geophysical characteristics of the coastal areas of bangladesh it is event from this research that almost every year the entire study area is exposed to the increased frequency of extreme climatic events consequently the households in this area are likely to become socioeconomically more vulnerable butut the range of vulnerability varies between these unions thats why the researchers have tried to calculate the index value of each domain from the perspectives of exposure sensitivity and capacity based on sevi index each domain scores with a different value of vulnerability the researchers tried explore the socioeconomic vulnerability by studying the major components of the physical social economic health and demographic from the perspective of average socioeconomic vulnerability this study reveals that among the selected unions bagali union is the most vulnerable from the perspective of almost all the domains of vulnerability index during the fieldwork it was quite clear that the reasons for which they are going through miserable conditions the researchers tried to incorporate the social perception of community people about natural disasters to analyze the social process of the community however the other three unions are also vulnerable due to the climate change induced weather extremes from the data analysis it is evident that the selected four unions have high exposure to the climate vulnerability are at high risk of increased frequency of the disasters this situation of exposure and sensitivity is rising the poverty rate and the living standard of the affected people is becoming low during the fieldwork the researchers have found some cases of child malnutrition failure to repay debt maternal and child motility dropout from school child labor and gender discrimination the study area is highly exposed to climate induced disasters and extremely sensitive towards the damages caused by these disasters moreover due to the socioeconomic vulnerability the adaptation capacity of the marginalized households remains low among sample households most of the households are affected by the economic vulnerability which limit their capacity to cope with the changing climate and disaster situations so these marginalized people are being trapped in the cycle of poverty during the disasters the damage and loss of their limited property exacerbate their situation and they become more sensitive to the extreme climatic events climate induced disasters also pose constant threat to the health of the vulnerable population living in the upazila loss of agricultural productivity creates food insecurity and the salinity intrusion and drought in the dry season compel the safe drinking water to become scarce the overall vulnerability scenario of the selected study area reveals the high socioeconomic vulnerability among the communities of koyra upazila in terms of low income crop failure vulnerable health status scarce safe drinking water inadequate infrastructure and so on moreover the social perception of the respondents reveals the social systems and power relation of the communities this social setup affects their adaptive capacity the study shows that the social perception of community members is derived from the social processes which ultimately determine their access to opportunities and exposure to natural hazards also the study shows that during disasters the local network of transportation becomes disrupted which leads towards a longterm communication disruption both the primary and secondary data sources also reveal that there is low level of literacy among the local people of selected unions moreover the displacement during disasters also exacerbates the prevailing vulnerable situation of the sufferer households inadequate capacity and lack of amenities pose devastating impact on the lives and livelihoods of the local inhabitants and this situation is becoming more vulnerable due to the increased change in the climate those households who are at risk becoming marginalized and they require effective adaptation and mitigation measures to cope with this changing climate conclusions in this research the researchers have tried to explore the existing vulnerability situation of the local communities of the southern coastal part of bangladesh by assessing different domains of socioeconomic perspectives which will be an important account for developing a contingency plan for the resilience of these localities moreover the researchers also had some limitations while conducting the fieldwork such as time and fund constrains which restricted them to have the holistic vulnerable situation of more local people and emic insights of their way of life their coping mechanisms and their reallife challenges during crisis events however the findings indicate that the socioeconomic vulnerability of the sampled households increases the poverty rate the domains which the researchers selected in this research to study vulnerability have direct link with the disrupted livelihood and living standard of the local people due to the frequent climate extreme events the damage and loss of the property infrastructure and social capital make the inhabitants of the vulnerable coastal areas marginalized and they are constantly being deprived because of the climate injustice also the findings of the study reveal that in marginal households the gender inequality persists and this often leads to genderbased violence so the women living these vulnerable unions are more vulnerable than their male counterparts though the vulnerable households sometimes perceive migration as an adaptation strategy but not all migration bring positive changes in the lives of the migrated households situation of the forced displaced households are far worst here so in conclusion it can be said that the sampled households of the selected coastal areas are extremely exposed to climate change impacts and due to the lack of capacity they are sensitive towards the climate induced disasters the selected unions of the koyra upazila are suffering from excessive socioeconomic vulnerability because of the disrupted livelihood low income economic insecurity physical vulnerability low literacy rate gender inequality low health status food insecurity and problems regarding infrastructure water and sanitation these vulnerable coastal areas require efficient disaster risk reduction strategies contingency plans policy measures and implementation for resilience formulation of holistic vulnerability assessment framework and effective coastal risk management will be helpful in lessening the impacts of climate change engaging local community people in communitybased risk assessment initiating structural and nonstructural mitigation measures and promoting indigenous adaptive strategies are highly recommended by the researchers to lessen the impact of vulnerability the researchers suggest more costeffective solutions awareness raising initiatives capacity building programs increased social security services effective disaster response and increased coordination among stakeholders and community people moreover strengthening the social system with increased economic opportunities is also an essential step in this regard the use of a comprehensive vulnerability index will escalate the feasibility of climate change induced vulnerability assessment these provisions will be very much helpful for the frontline vulnerable people who requires immediate attention social safety net assistance can play an important role is this regard and the proper disaster risk management formwork will be necessary for reducing the vulnerability of the frontline people of the coastal areas

the study intends to explore the socioeconomic vulnerability of climate change in the coastal koyra upazila of bangladesh the present study is concerned with climateinduced disasters and associated vulnerabilities which adversely impact the social and economic aspects of coastal inhabitants of bangladesh the researchers selected four unions koyra amadi bagali and dakshin bedkashi among the seven unions of koyra upazila for this study in this study the socioeconomic vulnerability of the community people at risk is assessed through the socioeconomic vulnerability index sevi this research focused on a mixedmethod strategy combining quantitative and qualitative data by conducting systemic data analysis the researchers tried to identify the socioeconomic vulnerability of the people of selected communities by using the vulnerability index this study reveals that the study area is highly exposed to climateinduced disasters and extremely sensitive towards the damages caused by these disasters moreover due to the socioeconomic vulnerability the adaptation capacity of the marginalized households remains low among sample households most are affected by the economic vulnerability which limits their capacity to cope with the changing climate and disaster situations this study not only focuses on the socioeconomic vulnerability but also it deals with social perception of the climateinduced disasters of the selected coastal areas of bangladesh this indexbased assessment with social perception can be an integral part of the contingency planning of the disasterprone coastal regions of bangladesh

introduction the role of journalists on social media is no longer restricted to being a news promoter or a columnist remarking on the factualness of twitters trending topics journalists are constantly taking on a didactic function and endorsing discourse on geopolitical debates social issues and even suggesting places reading material and restaurants for their followers on social media such characteristics reshape the journalists participation within digital environments in such a way that the interaction seems more active and closer to the public thus approaching a digital influencer persona brazil is the leading latin american country in the growth of influencers and strategic uses of digital networks according to consumer behavior surveys it is estimated that 71 of brazilian social media users follow some kind of digital influencer based on this context this article aims to discuss the construction of journalistic skills and the appropriation of influencers practices in journalists online communication the empirical analysis was based on three brazilian journalists all of them related to the television industry and with a bold digital presence astrid fontenelle guga chacra evaristo costa the new form of journalists presence on social media is leading the field towards a perspective that bruns has already identified we follow individual journalists … rather than trusting only in the imprints of news organisations in brazil supposedly these new communication actors are defining what is a successful online practice and even influencing journalists to build a digital presence therefore this article argues that the authoritative speech of journalism is facing a change that could be understood based on two questions 1 what are the similarities and differences between journalists online practices and that of digital influencers 2 how have social media and the intimate perspective shortened the distances between journalists and their audiences journalists attributes and authority the first academic and technical record of journalism is from the 1690s at that time peucer identified relevant elements that underpin the journalistic practice supported by the pillars of truth justice and ethics the influence of journalism is under threat even when it is built through professional ethical and deontological values in order to understand this context it is important to review some fundamental key values for legitimacy and journalistic authority issn 27638677 first before the journalistic practice itself there are deontological presuppositions that will together grant legitimacy and credibility to journalism ethics and morals are factors that guide the profession relationships with colleagues sources and the organization of the field abramo defends the public commitment of journalists and emphasizes that there is not a specific ethics of the journalist his ethics are the same as the citizen other value confer legitimacy to journalistic practice its professional ethos truthfulness precision inquiry into social problems separation of information and opinion verification interpretations of reality all of this is part of a general standard that abramo classifies as journalistic ethical value it may seem broad but that plays a determining role in the structures of this professional practice this paper aims not to discuss the ethical issue in depth however the understanding of a duty towards the citizens interest is essential to journalism and therefore to this article the journalistic practice relies on the ethics and morals inherent to the journalist and it is part of legitimacy and credibility as a result of daily professional activity legitimacy derives from the fulfillment of some attributes that make journalism socially recognized as a profession in other words the recognition of journalistic practice by the public guarantees institutionalization therefore recognition is professional assumption and a consequence of the professional practice based on ethics and morals but it is not necessarily a characteristic for the existence of journalistic discourse the same thing happens with the idea of journalistic credibility which is a value that arises with a journalists professional lifespan and its performance credibility arises from the bond of trust established between journalists and the public through the narrative and logic of the journalists performance when a performance is associated with truth it establishes a relationship of belief and reliability the existence of these essential principles to validate journalistic conduct only exist because the field has adhered to elementary characteristics to differentiate journalistic discourse from any other type of narrative first of all it is necessary to talk about the public interest that guides journalistic practice in short public interest comes from anything considered impactful on the life of a community and audience public interest anticipates the act of doing journalism and can be classified as collective motivation or social interest in this context groth has put forth the possibility of understanding journalism as a science and its essence as a result of society interest according to the authors conceptual and systematic model journalistic activity can only be considered as such by analyzing the characteristics that form it thus it is necessary to disassemble and reassemble the elements in order to understand their value and utility groth systematized some of them as elementary ones periodicity universality timeliness and publicity to build a logical analysis of the journalistic discourse it is necessary to add the characteristics of groths model to others such as plurality uniqueness objectivity proximity public interest and target audience issn 27638677 according to gadini plurality is a contemporary feature in journalism and it is greatly influenced by north american journalistic practice in the 1960s and 1970s plurality is the search for the opposition of a discourse when journalists research different and even opposite perspectives and interview diverse profiles to ensure various voices in a report on the pretext of increasing the reliability and credibility of newspapers through plurality the practice of listening to both sides became a key element in distinguishing journalistic discourse tuchman understands the plurality of sources as a fundamental attribute of the news and relates it directly to another founding element of journalistic discourse objectivity however the debate about this element as well as the notion of impartiality is considered an ideal to be achieved but it is impracticable in its totality according to tuchman objectivity is a strategic rite in content production because it systematizes journalistic practice another category defined by the brazilian professor genro filho in o segredo da pirâmide is singularity the concept is based on premises such as the path of the journalistic narrative the constant search for the new or unusual and the inherent potential of the practice to be a propellant for social debates although the author is criticized for the aristotelian and marxist thought that generated this category it is from this theoretical viewpoint that the research in brazilian journalism structures the discussion of the lead another reason to highlight this element is that journalism is a form of knowledge solidified in the singular in the unique in something neither universal nor particular another characteristic is proximity related to the question where it means the geographic space covered by journalists at the moment of news coverage through this characteristic one can evaluate the thematic scheduling given to subjects by journalism considering the degree of proximity and interest issn 27638677 that the subject has from a certain community the subject will have a greater repercussion in journalism speech also guarantees the confidence of the readerviewer and the communication vehicle therefore it is aggregated to the journalists behavior and language expression in addition the journalistic technique through elements that guide the professional practice also guarantees authority to the professional therefore journalistic authority brings together a community of social actors who primarily share an understanding of what journalism is and its main function placing journalists as professionals engaged in proving themselves as observers who truthfully report reality it would be possible to say that journalists claim their cultural authority this kind of authority arises through the modus operandi of journalists where the professionals themselves develop a professional identitypersonality based on ethical and technical values the result of the journalistic authority beginning with the professional culture built over the years is the recognition of the journalist as an authorized observer someone in whom the population of a city can trust and that with time adapts to technologies and communication transformations there are also other practices that legitimize journalists work professional orientation development of specific news forms and the personal narratives they circulate to support a privileged social place carlson argues that journalistic authority is always the product of complex and variable relationships as the ones with the audiences sources technologies and critics they are all responsible for shaping journalistic authority in the contemporary media environment digital influencers legitimacy and intimacy the term digital influencer became part of the academic mediatic and commercial vocabulary in 2015 in brazil and it refers to internet users producing content on social networks in various formats digital influencers are considered ordinary people originally amateurs that based on the participatory culture can produce content online and gain audiences this possibility is a result of a landscape of participatory lurch where the tools of distribution and production are now available online and the production sphere is occupied by everyday people and no longer confined just to the traditional media digital influencers can also be understood as a type of internet celebrity as members of a professionalized commercialized and monetized circuit and as opinion leaders becoming a digital influencer requires not just ones desire but also legitimation conceded by the public or followers on social media legitimation is based on the necessity to create or to reinforce the issn 27638677 position of legitimacy of the speaking subject through a journalistic perspective this process can be based on the speaker position of authority that can be conferred by an institutional authority in other words it means that a journalist is commonly recognized as credible because of the mediatic institution where they work giving them the right to the speech however the internet has broken down some traditional media processes digital influencers have not ever had an institutional authority that could give them the possibility to speak and to gain audiences interested in what they share online the legitimation process then depends fully on how followers recognize them as credible rightful and worthy of their attention previously fashion bloggers used to gain their audiences as a result of a democratic turn of fashion blogs were considered a space with a claim on the real one space where real fashion fashion as worn by real people can be seen this gave fashion blog readers the impression of a nonmediated relation as opposed to the traditional and mediated fashion media as digital influencers are a developed and adapted form of their predecessors the bloggers they are still attached to this characteristic of realness and nonmediated relations and as ordinary people digital influencers cannot expect to have any kind of previous authority and if they do so it seems that any offline capitals are not automatically transferred to digital relations thus legitimation needs to occur as followers acknowledge influence credit knowledge or some type of capital that is important in a social group or a niche that the digital influencer is trying to embrace as part of a very specific legitimation process digital influencers can be legitimated by traditional media and brands as a result of their followers recognition of their legitimacy and reputation and it can be identified in their potency to interfere in the consumption practices of their followers and the topics that they are able to circulate among an online community it is important to emphasize that digital influencers are a broad definition of individuals that can also call themselves youtubers instagrammers tiktokers bloggers or content creators and despite the stereotypical tendency to group digital influencers into a uniform homogenous category they can be part of very different genres such as fashion travel food games books humor and so on this is a key aspect of digital influencers and is also related to multiple possibilities of reputation and legitimacy granting in other terms the right to speech is variable in the digital influencer economy another standpoint to understand digital influencers is in accordance with what abidin has described as perceived interconnectedness the author debates intimacy as a business strategy for influencers and also highlights the importance of an impression of authenticity the same is identified by reade who describes how social media influencers employ practices of authenticity to foster relatability and intimacy with their followers these strategies are based on the participatory issn 27638677 culture that shares a sense of connectedness among users in different levels of visibility and production online a prominent content genre among digital influencers is lifestyle abidin has identified that these influencers resort to disclosing intimacies as they showcase trivial parts of their lives not only luxurious advertorial photos it gives the illusion of commonality horizontality and a less hierarchical relation more specifically abidin draws on ethnographic evaluations and states that horton wohls notion of parasocial relations … builds a model of communication through which influencers convey intimacies the framework of perceived interconnectedness is presented as a parallel to parasocial relations horton wohl theorize on how television and radio personalities produce onesided interpersonal connections and an illusion of intimacy with their audience through conversational small talk that appears informal casual and responsive although digital influencers enact similar relations online there are some differences that update the theory and make digital influencers relationship with their followers more complex the table below takes seven elements into consideration and characterizes each of them according to the traditional perspective and the digital one basically the framework of perceived interconnectedness also clarifies the legitimation process of digital influencers as it should be grounded in a flat organization of actors interactive dissemination of content a discursive strategy based on perceived intimacy and cocreation with their audiences reade describes three practices among digital influencers that could be related to what abidin has identified 1 posting raw images 2 storying the everyday 3 moments of issn 27638677 real talk about topics considered important to the audience this process of impression management is a way to ensure authenticity and relatability between digital influencers and their public reades findings also corroborate the notion of calibrated amateurism a practice and aesthetic in which actors in an attention economy labor specifically over crafting contrived authenticity that portrays the raw aesthetic of an amateur whether or not they really are amateurs to do so digital influencers can include behindthescenes content in their social media profiles as well as natural photos and snaps of their daily lives aiming to promote a sense of realness an impression of spontaneity and unfilteredness despite the contrary reality with their followers this intimate disclosure strategy however is not present in journalism practices nevertheless journalism is facing what authors consider a reputational decline mainly brought about by new technologies and postmodern disbelief in traditional institutions along with capital issues journalistic reputational capital is also under threat part of the historical authority of news institutions cannot be reduced to such easily quantifiable metrics as audience size revenue or even pulitzer prizes now it is not possible to construct a good reputation online by that or by professional competences like maintaining integrity adding value to information for an audience demonstrating knowledge linking to sources and explaining methodologies journalists are now required to do this in a public realtime realm a realm perfectly illustrated by digital influencers theoretical and methodological framework based on the theoretical discussion the authors identified some possible categories that could help analyzing and characterizing journalists and influencers practices online and it resulted in the proposition of a framework of analysis the theoretical framework describes the characteristics of journalists and digital influencers and it is strongly inspired by the proposition of abidin and the model of groth with the insertion of concepts of the theoreticians discussed above the objective of this framework is to serve as a theoreticalmethodological input throughout the analysis of the profiles of the journalists on social media platforms in the elements column there are points shared by journalists and digital influencers as media actors however each of these elements reserves specifications of their professional practices listed in columns 2 and 3 more than a checklist tool the framework may be used to describe the journalists profiles and then used as a qualitative perspective in order to more easily recognize major aspects of journalists and digital influencers issn 27638677 astrid evaristo and guga journalists on instagram as mentioned before this article discusses the digital presence of three brazilian journalists on instagram their selection as an empirical object shows the relevance of their journalistic work and demonstrates how they are important personalities in the brazilian media landscape also this is not the first study conducted in brazil about the trio of journalists astrid fontenelle evaristo costa guga chacra and their digital presence what reinforces validity within the field as a recognized empirical object among peers to recognize the similarities and differences between journalists online practices and digital influencers and how this convergence is capable of affecting the idea of journalism value this paper focuses on instagram profiles since it is an important platform for digital influencers and it is slowly being adopted by television journalists the first journalist analyzed is astrid fontenelle a brazilian journalist who is currently a tv host on gnt a pay channel from globo she has hosted a female roundtable called saia justa since 2013 astrid is known for soft journalism and variety programs during the period of this research she had 1 million followers on instagram and more than 5576 publications2 evaristo costa is a brazilian journalist who is currently an anchor at cnn on a soft news program3 from 1999 until 2017 evaristo costa worked at globo one of the major tv broadcasters in brazil and latin america he ended his globo career at the jornal hoje a daily newscast in february 2020 evaristo costa was considered the most influential personality in brazil according to research from ipsos 4 during the period of this research evaristo had 75 million followers on instagram and more than 800 publications gustavo cerello chacra known as guga chacra he is a television commentator specialized in the middle east and holds a masters degree in international relations from columbia university guga chacra lived in beirut lebanon during 2008 and 2009 as an international correspondent for the newspaper o estado de s paulo since 2009 he has been living in new york and is currently an international commentator at tv globo on its pay channel dedicated to the news broadcast globonews and on its issn 27638677 radio station rádio cbn he is also an international politics columnist at the newspaper o globo from the same media conglomerate during the period of this research guga chacra had the lowest number of followers of our sample 294000 and more than 2000 posts specifically this article studied astrid evaristo and gugas feed posts and stories through a nonparticipatory observation between january and october 2020 by live archiving screenshots of publications the research did only focus on journalists through the empirical observation since the authors have already a large history of investigating digital influencers practices so the influence logics were observed through theoretical and previous research and journalistic perspective was gained through empirical findings in order to constitute a framework of analysis to get into the field based on the discussions undertaken so far the authors were strongly inspired by the propositions of abidin and the model of groth with the insertion of concepts of the theoreticians discussed above to recognize elements that would reveal attributes of digital influencers or journalists in the field authority and flows of communication it is already a consensus that online social networks constitute such sites of selfpresentation and identity negotiation and as a result construct a networked self the three journalists analyzed dedicate the space of their instagram bio for institutional labels tv host anchor and commentator respectively when astrid evaristo and guga show their journalistic ties in their bios there is evidence of impression management the name of the media outlet also works as a sign of their position of authority an institutional authority the journalists have some credits and capital that they have accumulated from their offline career as opposed to an influencer that starts from digital the way in which they enunciate their ethos reveals that the trio is in a process of digitalization or adaption of their content and works to a digital sphere during the observation period of this research there was a lack of evidence of a bidirectional flow of communication between the journalists and their followers astrid fontenelle does not respond to all of the comments left on her instagram posts but she constantly likes all of them even without answering back but there are still some occasions when astrid answers a few messages guga chacra also likes almost every message from his followers even when not answering them evaristo costa however seems to be the least involved in bidirectional flows of communication since he rarely responds to comments on or likes the messages on his posts this element can be read through different perspectives career digital influencers are in a moment of professionalization where a team is required to handle social media interact and respond to messages considering that the journalists are not fully dedicated to social media as a career the amount of comments on their posts does not have the expected interactive flow of dialogue it is also possible to infer that their digital presence is not attached to a flat interaction but rather to a topdown distribution of content a replication of traditional media flows a journalistic approach is also acknowledged throughout the different content genres on instagram feed there is a balance of posts about private life professional life and social issues private life posts are marked by the appearance of her son and husband pictures with friends moments of leisure and even moments of disclosure concerning her faith 5 professional life posts are the ones where the journalist invites her followers to watch saia justa tells what happened on the show and shares institutional videos 6 transmedia expertise is an element present in digital influencer practices but crucial to journalists this convergence strategy spreading what was once on tv to social media also reinforces her professional links and a right to speech that is tacitly and constantly reminded to followers if astrid were a digital influencer it would be possible to describe her as a niche influencer or a minority influencer a digital influencer who is part of a social minority and produces content based on personal issues according to abidin but she is a journalist so the commitment to some specific discussions can be part of her practice as an opinion leader on instagram racism is a constant agenda from personal posts about her son during blacklivesmatter pictures of a brazilian black boy joão pedro killed at home by a stray bullet in rio de janeiro posts about thelma assis the young black woman who won big brother brasil 2020 7 and a wide variety of discussions but other agendas are also considered like antifascist posts or an outfit picture with a tshirt that says habibi a tribute to lebanese people after the explosion in beirut 8 5 posts published on 07032020 10182020 08062020 05252020 respectively 6 the posts were published on 09302020 09242020 07012020 respectively 7 posts published on 07072020 05192020 04282020 respectively 8 posts published on 07012020 08062020 respectively the publications about racism social minorities and even politics put astrid in an interesting context the journalist combines her own opinion with credible sources like data from social institutes and historical facts and even when there is a personal approach there is a clear element of discursive authority granted by journalistic expertise and referencing sources this is in contrast to digital influencer practices that constantly present an amalgamation of opinion information and even commercial content content strategies humor proximity and relatability evaristo costas instagram posts are not defined by a journalistic periodicity nor a digital influencer logic of publication determined by the speed imposed by algorithms the journalist does not post daily and his instagram has been left without publications for long periods there is also no editorial parameter or a clear thematic distinction among the posts as opposed to astrids the lack of consistency in evaristos posts reveals how instagram is secondary to his practice this is an important point as journalists tend to use social media as an extension of their profession and not issn 27638677 as a medium where journalism itself is made contrarily digital influencers use social media as a medium and as a labor locus at the same time evaristo has more followers than astrid fontenelle and guga chacra one of the main reasons can be credited to his career at tv globo and as an anchor of one of the major daily newscasts in brazil jornal hoje another assumption has to do with one of his unique characteristics online which is the humor employed in his posts that seems to catch his followers attention the first image of figure 3 is a post for journalists day where evaristo appears wearing unexpected bottoms for a hard news journalist in a different publication a smiling evaristo is posing in front of an ancient building in london wearing a suit and the caption reads my belly is shriveling up to button the suit laughing in despair the humoristic characteristic moves evaristo costa away from a stereotype of a journalist and approaches a digital influencer perspective he is not connected to his audience because of his role as a public representative or as a result of a sense of informational integration but instead is based on a proximity element and a communal sense concurrently humor is capable of a discursive generalization and a possibility of amplifying evaristos reach online as it does not depend on a niche audience or specific interests an element of universality evaristo does not employ many transmedia strategies there are some videos preparing the audience for his tv show debut on cnn but this is not constant on his profile furthermore professional posts are also presented in a humorous way despite the announcement of the tv show with an issn 27638677 institutional and more formal video evaristo publishes playful professional posts figure 8 is a behindthescenes image a common type of publication among digital influencers who work with an aesthetic of amateurism in the photo evaristo appears on a rainy day in london recording a part of his tv show and the caption reads this is what cnn doesnt show the caption is a joke about the journalists former outlet media tv globo this is not shown by globo was commonly said by brazilians as a complaint for more democratic media coverage but it is now used even as a meme to talk about controversial issues another example is the third image of figure 2 where evaristo is back in his suit in a professional pose with a cnn background the captions however are a part of an axé song by the brazilian singer ivete sangalo known as the queen of carnival in brazil the line says theres going to be a party humor and especially its brazilian component plays an important role on evaristos instagram working as a connector between him and his followers a supposed distant tv journalist shares ordinary jokes online an element of proximity and relatability these elements could characterize evaristo costa as a digital influencer since authenticity is a crucial element to their practice content strategies professional life and public interest lastly guga chacras instagram profile tends to a more impersonal perspective differently from astrid and evaristo a significant part of gugas publications is not personal pictures of himself guga is a frequent publisher there are new posts every other day and sometimes twice a day although his instagram does not have a daily periodicity his content strategy is possible to be grouped into four clusters 1 landscapes 2 professional posts 3 personal and family posts 4 facts and public interest posts landscape posts are frequent on guga chacras instagram feed as a brazilian living in new york he is constantly photographing the city these posts do not even have a caption the whole attention is on the view guga chacra is not known for his photography so this practice could be considered a type of amateurism and an entrance into participatory culture at the same time it works as another possibility of selfpresentation that is not restricted to an instagram bio the international lifestyle can be recognized also as a professional identity negotiation among guga and his followers professional posts replicate a unidirectional distribution flow because of the brevity of their captions that are not always stimulating conversations with followers like astrid fontenelles or causing laughs like evaristo costas in this category instagram posts are used as transmedia strategy the propagation of tv moments online and the presentation of articles or interviews published in print media9 it would be possible to characterize instagram as a repository of guga chacras achievements at work and his institutional authority even when using instagram for some behindthescenes moments among professional posts there are screenshots of his own tweets guga chacra has 11 million followers on twitter a telling number that is higher than the number of followers on instagram the chosen tweets addressed the covid19 situation and brazilian political issues emphasizing his role as a commentator where he is able and free to make more opinionated expressions the use of social media assumes some type of disclosure content and intimate relations this is not exclusive to digital influencers and it would not be different on guga chacras profile however his personal posts seem to have a double intention proximity with followers and legitimacy of his trajectory disclosive posts like the ones of his parents grants not only relatability but credit and authority as the posts are also linked to some of guga chacras professional abilities or skills from his youth his career is often intertwined with his personal life when he publishes a picture from 1997 of a road trip in lebanon and other countries from the middle east with his family or when he posts a throwback of him in jordan in 2004 10 but simultaneously there is a reinforcement of his work as a commentator specialized in the middle east or his role as an international correspondent who is expected to have visited the world 12 posts published on 09302020 09052020 06032020 respectively issn 27638677 transmedia expertise the last important issue about the journalists use of social media and appropriation of digital influencer practices is related to some specific tools the first one is instagram stories this tool is known for its ephemerality a post on stories remains there only for 24 hours so contrary to the feed it is not an archive but a space for conversation it recalls an oral paradigm of communication where the visual is now a disappearing utterance from the trio astrid fontenelle is the only one who uses stories as a consistent content strategy though astrid publishes every day on her feed sometimes even twice a day on stories she posts up to 70 posts daily consisting of selfvideos or photos benefiting from the ephemeral nature of stories astrid begins her day reading the newspaper with her followers the nature of these publications is sharing the news but she also stands out as a type of media critic questioning the headlines and approaches to some topics this group of stories postulates astrids commitment to accuracy information and impartiality journalistic expertise and ethics at the same time astrids use of stories reveals a grasp of instagram tools putting her in a category of users who can vary content and formats online this also brings her closer to digital influencer cultures where being a heavy user of social media and an expert in new tools is a prerogative of the job issn 27638677 stories are also a place for authenticity allowed by the disappearance of content in 24 hours so it is not uncommon to see astrid sharing her meals of the day home issues tv shows that she is watching a new filter being used 13 evaristo costa and guga chacra post more infrequently on instagram stories evaristo uses the tool for shooting landscapes from london using once again humor the third image of figure 6 is a story where the journalist chooses the song arcoíris by xuxa a former singer and tv host known as queen of the little ones because of her career on tv shows for kids the song gives a funny contrast as it has childish lyrics and musical arrangements conversely guga chacra uses stories mainly for reposts related to his participation in globonews the second tool is instagram reels a feature launched in august 2020 that allows users to post short and funny videos very similar to tiktok only astrid fontenelle and evaristo costa have experimented with reels but neither has used it for a long time however appropriation of tools is not just using what the platform offers but also recognizing some digital conventions evaristo costa does that when he posts a variety of formats on his feed there are tiktok videos where he dubs himself presenting his former tv show jornal hoje and funny voiceover audio clips about relationships from tiktok 14 evaristo costa also publishes memes photos edited by himself with a comic vein like with a picture of him beside kim kardashian when he was nominated the most influential personality in brazil or a photo with the british royal family at the time prince harry announced leaving his royal duties 15 13 stories published on 10282020 07092020 03022020 respectively 14 posts published on 04292020 05192020 respectively 15 posts published on 02172020 01082020 respectively lastly with digital influencers there is a business model that assumes partnering with brands an attachment to brands is not allowed for journalists that work at some specific media outlets in brazil guga chacra is likely under these contractual rules because he has no commercial publications on instagram nor any association with brands or sponsored posts astrid and evaristo seem to be in more flexible contracts evaristo costa is an ambassador for an investment agency and the brand appears on his feed alongside other brands astrid fontenelle occasionally shows brands mainly on instagram stories and some partnerships on her feed16 journalists or digital influencers as individuals who have made a career out of social media digital influencers can be considered experts in the uses of social networks like instagram youtube and twitter based on that it is natural to predict that anyone using social media according to some standards of success is a digital influencer or is trying to become one but considering that these individuals are a specific type of media actors professionals or celebrities good use of social media is not confined to them that is why it is important to assume that journalists can be influential as part of their work but they are not necessarily digital influencers as a career issn 27638677 but when the journalist becomes a digital influencer another part of their practice is in the game like the possibility of being a columnist or even a commentator journalists who keep a distance from controversies and opinions can enunciate them outside the institutional space on their social and personal profiles astrid fontenelle and guga chacra are good examples of that both of them gain visibility and strength in a space dominated by the dynamics of digital influencers because of differentiated knowledge an academic degree the mastery of several discursive types experience with travel and global cultures and other deontological assumptions of the profession in consonance with vasconcellos it would be possible to affirm that more than digital influencers journalists are information professionals and that commitment is irrefutable on the other hand social media can also work as a leisure moment disassociated from institutional codes or ethical duty evaristo costa uses instagram as a possibility to create new bonds with the public and disclose a more intimate personality that has nothing to do with his professional one as a result he tends to also be considered for brands and other types of partnerships since he uses more personal and detached strategies online the authority granted to journalists partly relies on the public perception of ethical conduct and a posture of a representative of citizens in other words ethical social and moral principles have a huge impact on journalists process of legitimation because of that proximity to social media is an important source of credibility among the audiences as the impacts of relatability can change perceptions of professional value conversely the legitimation process for digital influencers varies according to the influencer niche but it has little impact on how ethical the digital influencer is this is a crucial difference between the two professions besides that based on the theoretical framework proposed and the empirical analysis it is possible to derive a practical tool a scale of how close a journalist is to digital influencer practices or vice versa the scale is one possibility for quantifying which elements move a journalist closer to and which move them away from digital influencer practices it makes it possible to identify if a journalists behavior is nearer the behavior of digital influencers if it mainly follows journalistic practices or if it is still in the balance of both issn 27638677 the 13 elements serve for both professional categories with their own specifications astrid scored 8 points in the journalist degree and 5 points in the midpoint balanced degree this illustrates the qualitative findings astrid fontenelle is constantly employing her ethical values as well as her textual and transmedia expertise to create new forms of sociability online and even expand her work astrid is a watchdog of citizens issues a close friend and a proud mom for her audience evaristo costa in turn scored 5 points in the digital influencer degree 4 points in the journalist degree and 4 points in the midpoint balanced degree the metric reveals a more balanced score and also a behavior that is closer to digital influencers perhaps it is not a coincidence then that he is the journalist with the largest number of followers but the score also confirms the qualitative analysis evaristo is the only one who uses instagram as a tool for entertainment and a possibility to define a new performance of himself online a more generic discourse and less attachment to social issues seem to guarantee another possibility of bonding with his followers and a different locus of work guga chacra scored 11 points in the journalist degree and 2 points in the midpoint balanced degree again it corroborates the finding guga does not use instagram at its full potential and does not exploit features or even captions social media is a space to extend his institutional credibility and academic 17 a highquality image is available at viewuspsharing issn 27638677 specialized authority with equal portions of proximity and intimacy more related to social media in general than the practice of a digital influencer conclusions this paper had two guide questions 1 what are the similarities and differences between journalists online practices and that of digital influencers 2 how have social media and the intimate perspective shortened the distances between journalists and their audience the first question has already been answered but an extra observation is required everyone is confined to a visibility society we are all on different levels part of this culture and so are journalists the appropriation of some practices of digital influencers is natural for journalists doctors teachers and different liberal arts professionals since digital influencers seem to master social media rules and possibilities they can all be influential people in their own professional or social field influence is an attribute not restricted to social media but being a digital influencer as a career is different and demands specific abilities and competencies considering the other questions it is be possible to define a thesis 1 journalists are recognized from broadcast and not native to social media like digital influencers are as a consequence some social credit needs to be redefined and even granted again on social media and sharing intimacy is a way to do that 2 journalists use instagram because traditional media is facing a loss of prestige and a need to be more convergent so journalists themselves use their profiles on social media to promote their own tv shows a strategy to move audiences from digital to television 3 on different levels journalists recognize the importance of digital influencers and take some advantage of their narratives and content formats to try to seek the same kind of visibility and success fame online inspired by digital influencers performance journalists guarantee their own authority on social media it is not enough for journalists to control knowledge through the news it is also necessary to establish communication networks with the public online this reconfigures the professional prestige that was intertwined with the types of authority historically held by journalists but now lies within social media the impacts of that on institutional media and its credibility could be investigated in future works but what astrid evaristo and guga highlight is a reconfiguration of journalism and its prestige their examples map out how to enter fields where journalists have not yet occupied but are as usual extremely necessary

this article answers two main questions what are the similarities and differences between journalists online practices and that of digital influencers how have social media and the intimate perspective shortened the distances between journalists and their audience to understand this scenario a trio of brazilian television journalists was investigated to comprehend their digital presence the authors elaborated an exploratory methodology for qualitative analysis of instagram publications based on elements that characterize the digital influencers and journalistic practices a score was also created to understand the potentials of their discourse performances and content strategies online

background depressive symptoms are a wellrecognized public health problem throughout the globe and older adults are more likely to suffer from depressive symptoms 1 the data from world health organization have recognized ds as the most common mental disorder affecting approximately 7 of the population worldwide 2 however mental health among older adults has not been a priority area in many lowincome countries 3 epidemiological studies from south asian countries reported a high prevalence of depression among older people ranging from 344 in india 4 406 in pakistan 5 and 442 in bangladesh 6 a recent study from nepal showed 606 of older adults had ds 7 despite its higher prevalence there is poor access to early diagnosis and treatment of depression is generally held back because of social stigma with mental health issues and insufficient screening and treatment services in primary health care 89 symptoms of depression are not usually recognized by families caregivers or by older adults themselves because of a lack of understanding of the condition shame or denial that these conditions need medical care and a perception that ds are incurable in nepal various short and longterm factors across the life cycle influence the development of ds the presence of chronic disease and sociodemographic factors such as age gender illiteracy income level marital status mistreatment and lifestyle behaviors play a role in the development of ds 5 10 11 12 early screening and management of depression can improve the quality of life of older adults 1 however healthcare systems in low income countries like nepal are not able to deal with mental health problems including ds among this target population nepal is a signatory to the comprehensive mental health action plan and to the sustainable development goals which aim to reduce mental health problems through implementing strategies for promotion and prevention and providing comprehensive and social care in communitybased settings 1314 however performance falls well short of these objectives to date there have been no systematically conducted studies in rural parts of southeastern nepal where most of the marginalised communities resides in this line this study could provide evidence to guide policies and programs to tackle this overwhelming problem hence the present study aimed to address a critical knowledge gap by assessing the level of ds and its relationship with sociodemographic characteristics lifestyle factors and multimorbid conditions among community dwelling older adults of morang and sunsari district nepal methods study design and participants a communitybased crosssectional study among older adults aged 60 or above was conducted between january and april 2018 a multistage cluster sampling approach was adopted to select study subjects in the rural setting of the morang and sunsari districts primary data was collected from 794 older nepalese people adults aged ≥60 years in the first stage eight rural municipalities were randomly selected from the list of rms within each of the morang and sunsari districts second five wards in each of the selected rms were randomly selected finally samples were selected randomly from the list of eligible subjects and were interviewed by the trained interviewers the detailed methodology of this study has been published previously 15 measures sociodemographics and lifestyle factors a semistructured questionnaire was used to collect information on sociodemographic profiles and behavior and lifestyle characteristics from the study participants sociodemographic and lifestyle variables are described in our previous work that is published by yadav etal 16 chronic disease history data was collected on the presence of diabetes cardiovascular disease arthritis and chronic obstructive pulmonary disease from respondents information on selfreported chronic disease was then verified either from medical records or by asking to see any prescribed medicines which patient was taking for the relevant condition depressive symptoms the 15item geriatric depression scale was used to assess depression symptoms among our study population 17 this instrument has previously been validated and used in nepalese older population 18 scores range from 0 to 15 a test score from 0 to 5 is considered normal and patients with test scores greater than 5 were assessed as having depressive symptoms factor analysis was performed and the cronbachs alpha for gds was found to be 081 indicating high consistency data collection the study used both selfconstructed semistructured questionnaire and a structured validated short form of the geriatric depression scale to collect the information the semistructured tool was constructed through a rigorous literature review and with input from an expert already working in the field of geriatric health the english version of the questionnaire was first translated into nepali and back translated into english to check the consistency pretesting of the questionnaire was carried on a similar group of participants to assess its acceptability and validity before the study began the data was collected by four trained enumerators via face to face interviews with the subjects in the community setting the study received ethics approval from nepal health research council nepal a written informed consent form was obtained from each study participants prior to interview statistical analysis descriptive analysis was performed to assess the distribution of the variables the χ2 test was employed to compare the prevalence of ds within different categories of a variable with 5 level of significance since the survey data were nested in nature with variations among clusters we used a mixedeffect logistic regression model to determine the true association between ds and associated factors we considered sociodemographic lifestyle and chronic disease variables as fixed effects and cluster variation as random effects the parameters of the model were estimated through the generalized estimating equation approach by considering exchangeable correlation structure among clusters 19 the full model was run with those variables showing p 025 in the unadjusted analysis we used 2 models for multivariable modeling in model 1 we analyzed the association between ds and socioeconomic as well as lifestyle variables whereas in model 2 we analyzed the association between ds and chronic diseases adjusted for both sociodemographic and lifestyle factors both unadjusted and adjusted odds ratios were reported with 95 confidence intervals all analyses were performed using the statistical software stata results background characteristics a total of 794 people aged 60 years or above participated in the study with a mean age of 699 years where 554 of the participants were aged between 60 and 69 years and 15 aged 80 years or above as summarized in table 1 the malefemale ratio was similar among the study population a majority of the participants were hindu and illiterate nearly 38 of the participants were of indigenous origin and nearly 20 were dalit only around half of the older adults reported being married at the time of the survey in terms of occupational status 542 of the people reported not being involved in any type of income generating activities as such around half of the participants had a family income of 5000 nrs or less of the participants 622 reported smoking history and 482 used to consume smokeless tobacco in addition 365 of the participants reported alcohol consumption and 771 did not take part in any physical exercise moreover the prevalence of osteoarthritis cvd diabetes and copd was 417 239 53 146 respectively and 146 of the participants were suffering from at least two of these comorbidities prevalence of depressive symptoms overall 558 of the participants were suffering from ds univariate analysis revealed that ds were significantly higher among female participants from sunsari district buddhist dalit madhesi ethnicity illiterate unemployed and participants with low family income prevalence was also higher among those who smoke do not exercise and suffer from osteoarthritis cvd copd multiple morbidities association of risk factors with depressive symptoms in the unadjusted analyses age gender religion ethnicity marital status literacy occupation family income smoking history physical exercise and having multiple morbidities were shown as moderately to highly significant in association with ds however after adjusting all the potential covariates in the multiple logistic regression model only gender religion ethnicity occupation family income smoking history and having multiple morbidities remained as significant risk factors for ds at 5 level of significance it was found that female participants had 61 higher odds of suffering from ds compared to their male counterparts an individual of the buddhist community had around 19 times higher odds of suffering from ds compared to a hindu person and compared to people of brahminchettrithakur origin an individual from dalit community had 26 times higher odds of suffering from ds notably an unemployed person had nearly two times higher odds of suffering from ds compared to a person engaged with any income generating activities participants with a smoking history had around 50 higher odds of suffering from ds than those who never consumed tobacco economic status was also identified as a prime risk factor as the participants with a family income of 500010000 nrs had 77 higher odds of suffering from ds than those with a family income of 10000 nrs or high also a person suffering from multiple morbidities had 67 higher odds of suffering from ds than those with no multiple morbidities discussion this study was an investigation that demonstrates an association between sociodemographic variables lifestyle characteristics and chronic conditions with ds among the older adults in rural setting of nepal our results showed that being female buddhist dalits and madhesi ethnicity unemployed low family income the presence of multiple morbidity and smoking are significant risk factors for ds among older adults in nepal nearly 558 of the older adults were found to be suffering from depressive symptoms this is lower than reported from other studies in nepal 718 a possible explanation for the heterogeneity of prevalence in nepal could be that different study settings were used or samples were drawn from diverse ethnicities and castes from the southern plain region were included the prevalence was also higher than that of a communitybased study conducted in rural setting of india and bangladesh 420 in support of our findings research from low and middle income countries noted a higher proportion of depression among the older population than that of high income countries such as usa canada and australia 21 22 23 24 our study found that social determinants were associated with ds and females were more likely to have ds this is consistent with findings reported by chalise and rai from nepal where authors reported females were more depressed than their male counterparts 25 this is also supported by the findings from a cohort study that showed a clear link between depressive mood and female gender 26 a possible explanation for this could be that females in a patriarchal society in nepal may have low selfesteem low social status and empowerment feeling helplessness low health literacy a longer life expectancy and limited access to health services compared to the males this is supported by the low position of nepal in the gender inequality index 0476 115th position in the world which depicts the disparity of health across genders 27 in the present study the subjects who ascribed to buddhism religion was also found to be more depressed which could be because of the poor socioeconomic status of this minority group in the study setting however we are cautious in interpreting this result because of the small number of participants in this group moreover we could not find any other studies confirming this association in contrast to another study from nepal 7 we found smoking was associated with ds in our study population our finding is in line with the findings to that from china and japan 1028 the underlying mechanism linking smoking and ds are complex nicotine has antidepressant properties that release dopamine in the mesolimbic reward pathway which in turn elevate the mood and alleviate stress 29 however evidence suggests that smoking plays an important role in changing neurophysiology that increases a smokers risk of ds 30 it is also evidenced that smoking is the vascular risk factor for vascular depression 31 additionally one author mentioned that association between smoking and mental disorders are a result of shared environmental and genetic factors 30 literacy an important socioeconomic factor was not found to be significant with the occurrence of ds in contrast the studies from various settings showed illiteracy as a strong predictor of ds 5732 the underlying reason for this discrepancy is not clearly understood unemployment and insufficient family income were both associated with ds the possible explanation could be that older adults engaged in low income occupation might have led to financial constraints in their life eventually leading to depression adding to this 2019 human development index has revealed that 34 of the nepalese population is multidimensionally poor and 23 is vulnerable to multidimensional poverty which shows that the country has a deep chasm to fill when it comes to addressing health equity 27 meanwhile in the nepalese context most of the older adults depends on family memberscaregivers for their daily needs where families tend to provide better care if the older adults have some economic resources this situation may turn to increased conflict at the family level which in turn puts older populations at risk of mistreatment which may increase the risk of depression 1633 however in this current study we havent accessed the association between elder mistreatment and depression and we suggest the need of future studies to check this hypothesis in the nepalese context casteethnicity has been a central feature to describe the level of poverty poor health literacy and health status in this light our study demonstrated that the risk of ds was two times higher in dalits compared to those of higher caste emerging evidence shows that dalits experience a wide range of social and economic discrimination at various levels and this results in a severe form of health inequalities 153334 stigmatization is pervasive and worsens psychological stress for those in the dalit communities 35 the prevalence of depression among the older population suffering from chronic multimorbidities was significantly higher than those with one or fewer conditions this is consistent with findings from other studies 3637 this is the first study from nepal to report an association between multimorbidity and ds among nepalese older adults this finding is consistent with a metaanalysis that showed chronic illness to be a major risk for depression among older adults 38 evidence has shown that people among whom depression coexisted with multimorbidity may have more functional impairment poorer quality of life and increased mortality 39 depression impairs independence in the older population and over time worsens functional outcomes among the multimorbid group the decline in functional status may make them more dependent and vulnerable to mistreatment our findings underscore the need for programs to detect prevent and manage ds in these groups more specifically programs need to adopt a populationbased approach that includes screening and diagnosis of ds among older adults mental health literacy of patients and use of evidencebased practices to manage the ds in the community setting particularly focusing on women and marginalized ethnic minorities in addition the government of nepal is in the process of scaling up the package of essential noncommunicable disease throughout nepal this is a great opportunity to consider the establishment of health and wellness centers under this program to encourage participation of older adults in yoga relaxation techniques and meditation which may be useful for good psychological health furthermore peripheral health care professionals community health workers psychologists and psychiatrists need to work together to reach and treat older adults with depression in rural nepal strengths of our study include its large sample size and high response rate another strength of this study includes the strong methodology and use of locally trained enumerators for data collection however our study is subjected to certain limitations too all the associations in this study were cross sectional and cannot evaluate causality there is a need for longitudinal studies to establish this casual pathway and evaluation of interventions that could address the impact multimorbidity as this study only involves the participants from two districts of nepal findings cannot be generalized to other setting of nepal another limitation was the use of selfreported data where socialdesirability bias may have occurred conclusions a large proportion of the nepalese older populations were found to have ds and these were associated with sociodemographic characteristics lifestyle factors and the presence of multimorbid conditions our findings emphasize the need for programs to detect prevent and manage depression among the older adults in the community setting we also suggest the need of targeted screening for ds in the clinical setting focusing on high risks groups such as older adults with multiple morbidities or any chronic conditions stressful environments or social isolation this may help health professionals to intervene early in order to avert worsening of the condition competing interests the authors declare that they have no competing interests

background depressive symptoms ds are a wellrecognized public health problem across the world there is limited evidence with regard to ds and its associates such as sociodemographic characteristics lifestyle factors and chronic conditions in lowincome countries like nepal in this study we aimed to assess the level of ds and its relationship with sociodemographic characteristics lifestyle factors and chronic disease conditions among community dwelling older people in nepal methods we conducted a crosssectional study of 794 older adults aged 60 or above residing in the rural setting of the sunsari and morang districts of eastern nepal between january and april 2018 multistage cluster sampling was adopted to select the study participants data included sociodemographics lifestyle factors selfreported chronic disease conditions and the geriatric depression scale on geriatric depression scale an older adult with a test score greater than five were defined as having depressive symptoms determinants of ds were estimated through the generalized estimating equation gee approach by considering exchangeable correlation structure among clusters results in our study samples nearly 558 of the older adults were found to be suffering from ds we found a significant association between ds and being female aor 125 95 ci 089209 buddhism aor 195 95 ci 158242 dalits aor 260 95 ci 119565 unemployed low family income aor 177 95 ci 107292 smokers aor 149 95 ci 101220 and having chronic multimorbid conditions aor 167 95 ci 109255 conclusions the prevalence of ds was high among communitydwelling older adults in eastern nepal our findings suggest the need for mental health prevention and management programs targeting the older population in rural nepal

the different groups belong given that biology and genes clearly play important roles in peoples mental and physical health there is certainly some merit to this explanation the second explanation is that the differences reflect a social problem health disparities health disparities refer to systematic variations in the mental or physical wellbeing of members of different social groups that specifically result from inequitable economic political social and psychological processes this article only considers health disparities however these two kinds of explanations are not mutually exclusive indeed recent research strongly suggests that genetic and social factors have a reciprocal relationship as they affect health and a host of other outcomes one influential contributor to health status disparities is healthcare disparities which are inequalities in access to andor the quality of medical care among different social groups in other words it is posited that members of socially disadvantaged groups experience poorer health than their counterparts from socially advantaged groups because they receive poorer healthcare in this article to limit the scope of this review we primarily focus on how social psychological processes specifically those related to intergroup relations and intergroup bias can produce healthcare disparities however we note that there are other literatures on how some of the same kinds of social psychological variables may more directly affect peoples health for example there is a large body of research on how perceived and actual discrimination directly affect the physical and mental health of members of target groups until relatively recently healthcare disparities have been primarily studied by social epidemiologists public health researchers health economists and political scientists these scholars have mainly focused primarily on societal and structural causes of this social problem such as differences in health insurance coverage and access to comparable medical facilities these remain important and useful approaches to understanding healthcare disparities nevertheless in the last decade or so reports in the united states and europe on the role of bias and discrimination in healthcare disparities have brought increased attention to the relevance of social psychology and related disciplines to the study of healthcare disparities this review presents an overview of our own and other researchers social psychological analyses of healthcare disparities in the review we focus on healthcare disparities among members of racialethnic minorities because this is the focus of the clear majority of research on healthcare disparities however raceethnicity is not the only group characteristic that has been linked to healthcare disparities for example patients who have lower socioeconomic status have developmental mental or physical disabilities are elderly are members of certain religions andor are gay lesbian bisexual or transgendered all experience healthcare disparities because we base our analysis on generalizable psychological processes and intergroup dynamics we believe that most of the models and theories we present can be readily applied to these other forms of bias and healthcare disparities beyond those involving raceethnicity our review also primarily presents research conducted in the us this is because in the us substantial differences in the health status of whites and of racialethnic minorities especially those who selfidentify as black andor africanafrocaribbean american have been very well documented racial healthcare disparities have received relatively more attention in both the medical and psychological literatures than in other countries and there has been a longstanding interest in racial bias in social psychological research the attention given to healthcare disparities in the us has led some health researchers to suggest that serious healthcare disparities are largely confined to countries in which healthcare systems are primarily privately financed such as the us there is indeed ample evidence that structural differences in the healthcare systems and how they are financed affect patients access to healthcare and the quality of care provided however research clearly shows that throughout the world racialethnic minorities typically receive poorer healthcare than members of racialethnic majority groups for example racialethnic healthcare disparities are found in countries with government supported healthcare systems such as canada israel new zealand sweden the united kingdom serbia and in many latin american countries in summary healthcare disparities among racialethnic minorities and majorities represent a ubiquitous multinational problem in our review of healthcare disparities we begin by considering some factors other than racial bias and discrimination that might covary with membership in a racial minority and affect the quality of healthcare people receive we readily acknowledge the importance of these other factors but a core argument of this article is that even when these factors are controlled racialminority patients and nonminority physicians racerelated thoughts feelings and behaviors can each influence the quality of the healthcare members of racial minorities receive and thus produce disparities in health status this argument is presented in a threelevel model of the causes of healthcare disparities that can lead to health status disparities the levels of analysis societal intrapersonal and interpersonal are clearly interrelated and overlap with one another but for the purpose of organizational clarity we consider them separately after presenting the model we suggest interventions at each of these levels for addressing racial disparities in healthcare causes of racial healthcare disparities as bhopal rightly pointed out in his discussion of racial health and healthcare disparities in the uk and europe t he causes of the inequalities in health status and quality of healthcare that are so easily demonstrable by ethnicity and race are complex and difficult to disentangle however several factors have been identified as major contributors to healthcare disparities socioeconomic status one major potential source of racial 1 healthcare disparities is socioeconomic status in many countries ses strongly covaries with race such that racial minorities on average have lower ses than racial majorities low ses is an environmental stressor and has direct deleterious affects on peoples health but here we are concerned with ses and healthcare disparities research has shown that healthcare providers often provide poorer care to low ses individuals perhaps in part because relative to high ses patients low ses patients may be seen as having poorer selfcontrol and less likely to adhere to treatment recommendations other potential causes of poorer healthcare for low ses individuals may be that many people with low ses are not able to take time off work to seek medical help or afford health insurance andor copays however racial healthcare disparities exist across all levels of ses and are evident even among the most affluent groups statistically controlling for differences in ses reduces but does not eliminate healthcare disparities between racial groups thus ses is an important cause of healthcare disparities but by itself is not a sufficient explanation of the racial healthcare disparities reported throughout the world language proficiency research in several different countries has shown that language barriers faced by immigrants often play a role in healthcare disparities among racial minorities for instance in the us limited english language proficiency is associated with decreased utilization of preventive healthcare services longer hospital stays poorer health control and increased medical errors however the fact remains that in many countries healthcare disparities commonly occur among members of racial minorities comprised almost exclusively of native language speakers suggesting that language barriers only explain a portion of healthcare disparities health literacy health literacy is the degree to which individuals have the capacity to obtain process and understand basic health information and services they need to make appropriate health decisions health information provided to the lay public may include complex and unfamiliar terms individuals with limited health literacy may experience difficulty processing such information and become so discouraged or intimidated that they may become reluctant to seek healthcare in the us there is a strong association 1 because so much of the research to be reviewed focuses on healthcare disparities among black patients we will primarily use the term racial minority for the remainder of this paper racial minority as it is used here describes a social construction of race as a meaningful category rather than a description of a groups genetic characteristics between level of health literacy and race thus some health researchers argue that health literacy rather than social variables is a major cause of racial healthcare disparities indeed studies in the us sometimes find that when differences in health literacy are controlled the size of healthcare disparities between racial minorities and whites in the us is reduced however evidence of healthcare disparities tyoically remains even after controlling for health literacy although health literacy may be a unique cause of healthcare disparities in practice it may be hard to disentangle the role of health literacy in racial healthcare disparities from the effects of racial attitudes and beliefs for example physicians may be less accurate in judging the health literacy of black than white patients suggesting that health literacys impact on medical interactions may in part be moderated by physicians racial attitudes or cultural competence also health literacy levels among blacks may be influenced by the fact that they have a much higher level of distrust of physicians and the medical system than whites which in turn may cause them to seek medical information less often than whites and to be less accepting of the information they obtain such reactions would serve to reduce a persons health literacy taken together there is substantial evidence that ses language proficiency and health literacy contribute to inequalities in the relative quality of healthcare different racial groups receive however these explanations which primarily focus just on the attributes of racial minoritygroup members do not provide a sufficient explanation of racial healthcare disparities social psychological processes also play an important role an increasing number of public health researchers and government officials have begun to focus on how racerelated thoughts feelings and actions may relate to racial healthcare disparities for example in their article in the european journal of public health agyemang seeleman suurmond and stronks argued that the time is right to take discrimination in health and welfare services more seriously in europe research reports in the uk new zealand the us and sweden have made similar arguments in the next section we provide explanations of how and why racialrelated phenomena contribute to healthcare disparities and then some possible solutions to the problem multilevel processes of healthcare disparities the model presented in figure 1 presents causes of healthcare disparities the model considers three separate but clearly interrelated processes that might be associated with healthcare disparities societal intrapersonal and interpersonal processes for purposes of clarity the three levels in the model are discussed separately but as the bidirectional arrows in figure 1 indicate there are interrelationships and complementary influences among the levels in this section we briefly describe each level of analysis then in the next section we more fully examine specific processes within the intrapersonal and interpersonal levels in the exposition of these parts of the model we use social psychological theory and research on explicit and implicit social cognitions social identity and categorization and related intergroup processes to help us better understand how racial bias and discrimination may produce healthcare disparities and thus disparities in the health of members of minority groups because our focus is on social psychological processes rather than societalstructural processes responsible for racial healthcare disparities we give much more emphasis to the latter two levels than to the societal structural one societallevel processes the first level of analysis the societal or structural level focuses on how racerelated social environments institutional practices and attitudes that characterize a particular society region or specific community affect healthcare disparities at this level of analysis the presumed causes of healthcare disparities are not primarily psychological processes occurring within and between individuals rather healthcare disparities are presumed to be manifestations of widespread racial bias andor discrimination more specifically they are racerelated historical societal economic and structural factors that result in certain racial minority groups experiencing persistent and widespread unfair treatment and institutional discrimination in a variety of realms one consequence of societallevel processes is that racial minorities may live in difficult social environments characterized by for example less mobility greater isolation from other segments of the population fewer treatment options available to them less exposure to treatment innovations and fewer high quality medical facilities within close proximity these challenging social environments may prevent racial minorities from receiving the same quality of healthcare as people living in betterresourced neighborhoods bias and discrimination at a societal or structural level may also be related to healthcare disparities in other less direct but important ways recent research by reid dovidio ballester and johnson illustrates this process reid et al examined how community level stigma may affect the efficacy of health interventions directed at minority group members the interventions conducted in various communities around the us were intended to increase condom usage among black americans in their metaanalysis of 70 separate studies reid et al found that interventions were most effective when whites in the community had positive attitudes toward blacks and residential segregation was low reid and colleagues posit that blacks living in communities with widespread negative attitudes toward blacks and high levels of residential segregation may feel they are the targets of discrimination and stigmatization and as a result trust members of outgroups less when outgroup members offer black community members healthrelated interventions they may be less likely to accept them finally as already noted feelings of being the target of discrimination may serve as a life stressor for racial minorities increasing the physiological load on their bodies and thus their susceptibility to various diseases for example sims et al found in large sample of black adults a significant association between exposure to discrimination and the prevalence of hypertension our model therefore posits that at the societal level racialethnic bias and discriminatory norms policies and practices can create social environments and conditions that can directly lead to healthcare disparities further it also appears that bias and discrimination at a societal level may create psychological environments that can also produce healthcare disparities among members of a stigmatized target group there is considerable overlap between the next two levels of the model intrapersonal and interpersonal processes however as noted we believe that to best understand the psychological processes that underlie healthcare disparities we need to consider them separately for the purposes of this article the intrapersonal level concerns what is within a person that is thoughts and feelings that operate at both explicit and implicit levels and affect peoples reactions to a socially defined group in the absence of direct contact with a member of that group andor in situations where they actually encounter a person perceived to be a member of that group specifically the intrapersonal level of the model concerns how the racerelated thoughts and feelings of minority patients and of nonminority physicians affect healthcare related thoughts feelings and actions for example black patients feelings about past racial discrimination may affect things such as the kind of medical care they seek what they think of the care they receive the health behaviors in which they engage and perhaps most importantly their reactions to interactions with healthcare providers in a similar fashion racial bias and stereotyping among physicians may affect diagnosis and treatment decisions and perhaps most importantly their reactions to racial minority patients the interpersonal level in the model focuses on medical interactions between patients from one ethnicracial group and physicians from another racial group at this level the analysis concerns what patients and physicians say and do during these interactions and how each reacts to the others words and actions this is an important aspect of racial healthcare disparities in the us because racial minority patients are much more likely than racial majority patients to engage in racially discordant medical interactions for example in the us approximately 75 of black patients see nonblack physicians when they seek medical help this statistic also reflects the dramatic under representation of racial minorities in medical school and medical practice for instance in the us where blacks are about 12 of the population only about 4 of all physicians selfidentify as black this percentage has been the same for about the last 30 years although we use the term interpersonal to describe this level of the model one might quite reasonably also use the term intergroup contact to describe racially discordant medical interactions in primary care interactions patients and physicians may often be at most only minimally acquainted with one another prior to their interaction thus while the physician and patient are in a facetoface interaction that involves considerable dialogue in a racially discordant medical interaction they may react to one another more as representatives of a group than as individuals from this perspective such interactions may represent one of the kinds of intergroup contact described by brown and hewstone specifically a racially discordant medical interaction may often be an instance of intergroup contact in which intergroup differences are salient and important but it is also interpersonal because the patient may provide sensitive personalized information to the physician as already noted the racerelated thoughts and feelings patients and physicians bring with them to racially discordant medical interactions have an extremely important influence on what transpires during the interaction specifically these intrapersonal processes influence what each party says and does during the interaction which in turn shapes what the other saysdoes during the interaction and thus the quality of communication in the medical interaction however as we discuss there are other interpersonal processes that can affect communication between the participants and we shall consider them as well whatever the cause the quality of communication can affect the quality of treatment decisions each party makes and in the case of the patients also influence how likely it is that they will adhere to these treatment decisions social psychological theory and racial healthcare disparities in this section we review social psychological research on how the ways people think about and respond emotionally to others and how people interact with each other can result in healthcare disparities intrapersonallevel processes a core assumption of our approach to health disparities is that as the iom report posited racerelated attitudes and beliefs play a critical role in healthcare disparities and thus are responsible for disparities in health status racerelated stereotyping and attitudes can be conscious or explicit that is people are aware of their thoughts and feelings and can manage them consciously however as the result of overlearned racial associations stereotypes and attitudes can also be automatic nonconscious or implicit that is people may not be aware of these feelings and thoughts the intrapersonal level of the model concerns processes through which an individuals own racerelated thoughts and feelings affect their healthcarerelated thoughts feelings and behaviors while these intrapersonal processes obviously have social origins and consequences in this section we consider instances where their impact on healthcare disparities is substantially independent of the thoughts feelings and actions of another person we consider these intrapersonal processes in patients and physicians separately racial minority patientsblack patients prefer to see black physicians and report higher quality care and greater satisfaction with their medical care when the physician is black than when the physician is white importantly racial minority individuals negative perceptions of physicians are directly linked to their healthcarerelated behaviors for example black patients are more likely to schedule and keep appointments with black than white physicians additionally racial minorities are more likely to delay or fail to seek mental healthcare and terminate treatment prematurely compared to racial majorities these racial minority patients negative perceptions of physicians may be at least partially due to lack of trust when compared to members of majority racial groups members of racial minority groups are more likely to experience mistrust of and dissatisfaction with their medical care and to believe they are mistreated by healthcare providers furthermore individuals who are less trusting of physicians are less likely to use preventive services and adhere to physicians recommendations this relationship is illustrated in data that we collected from a primary care clinic in a large us city this study is one of a series of studies conducted in this setting which is described in more detail in a later section immediately before black clinic patients had their appointment with a nonblack physician we measured how much they trusted physicians in general using two items taken from dugan trachtenberg and halls interpersonal trust in a physician short form i completely trust the doctors decisions about which medical treatments are best and all in all i trust doctors completely sixteen weeks after their appointment with the doctor in the clinic these patients received a mail survey about their adherence to their own physicians treatment recommendations figure 2 presents a scatter plot of the relationship between the black patients trust of physicians prior to racially discordant medical interactions and their adherence to their own physicians recommendations 16 weeks after the interactions there was a significant positive relationship 43 p003 between general trust and specific adherence although our emphasis is on social psychological explanations of these thoughts and feelings one cannot consider the attitudes and feelings of racial minority patients without first placing them in a social and historical context a substantial portion of racial minorities mistrust of medical care and preference for racially concordant physicians very likely has its origins in the general levels of racism and racial discrimination that are part of the past history of many western industrialized countries embedded in this history is the dismal legacy of racist beliefs and practices in the medical profession for example in the us and europe polygenismthe theory that human races were separate biological speciesdominated scientific theory from the early 17 th century until perhaps as recently as the early 20 th century blacks latinos and other socially disadvantaged racial minority groups were also frequently used as participants in dangerous medical experiments without their willing consent and with little regard for their welfare thus it cannot be overlooked that some of racial minorities mistrust of general medical care is rooted in harsh and potentially traumatic historical realities this mistrust may represent a rational response to a system that has illserved racial minority patients in the past however we believe there are other more basic social psychological processes at work as well social categorization and social identity also play important roles in what racial minority patients think and feel about their medical care and their healthcare related behavior because human beings are constantly required to process large amounts of complex information they develop strategies to reduce cognitive effort and preserve cognitive resources by using categorization and generalization of information categorization and application of social categories to evaluations perceptions and treatment of others clearly help people function more effectively in everyday life however the process of social categorization inevitably makes a persons social identity more salient and provides the basis for intergroup bias in addition according to social identity theory when peoples group membership is salient their feelings of esteem are closely tied to their groups status and they respond in ways that promote their groups distinctiveness and enhance its status people generally assume that ingroup members share their attitudes and beliefs and they expect outgroup members to have a contrasting perspective minoritygroup members are particularly vigilant to cues of bias from outgroup members these psychological processes systematically influence the perceptions and behavior of minority patients in this context their identity as a member of a racial minority group that has been the target of prejudice and discrimination is highly salient expectations of prejudicediscrimination among minority patients play an important role in intergroup encounters generally and in medical interactions specifically richeson and shelton demonstrated that when blacks interact with whites they often worry they will be the target of prejudice andor confirm negative stereotypes associated with their racial groups thus one source of racial minority patients possible negative reactions to the healthcare system may be expectations they will experience stereotyping prejudice or discrimination in their medical care related to this burgess warren phelan dovidio and van ryn argue that racial minority patients in racially discordant medical interactions may experience stereotype threat which involves the activation of cultural stereotypes about ones group and triggers stereotypeconfirming behavior this may have particularly detrimental effects on the responses of racial minorities to healthcare interventions that might reinforce these stereotypes for example some black patients could be reluctant to participate in classes that provide health information because they may fear this would reinforce stereotypes about their intellectual abilities and educational achievements however such feelings are probably not uniform across racial minority group members there are clearly individual differences in recognition and expectations of racial bias theories such as stigma consciousness or racebased rejection sensitivity concern the chronic affective and cognitive consequences of being the target of stereotyping prejudice and discrimination according to these theories individuals who score high on stigma consciousness or racebased rejection sensitivity often expect to be the target of prejudice research has shown that individuals who expect to be the target of prejudice evaluate intergroup interactions more negatively and make efforts to avoid them in addition it has been shown that when individuals expect to be a target of prejudice and discrimination they become vigilant for signs of prejudice and discrimination resulting in a confirmation of their negative expectations in the healthcare context heightened sensitivity to discrimination and prejudice due to past experiences may influence how racial minority patients perceive their physicians and thus healthcare related decisions for example greer found that black hypertension patients who perceived their physicians to be racially biased were less likely to make future appointments than patients who did not perceive their physicians in this way importantly general expectations of prejudice and discrimination that are not directly related to healthcare or specific healthcare facilitiespersonnel can also affect patients healthrelated attitudes and behaviors benkert peters clark and kevesfoster reported that the more racism blacks perceive in the world around them the less trust they have in the healthcare system perceptions of general discrimination including experiences of bias outside the medical encounter and in everyday life can also affect reactions to individual medical interactions we used a larger sample of black patients at the same innercity clinic employed in the hagiwara et al study to examine the impact of perceived discrimination immediately prior to the meeting with the doctor we assessed patients general experiences with discrimination to do this we used items from browns selfperceived racial and ethnic discrimination scale in which respondents were asked whether they had ever experienced unfair treatment in each of seven social domains jobs education medical treatments job applications police encounters housing and dealing with neighbors in our sample the majority of patients reported they had experienced discrimination in the past at least in one domain in mail surveys sent 4 and 16 weeks after their appointment with the doctor patients reported on their adherence to the doctors recommendations as well as their selfreported health using the 20item short form health survey which assesses physical functioning role functioning social functioning mental health pain and current general health status we found that when compared to black patients who reported experiencing relatively little past discrimination those who reported experiencing high levels of past discrimination expressed significantly less satisfaction with their medical interactions and closeness with the physician they had just seen black patients who experienced higher levels of discrimination were also less likely to adhere to their physicians recommendations four weeks after the visit and this lower adherence in turn was associated with poorer health status among these patients 16 weeks after the visit casagrande gary laveist gaskin and cooper also found that experiences with discrimination were associated with delays in seeking medical care and poor medical adherence even when controlling for medical mistrust racial minority patients negative healthrelated attitudes and behaviors may not always be the result of negative perceptions of physicians and medical care they may also sometimes be the result of strong identification with their own racial group and consequent identitybased motivations according to the identitybased motivation model in order to maintain their social identity people tend to engage in behaviors that are perceived to be what other ingroup members typically do regardless of whether the behaviors have objectively positive or negative consequences for them thus if individuals perceive that exercising and maintaining a healthy diet is the norm for their social group they are apt to engage in regular exercise and healthy eating habits in contrast if individuals believe that many fellow ingroup members smoke andor value smoking they are likely to smoke even if they recognize the negative consequences of smoking oyserman et al have shown that racial minorities viewed health promotion behaviors such as exercising getting enough sleep and eating fruits and vegetables as outgroupdefining behaviors and unhealthy behaviors as ingroupdefining behaviors oyserman et al also investigated the effects of increasing the salience of racial identity among racial minorities when the minority participants social identities were made salient they expressed more feelings of fatalism about improving their health and had more difficulty correctly identifying healthrelated knowledge nonminority physicians there is more than ample evidence that racial minorities receive less appropriate and aggressive healthcare than members of racial majorities disparities have been found in the general level of care black and white patients receive and in the treatment of specific diseases these disparities cut across specific mental and physical diseases and healthcare settings regarding mental health racial minorities are less likely to receive mental healthcare and receive poorer quality care when they are treated for example mallinger and lamberti studied black and white patients with schizophrenia who were receiving antipsychotic medications they found that black patients were less than likely than white patients to receive other medications to control the ancillary symptoms of schizophrenia mental healthcare disparities remain even when ses and relevant demographic factors are controlled turning to physical health racial disparities are also found in the treatment of cardiac disease and many different cancers including breast lung prostate colorectal and other gastrointestinal cancers one might expect that in situations in which swift and decisive action is required racial healthcare disparities might disappear but treatment disparities also exist in emergency room settings for example racial minorities with symptoms of a heart condition are less likely than white patients to receive analgesics and their myocardial infarctions are more likely to be missed these disparities exist even when one controls for levels of disease severity and factors such as ses demographic characteristics and insurance availability finally healthcare disparities can be found in pediatric practices as well in a study of over one million medical encounters gerber et al found that physicians were significantly less likely to give antibiotics to their black than their white patients and if antibiotics were given to black children they were less likely to be broad spectrum drugs it would be an oversimplification to attribute these and a host of other treatment disparities simply to physician racerelated thoughts and feelings treatment disparities are a complex social problem with multiple causes many of which are likely at the societal level of explanation and of course patient preferences and decisions play important roles in what treatments are provided in this section we only consider those treatment disparities that theory or empirical evidence suggest may be due to racerelated intrapersonal processes among physicians as was the case with patient effects we rely heavily on theories that have their origins in social categorization and social identity processes these include stereotype activation contemporary racial bias and cognitive load stereotype activation stemming from social categorization among physicians may at least partially explain the apparent contradiction between the widely expressed condemnation of bias in medical care by healthcare professionals and the welldocumented treatment disparities that continue to exist van ryn and her colleagues have proposed a socialcognitive model that uses social categorization processes to explain how patients race influences physicians diagnosis and treatment decisions according to this model physicians more or less automatically categorize their patients into social groups based on race which is often the most salient social group cue upon categorization stereotypes and prejudice associated with racial groups in which the patient is categorized are activated these activated stereotypes then influence physicians perceptions of patients and expectations about patient adherence which in turn affect physicians treatment decisions for instance it has been shown that physicians stereotype black patients as poorer less educated less intelligent less trustworthy more likely to engage in risky health behaviors and less likely to comply with medical recommendations than white patients these negative stereotypes and expectations about blacks may further influence physicians treatment decisions such that they may be less likely to recommend an appropriate treatment for black than white patients for example van ryn et al examined physicians decisions to recommend coronary bypass surgery for black and white patients with the same cardiac conditions they found that physicians were more likely to recommend this procedure to whites than blacks but this effect was fully mediated by the physicians perceptions that the black patients were less educated and had a less active lifestyle moskowitz et al have also shown that physicians trust nonwhite patients less than white patients when prescribing opioid analgesics this occurs despite the fact that rates of illicit use and opioid analgesic misuse between these two groups are similar stereotypes activated by social categorization also influence how people interpret others behaviors and intentions explicit and implicit stereotypes associated with social categories may therefore also influence physicians diagnostic assessments as an example hirsh jensen and robinson found that nurses evaluate pain expressed by patients differently based on their beliefs and expectations as to how individuals with certain social characteristics would react to pain more recently moskowitz stone and childs used a priming paradigm and found that white doctors were faster to recognize diseases and conditions such as hiv drug abuse obesity and stroke after being subliminally primed with a black face moskowitz et al thus concluded that physicians initial reactions to patients may be influenced by racialethnic stereotypes about the frequency of certain diseases among blacks relative to whites this stereotyping may lead to misdiagnoses and inappropriate treatments importantly in neither the hirsch et al or moskowitz et al study did the participants have any conscious awareness of their biases these findings suggest that healthcare professionals may be biased even in the absence of the practitioners intent or awareness no study to date has systematically examined how accurate physicians negative stereotypes about racial minority patients are however as noted above racial minorities are indeed less likely to adhere to physicians medical recommendations and keep appointments thus as with any other stereotypes there may be some basis to some of physicians expectations about racial minority patients nevertheless the major problem with stereotype activation is that negative expectations based on stereotypes are generalized to the entire social group regardless of whether particular individuals actually possess stereotypical characteristics furthermore when physicians act on their negative expectations about racial minority patients the patients may ultimately confirm the negative expectations by acting in accord with these negative stereotypes thus resulting in a vicious circle for example physicians who expect their minority patients to be less adherent to their medical recommendations may devote less time to discussing the condition and treatment with minority patients which then leads minority patients to understand the recommendation less well this lack of understanding the doctors recommendation in turn may produce less adherence creating the selffulfilling prophecy in the medical encounter within the medical profession explicit expressions of racial bias are especially rare and behavior that might represent such bias in medical care is widely and vigorously condemned despite this there is evidence of more subtle perhaps often unintentional contemporary racial bias the majority of physicians show a moderate to strong implicit preference for whites relative to blacks moreover such biases do affect treatment decisions for example in a vignette study green et al found that implicit racial bias affected physician recommendations for black patients with acute coronary syndromes as implicit racial bias increased so did the likelihood that physicians would treat a white patient more aggressively and appropriately than a black patient more recently sabin and greenwald used vignettes involving pediatric patients and found that as physicians prowhite bias increased their willingness to prescribe narcotics for black children with pain due to surgery decreased theories of contemporary racial bias such as aversive racism theory symbolic racism and the justificationsuppression model would lead us to expect that such discriminatory actions are most likely to occur when a situation allows people to rationalize that their actions toward racial minorities are not due to racism but due to something else in the health context one situation in which this may occur is when the guidelines or cues for appropriate medical decisions are somewhat ambiguous for instance few guidelines for treating pain exist because many patients reports of pain are diffuse nonspecific and difficult to empirically verify and quantify studies have shown that as predicted by these theories across a variety of different kinds of pain and medical settings racial minority patients are more likely to be undertreated for pain than whites burgess et al argued that implicit stereotypes about blacks may cause physicians to either underestimate the seriousness of the pain or overestimate the likelihood a patient might abuse pain medications however importantly in this situation physicians could also rationalize the undertreatment of blacks by using other factors that are much more justifiable and apparently nondiscriminatory than their bias against blacks trawalter hoffman and waytz found that people believe that blacks and individuals from lower ses feel less pain when injured than white upper ses individuals such biased perceptions may also be held by physicians finally we consider some circumstances in which physicians may be more likely to make less appropriate diagnosis and treatment decisions for racial minority patients than racial majority patients the cognitive load that physicians experience when making their decisions may be a significant factor in their responses to minority relative to majority patients a depletion of cognitive resources due to increased cognitive load is likely to increase the probability that people will engage in automatic rather than controlled cognitive processes because they need to prioritize multiple cognitive processes when one encounters a member of an outgroup the activation and application of social categories are rather automatic and require minimum cognitive efforts whereas individuation of that person requires conscious efforts therefore when people are under high cognitive load they are more likely to rely on social categories and stereotypes as opposed to individuating information as mentioned earlier richeson and trawalter showed that racially discordant interactions often activate whites need to selfregulate their behaviors in order to avoid appearing to be racist this engagement in selfregulation depletes their cognitive resources because contemporary physicians are encouraged to act and treat all patients in the same way they are likely to engage in selfregulation which in turn results in depletion of cognitive resources additionally among physicians such effects may be exacerbated by their workload in most industrialized countries caseloads and work demands on physicians have increased dramatically thus physicians may be more inclined to rely on stereotypes associated with their patients racial groups as they make diagnostic and treatment decisions in higherstress clinical situations in summary intrapersonal processes in the form of explicit and implicit racerelated thoughts and feelings affect what minority patients and their physicians think and do in regard to healthcare although some of the theories and models we have presented have not been directly tested in healthcare settings those that have provided substantial evidence for the utility of social psychological theory for an understanding of how intrapersonal processes can help us understand racial healthcare disparities interpersonallevel processes as already discussed there is a high probability that when a member of a racial minority group sees a physician the physician will not be a member of this group these racially discordant medical interactions are usually qualitatively different from racially concordant medical interactions it has been shown for example that relative to racially concordant medical interactions racially discordant interactions are shorter in length less patientcentered less positive and involve fewer attempts at relationship building furthermore white physicians spent significantly less time planning treatment providing health education engaging in informal conversation and answering questions with black than white patients we have explored interpersonallevel processes in medical interactions in cancer treatment settings we collected data over five years at two large comprehensive cancer centers in different regions of the us one in detroit michigan and the other in tampa florida at the center of this research are analyses of 235 video recordings of discussions between cancer patients eligible for clinical trials and their oncologists although one might think the video recording of these interactions would affect the behavior of patients and physicians in fact we have found that after the first minute or so of the discussions they pay almost no attention to the camera a portion of these discussions were racially discordant medical interactions between black patients and their nonblack physician our analyses of these interactions focus primarily on communication between the parties the studies we describe here do not contain data on either patient or physician racerelated thoughts or affect they do however speak to healthcare disparities for example we have conducted two separate kinds of analyses to compare how much information physicians provide to black and white patients when they discuss clinical trials in one study coders watched the video and used a checklist to record how many of a list of potential drug side effects were discussed with patients physicians were almost twice as likely to mention any side effects with white than black patients and if side effects were discussed whites had more of them described to them than did blacks eggly barton winckles penner and albrecht conducted a discourse analysis of discussions of clinical trials with two matched small samples of black and white patients in the discourse analysis transcripts were made of all the conversations topic areas were identified from the transcripts and then the words spoken by the physician about each of these topics were counted overall the physicians used more words in the discussions with whites than with blacks and said more words specifically about clinical trials 106 furthermore physicians spoke more about the study purpose and about risks to white than black patients we have also found that black cancer patients are less likely than white cancer patients to receive important general information in oncology settings eggly et al studied the frequency of direct questions and indirect questions eggly et al found that black cancer patients as compared to white cancer patients asked fewer questions and a smaller proportion of these were direct questions these findings point to the fundamentally different nature of the interpersonal exchange that occurs in racially discordant than racially concordant medical interactions we now consider some of the social psychological processes that may explain these effects because the behavior of patients and physicians is highly interdependent in medical interactions we discuss the influence of social psychological processes on the patientphysician interaction rather than on patients and physicians separately social identityas previously discussed the process of social categorization which conserves cognitive resources makes social identity more salient and provides the basis for intergroup bias according to social identity theory when group membership becomes salient as often occurs in racially discordant medical interactions people derive their selfimage from the social categories to which they perceive themselves as belonging thus they strive to achieve or maintain positive social group images group membership is very likely to be salient in racially discordant medical interactions as racial membership is one of the most frequently used features for categorizing people into different social groups consistent with this street omalley cooper and haidet reported that patients feel more personal and ethnic shared identity with their physician in racially concordant than racially discordant medical interactions several processes are associated with social identity and attempts to achieve or maintain positive social group images we posit that these processes may contribute to racial disparities in the quality of medical interactions communication across group lines is often less effective than within groups not only because people are generally less accurate at perceiving expressions of emotion displayed by outgroup than ingroup members but also because they are biased in their misperceptions for instance people are more likely to perceive a hostile face as belonging to an outgroup member and to misinterpret neutral facial expressions as conveying anger for outgroup than ingroup members one way to achieve or maintain positive images of ones own social group is to perceive evaluate and treat ingroup members more positively than outgroup members andor outgroup members more negatively than ingroup members at the same time ingroup members tend to see members of outgroups as homogeneous and are less trusting of them than members of their own group in addition they also expect that outgroup members will be biased against them as well these differential responses to ingroup versus outgroup members are likely to affect the quality of racially discordant medical interactions because both patients and physicians are likely to strive to achieve or maintain their positive racial group images they may engage in ingroup favoritism outgroup derogation or both as a consequence healthcare disparities based on ingroup favoritism would likely reflect particularly positive affect toward ingroup patientsphysicians whereas healthcare disparities based on outgroup derogation would reflect negative affect toward outgroup patientsphysicians divergent interaction goalsanother way to achieve or maintain positive social group images is to present oneself in a positive manner shelton richeson and their colleagues propose that in interracial interactions individuals salient social identities are each associated with different or even conflicting interaction motives or goals specifically in such interactions participants from racial majority groups may be concerned with not appearing to be prejudiced while racial minority participants may be equally concerned with not being the target of prejudice or discrimination andor not confirming racial stereotypes in support of this latter proposal bergsieker et al found that latinos and blacks but not whites were much more concerned with being respected and seen as competent when they were in racially discordant dyads than in racially concordant ones these divergent interaction goals of majority and of minority participants may undermine effective communication between them for example in a recent analysis of physicianpatient interdependence in racially discordant medical interactions hagiwara kashy and penner found that nonblack physicians perceptions of the extent which they and their black patients were working as a team during a medical interaction were essentially orthogonal to the patients perceptions of teamness this kind of lack of convergence in perceptions of the interaction is seen by many researchers as a major cause of disparities in minority use of healthcare services additionally when individuals are concerned with selfpresentation they often engage in selfregulation as described above selfregulation requires cognitive resources as individuals try to monitor for undesirable behaviors while executing more desirable behaviors during medical interactions because cognitive resources are limited individuals engaging in selfregulation often are unable to attend to other tasks this selffocus may result in individuals appearing to lack interest in their interaction partners for instance shelton et al found that when whites selfregulated their behaviors apparently to avoid appearing biased blacks interpreted this excessive selfregulation as a lack of interest in them these findings suggest that divergent interaction goals of minority patients and majority physicians and their attempts at selfregulation to attain these goals could result in ineffective communication during medical interactions poor communication during the medical interaction in turn could also result in more negative feelings after a medical interaction even if these feelings did not exist prior to the interaction some empirical support for this conjecture comes from gordon et al who studied trust among black and white lung cancer patients gordon and colleagues reported that while the two groups did not differ on trust of the oncologists prior to the interaction black patients had lower postvisit trust than white patients patient perceptions of how the physician communicated with them predicted postvisit trust intergroup anxiety and stressintergroup anxiety and stress is another process that may also shape racially discordant medical interactions the theory of intergroup anxiety proposed by stephan and stephan also provides a possible explanation for why the quality of racially discordant medical interactions is often poorer than that of racially concordant ones even when physicians and patients may not hold negative attitudes toward andor perceptions of one another according to the intergroup anxiety theory peoples expectations that their interactions with outgroup members can go wrong can often result in intergroup anxiety this general negative arousal in turn may result in a desire to minimize interactions with outgroup members or even in hostility toward outgroup members however as already noted physicians and patients often cannot avoid racially discordant medical interactions thus racially discordant interactions may often be awkward threatening and distressing indeed trawalter et al propose that peoples behavior in racially discordant interactions can be understood as initial stress reactions and subsequent coping responses under such circumstances the choice of how to cope with this stressor depends on whether the person sees the situation as a challenge or a threat if people feel they have enough resources to cope with the stressor they are likely to perceive the stressor as a challenge and respond in an effective productive manner by contrast if people believe they do not have enough resources to cope with the stressor they see it as a threat and their response is likely to lead to a negative and unproductive interaction threatened individuals may depending on perceived resources antagonize their partner psychologically withdraw from the interaction or as suggested above overcompensate all of these responses are consistent with the descriptions of racially discordant medical interactions provided earlier in this section explicit and implicit attitudesmuch of our own recent research has focused on the influence of physicians implicit attitudes both directly and in combination with their explicit attitudes on the interpersonallevel dynamics of medical encounters as we have already discussed racerelated thoughts and feelings can affect nonblack physician and black patient healthcarerelated thoughts feelings and actions independent of actual interactions between them in this section we consider how racerelated affect and cognitions can affect the quality of racially discordant medical interactions we illustrate several of these processes with our own research in this area which highlights the distinction between explicit and implicit racial bias as already noted although there is typically an association between explicit and implicit processes this association is often rather small furthermore explicit and implicit racial bias can influence behaviors in different ways more specifically explicit bias generally predicts deliberative controllable behaviors whereas implicit bias generally predicts spontaneous behaviors that are hard to monitor and control thus individuals may not be able to selfregulate undesirable behaviors stemming from implicit bias which would affect their interactions with people who are the object of this bias the impact of implicit physician bias on racially discordant medical interactions has been the focus of much of our research on health disparities earlier in the section on intrapersonallevel processes we briefly discussed two findings from our research at the primary care clinic showing that if black patients report experiencing more racial discrimination in their everyday life andor feeling less trust in physicians they are less likely to adhere to a nonblack doctors medical recommendations in this section we discuss a series of studies related directly to interpersonallevel processes that draw on various measures in the longitudinal database collected on this sample of black patients and their physicians at the clinic thus we offer more details of the social environment and research procedures to provide a context for the work the clinic is in the inner city of detroit michigan the great majority of detroit residents selfidentify as blackafrican american and detroit is one of the most racially segregated cities in the us over two years we recruited 156 black patients at the clinic the sample was predominantly female and all patients had health insurance participants were of quite low ses 45 had annual family incomes of less than 20000 usd which is below the official us government poverty level for a family of four another 30 had family incomes of less than 40000 and almost 30 had less than 12 years of formal education there were no systematic effects for patient ses across our studies perhaps in part due to the limited range of income in the patient sample the physicians were 19 medical residents most were east asian which is quite common in the us for primary care clinics in low ses minority communities ten of the physicians were women patients were approached by a black research coordinator when they arrived for a scheduled medical appointment 73 agreed to participate after being consented patients provided demographic information and completed the measures that have already been described before they saw their physician patients then interacted with the physician one hundred and thirtysix of these interactions were video recorded immediately following the interaction patients completed several measures including a 14 item measure of the extent to which they believed the physician was patientcentered and their perceptions of physician warmthcoldness and their satisfaction with the encounter the patients also answered items about trust in the physician they had just seen and two items that measured team perceptions as already noted four and sixteen weeks after the interaction we sent patients mail questionnaires asking them about their health and their adherence to their own physicians recommendations patients also received the measures of physicianspecific and general trust and controlling for attrition did not change any findings that we report when the physicians enrolled in the study they provided demographic information and 15 of them completed measures of explicit racial bias and a racebased implicit association test immediately after the interactions physicians completed two team items parallel to those completed by the patients to examine the dynamics of the interpersonallevel processes in these medical interactions we used the video recorded interactions to examine the amount of time physicians and patients each talked during the interactions then they computed ratios of physician to patient talk time relative talk time was chosen for several reasons first relative talk time is considered a valid measure of participants motivation to dominate an interaction second there is clinical significance to the relative amount of time patients and physicians talk during medical interactions because it is believed to be related to health care outcomes such as patient satisfaction and adherence for example according to the patientcentered communication model greater physician talk time is associated with less patient satisfaction and adherence while greater patient talk time is associated with more satisfaction adherence and third people are better at selfregulating how explicit racial bias is manifested in more planned behaviors than they are at regulating how implicit racial bias is manifested in more spontaneous behaviors thus how much time physicians talk may systematically reflect physicians implicit racial bias overall physicians talked more than patients in addition as expected we found that physicians implicit but not explicit levels of racial bias influenced the physicianpatient talk time ratio the higher the level of physicians implicit racial bias the more they talked relative to physicians with lower levels of implicit bias that is more implicitly prejudiced physicians dominated the medical interaction more verbally cooper et al reported convergent findings for a separate sample of medical interactions hagiwara et al speculated that physicians with higher levels of implicit bias harbor negative attitudes toward and stereotypes about black patients which might lead them to want to exert more control during interactions with them this is manifested in the association between their implicit bias and how much they talked relative to their patients in the same study we also examined the impact of patients reports of previous experiences of discrimination by whites on physicianpatient talk time ratio as seen in figure 3b the greater perceived past discrimination patients reported the smaller was the physicianpatient talk time ratio that is participants who reported experiencing high levels of previous discrimination talked more than those who reported experiencing low levels of discrimination the same pattern was observed for trustthe less the trust the more the patients talked at first glance these findings seem inconsistent with a patientcentered perspective on medical interactions in attempting to explain this inconsistency hagiwara et al argued that greater patient talk time may not always reflect positive patient reactions to medical interactions specifically we proposed that in racially discordant medical interactions black patients may fear that based on their prior experiences with bias and mistrust of the physician they may become the victims of discrimination they therefore attempt to assert more control in their medical interactions to achieve higher quality care indeed consistent with this interpretation of greater talktime among black patients we found that the smaller the ratios the less they subsequently adhered to physician recommendations we acknowledge that patientcenteredness is a valid and desired goal for all medical interactions but propose that the behaviors associated with patientcenteredness may differ between racially concordant and racially discordant medical interactions as shelton west and trail have shown sometimes exactly the same behaviors may be viewed in different frequently opposite ways in samerace interactions and differentrace interactions thus our research further highlights the importance of recognizing and understanding how the distinctive dynamics of racially concordant and discordant interactions can affect medical encounters and outcomes physicians racial prejudice implicit and explicit can have a direct negative impact on the experience of blacks in medical encounters and ultimately on the quality of care that blacks receive for example cooper et al found that higher implicit physician bias was associated with less positive affect and poorer ratings of interpersonal care from black patients similarly blair et al found that higher physician implicit bias was significantly associated with lower patientcentered care as reported by black patients in our own work we have examined how the interaction between explicit and implicit bias may affect black patients reactions in racially discordant medical interactions this study again uses data from participants in the primary care clinic specifically the 15 physicians who completed the measures of explicit and implicit racial bais and the patients they saw this work was based on aversive racism theory aversive racism theory proposes that racial majorities often hold positive explicit conscious thoughts about and feelings toward racial minorities that are consistent with their egalitarian values however at the same time they also hold negative implicit nonconscious thoughts about and feelings toward these minorities resulting in discomfort from the dissociation between their explicit egalitarian values and their implicit negative feelings toward racial minorities and their fear of appearing to be a racist in order to alleviate their discomfort and fear individuals characterized by aversive racism tend to avoid or disengage from racially discordant interactions often without conscious awareness of the reasons for their behavior however people often cannot avoid certain racially discordant interactions once engaged in these interactions people who fit the profile of an aversive racist may display inconsistent behaviors because they can selfregulate deliberate behaviors that are usually associated with explicit attitudes while they have difficulties selfregulating automatic behaviors that are usually associated with implicit attitudes these inconsistent behaviors may elicit negative reactions from members of racial minority groups although the phenomenon of aversive racism was first demonstrated in the context of white americans response to blacks it has subsequently been found with other target minorities in countries such as canada the uk and the netherlands the negative consequences of aversive racism may be especially relevant to racially discordant medical interactions because for legal and ethical reasons physicians cannot typically avoid racially discordant medical interactions research on blacks reactions to racially discordant social interactions led us to examine whether physicians who fit the profile of an aversive racist may elicit negative reactions from racial minority patients in this study we used the scores on the explicit and implicit racial bias measures described above to identify physicians who relative to other physicians showed the aversive racism profile that is low explicit and high implicit bias we also computed a composite measure of patients perceptions of the patientcenteredness of the interaction including the items about patient satisfaction and perceived doctor warmth we then compared differences in patients experiences in the interactions with physicians reflecting the four configurations of explicit and implicit physician bias high explicithigh implicit high explicitlow implicit low explicithigh implicit and low explicitlow implicit we found that physician explicit bias affected their own perceptions of being on a team with the patients but had no impact on patient reactions however as can be seen in figure 4 black patients who interacted with the aversive racist physicians were less satisfied with the interaction and felt less positive about and close to their physicians than black patients who interacted with other physicians including physicians who were high on both explicit and implicit bias we have also found using just the patients who completed the trust measures that patients trusted the aversive racist physicians significantly less than the other physicians turning to the issue of the role of patient attitudes we know that patient behavior affects how physicians communicate with them for example contentious patients elicit contentious communication from their physician we know of no published work on how patient racerelated attitudesbeliefs may affect physician reactions to them however a subsequent analysis of our original patientphysician data suggests there may be such a relationship in this analysis of physicianpatient interdependence in the racially discordant medical interactions we examined the impact of patients experience with discrimination on their physicians reactions to the interaction we found the more past discrimination patients reported the less likely their physicians were see the two of them as a team to summarize at the interpersonal level racially discordant relative to racially concordant medical interactions are typically characterized by poorer communication and more negative affect social identity theory may provide a general theoretical framework in which to place many of these negative outcomes social identity processes can influence the quality of racially discordant medical interactions through several paths people tend to engage in ingroup favoritism andor outgroup derogation which may explain why racial majorities are more likely than racial minorities to have positive medical interactions theories of how individuals selfregulate their behaviors to achieve interaction goals as well as how individuals cope with the stress associated with interracial interactions may provide further insight into why these interactions often have less than positive outcomes even in the absence of obvious intergroup bias contemporary research on explicit and implicit racial attitudes suggests that these attitudes affect the quality of these interactions and indeed our own work provides substantial support for this perhaps the most intriguing finding in this regard is that although we currently do not know exactly what behaviors they are reacting to black patients are very good at detecting implicit bias among their physicians and react negatively to it their dissatisfaction and distrust are directly negatively linked to the likelihood they will adhere to the treatment recommendations their physicians make and thus how much they may benefit from a medical interaction thus as was true with intrapersonal processes social psychological theories of processes that occur at the interpersonal level seem to be quite useful in understanding racial healthcare disparities in the final section of this article we consider how these theories may be used to develop effective interventions to reduce these disparities social psychological approaches to the reduction of healthcare disparities in this section we consider ways to address healthcare disparities at the intrapersonal and interpersonal levels we acknowledge that interventions at the societal level are critical and necessary to fully address healthcare disparities however discussion of these societallevel interventions is beyond this reviews scope following a key distinction in our model this section is divided into interventions at the intrapersonal and interpersonal levels in other words we consider interventions based on social psychological theory and research that may effectively improve the quality of racially discordant medical interactions at the outset we must acknowledge the relative dearth of interventions that specifically target racially discordant medical interactions we shall present these and where appropriate also discuss possible interventions that draw on social psychological theory and research we discuss two general kinds of interventions one kind is interventions that target negative stereotypes and attitudes towards all members of some racial minority the goals of such interventions we describe are to produce general changes in physicians and patients that might affect healthcare disparities the other kind is interventions that target a specific racially discordant interaction their goal is to improve the outcome of these interactions by reducing the impact of negative racerelated thoughts and feelings of the specific patient andor physician participating in the interaction one might hope that these effects might generalize beyond this interaction but our primary goal is much more modest we simply want to reduce healthcare disparities in that interaction intrapersonal level processes in this section we focus on potential interventions that target the racerelated thoughts and feelings patients and physicians may bring to racially discordant medical interactions first we consider the racial minority patients racial minority patientsinterventions with racial minority patients have focused on both cognitive and motivational processes specifically these interventions have addressed patients expectations of bias and the health consequences of identitybased motivations members of both racial majority and minority groups approach interracial interactions guardedly and with negative expectations when racial minority members expect to be treated unfairly by a majority group member in racially discordant interactions they experience negative moods andor interaction anxiety and may become defensive during the interactions therefore one target for interventions is to reduce the impact of these expectations on racially discordant medical interactions as noted earlier burgess and colleagues proposed that one manifestation of racial minority patients expecting to be the target of prejudice and discrimination is the activation of stereotype threat wherein minority group patients may worry that their physicians may negatively stereotype them thus minority patients may not fully and actively participate in the interaction lest they engage in behaviors that might reinforce these stereotypes recently havranek et al tested the impact of an intervention intended to reduce stereotype threat among minority patients on the patients reactions to racially discordant medical interactions in this study patients were randomly assigned to either a treatment group in which they engaged in a valuesaffirmation exercise shortly before they met with their physician or to a control group valuesaffirmation exercises encourage people to identify personal values that are important to them such exercises have been shown to reduce stereotype threat presumably due to the positive impact on the self the interactions were audio recorded patients who engaged in the values affirmation exercise asked for more information about their medical condition during the interactions and reported a less negative mood after the interactions as compared to patients in the control group additionally independent coders rated these patients as more friendly and responsive during the interactions the goals of medical interactions extend beyond accurate diagnosis and the best treatments today most medical facilities also emphasize steps that people can take to prevent diseases indeed there is already a very large public health and communication literature on persuasive messages that target and attempt to change healthrelated beliefs and behavior recently communication researchers have proposed that health messages should be tailored based on the targets social identity this approach is based primarily on classic models of persuasive communication we would suggest another approach based on oyserman and colleagues report of their efforts to change identitybased motivations in middle school students oyersman bybee and terry targeted racial minority students selfconcepts social identity and academic achievement they developed classroom exercises aimed at connecting students possible selves and their social identity specifically the classroom exercises encouraged minority students to see their possible selves as congruent with a social identity that was associated with academic success the primary means to do this was to have students think about another student andor adult with whom they identified who provided a model of their academically successful possible self this intervention was successful and had substantial longterm academic consequences for the students for example relative to comparable students who did not receive the intervention the targeted students had fewer school absences and higher grades and scores on standardized tests moreover these effects persisted over time it would seem useful to explore whether similar interventions that target selfconcept and social identity might be developed for healthrelated behaviors among racial minorities physiciansat both explicit and implicit levels nonminority physicians tend to harbor negative feelings towards members of racial minorities and hold negative stereotypes about minority patients thus interventions that target these attitudes and beliefs might serve to reduce healthcare disparities these interventions target peoples general stereotypes and attitudes that affect reactions to some target group including their thoughts feelings and actions when they interact with members of that group burgess and colleagues argued that changes in physician training will reduce the impact of ingroup bias and racerelated stereotypes and attitudes on healthcare most medical schools now require training in cultural competencya set of attitudes skills behaviors and policies enabling individuals to establish effective interpersonal and working relationships that supersede cultural differences the term cultural competency training covers a host of different approaches but in the training models that have been empirically evaluated do not directly address intergroup relations or racial bias burgess et al recommended teaching medical trainees about the nature of stereotyping thus increasing their understanding that even negative stereotypes are a pervasive social phenomenon that can unintentionally shape medical decision making and interactions this type of training should help them to devise strategies to counteract stereotypes rather than try to deny or suppress them at a conceptual level we would agree that such an approach has value in fact this approach is consistent with findings from the social psychological literature showing that with some practice people can develop strategies to counteract the influence of implicit racial bias on their explicit thoughts feelings and actions however given the other demands on medical education to prepare trainees for the current rapidlychanging healthcare environment these kinds of programs will need to be integrated into already crowded medical curricula which may make them less feasible or effective although it may be difficult to directly address medical trainees racerelated thoughts and feelings through special training it might be possible to modify the training experience in ways that reduce racial stereotypes and the anxiety and uncertainty that often accompanies interracial interactions allports classic contact hypothesis suggests some strategies repeated positive and constructive contact between ingroup and outgroup members can often reduce implicit and explicit negative attitudes and beliefs about members of an outgroup as well as negative affective reactions that often accompany interacting with members of the outgroup and thus improve intergroup relations so one way to reduce physicians negative racerelated feelings during racially discordant medical interactions is to provide them with multiple opportunities to interact with minority patients during their training this could be done in the context of a widely used training tool in medical schoolsinteractions with standardized patients that is one possible way to give medical students experience with minority patients is simply to increase the diversity of the standardized patients they see and provide feedback that specifically addresses those aspects of the interaction that concern intergroup relations it might also be useful to provide students with behavioral scripts before these interactions this approach is suggested by a study by avery richeson hebl and ambady that found providing whites with behavioral scripts to follow before their interactions with blacks significantly reduced their anxiety during the interactions this might serve to desensitize nonminority physicians to minority patients early in their medical training it would also be beneficial to provide nonminority medical students with naturally occurring contact with equal or higher status individuals from racial minorities such as minority medical students or medical school faculty however only a small portion of medical students are from racial minorities and minorities are also substantially under represented on medical school faculties one possible reason is for this is that at least in the us minority medical school faculty members have significantly lower promotion rates than white faculty this limits the opportunities for white students and faculty to have contact with equal or higher status minority group members other interventions might attempt to reduce physicians reliance on racial stereotypes when they interact with racial minority patients for example one might attempt to reduce the cognitive load of physicians whose practices involve a high percentage of racial minority patients laboratory studies of racially discordant interactions suggest that whites under low cognitive load are less likely to engage in social categorization and more able to individuate their interaction partner than those under high cognitive load thus interventions might be developed to increase physicians cognitive resources by reducing the stress and anxiety associated with their clinical practice this might involve organizational interventions such as reducing patient caseloads through the use of nurses or other physician extenders of course given the fiscal realities of medical practice in the 21 st century in almost all countries it seems that such changes in organizational practice will not be easy to achieve interpersonal level processes we have argued that one major reason for the less productive and positive communication in racially discordant medical interactions involves the social biases that physicians bring often without conscious awareness to these formal encounters basic social psychological research and theory can help guide the development of interpersonallevel interventions to reduce healthcare disparities in this section we consider strategies for structuring racially discordant medical interactions and reshaping social categorization processes to enhance the effectiveness of racially discordant medical interactions creating equal status in racially discordant medical interactionsa metaanalysis conducted by pettigrew and tropp testing contact theory reveals that intergroup contact and particularly under conditions of equal status common goals acquaintance potential and support of authorities has beneficial effects on intergroup attitudes within medical contexts the patientcentered communication model of physician communication which is widely taught in north american and european medical schools may serve to promote these facilitating conditions especially equalstatus relations whereas physicianpatient interactions have traditionally reflected marked status distinctions the patientcentered communication model stresses the need for physicians to understand the patients perspective consider the patients psychological and social context reach a shared understanding of the patients problem and its treatment and offer patients meaningful involvement in treatment decisions a central goal of patientcentered physician communication is to empower patients to participate actively in medical interactions research shows that patientcentered medical interactions produce more patient involvement and more positive outcomes however as we have already noted the effects of patientcentered communication have not been systematically examined in the context of racially discordant medical interactions moreover our own research suggests that greater patient participation may not always reflect physicians empowering patients recall that hagiwara et al found that black patients who perceived greater past discrimination and reported less trust talked more in their medical interactions with nonblack physicians this suggests that this behavior may have reflected negative rather than positive affect as a consequence in these raciallydiscordant interactions greater talktime by patients predicted less subsequent adherence to the doctors recommendations thus while patientcentered communication may have value in improving the outcomes of racially discordant medical interactions it needs to be empirically evaluated before being implemented as a remedy for the problems associated with these interactions one intriguing but as yet untested idea for an intervention to create optimal conditions for racially discordant medical interactions is to try interventions modeled on aronsons jigsaw technique the jigsaw technique was designed to reduce intergroup conflict in small groups and emphasizes the importance of each individuals participation and of the information each has in the solution of a problem of mutual interest this technique can create equal status among the participants although this technique was originally developed to improve diverse classroom environments it might be meaningfully modified for medical interactions for example framing the medical interaction as one in which each party has valuable information that the other one needs to solve the problem might engender a more equal status cooperative interaction than is the norm in racially discordant interactions it would seem worthwhile to explore this approach to improving racially discordant medical interactions the optimal conditions identified by contact theory and the dynamics of the jigsaw technique operate to reduce intergroup bias by altering the ways people in these interactions socially categorize others 2 as already discussed because of the importance of race and ethnicity in social relations generally people automatically and often unconsciously respond to others primarily based on their race or ethnicity which can negatively affect racially discordant medical interactions thus one possible avenue to prevent such outcomes in interactions is to reduce the likelihood that participants automatically categorize themselves as members of two different groups specifically positive intergroup contact and cooperative interdependence as identified by contact theory and the jigsaw technique can alter physician and patient perceptions of membership in an ingroup and in an outgroup based on raceethnicity to more individuated perceptions of one another andor to recognition of a shared identity within the context of a specific medical interaction to the extent that social categorization processes are a critical factor biasing perceptions and interpersonallevel processes in racially discordant medical encounters interventions targeted more directly at changing the nature of social categorization can help eliminate healthcare disparities in the remainder of this section we discuss interventions designed to create more individuated impressions or commongroup representations in medical encounters individuation of participants in racially discordant medical interactions several models of intergroup relations posit that people do not categorize others into specific social categories when they are provided with rich individuating information about target individuals for instance turner hewstone and voci have shown that selfdisclosure among members of different groups is associated with an increase in positive attitudes and more heterogeneous perceptions of members of the outgroup consistent with these research findings burgess and colleagues specifically argued that individuation of a minority patient is an effective way to reduce the impact of racerelated thoughtsfeelings on physician reactions to that patient we are currently testing an intervention that is partially intended to help individuate racial minority cancer patients in the eyes of their oncologists prior to meeting the oncologist minority patients are provided with a list of questions they might ask their nonminority oncologists during discussions of their treatment and given advice on the best way to ask them we believe that patients asking more questions about their specific condition and treatment will activate more individuated impressions of minority patients during the interactions in addition asking these questions provides an example of an engaged interested patient that contrasts with documented physician expectations that minority patients are unintelligent uninterested or uncooperative the patient may be seen as an exception to the social category thus diminishing the impact of preexisting stereotypes on the oncologists views of the patient as a result treatment decisions will be more likely to be based on the particular characteristics of this patient than stereotypes about the group to which heshe belongs 2 we thank the editor for suggesting the potential usefulness of the jigsaw technique in interventions that address healthcare disparities in the same vein previous research reveals that minority cancer patients typically receive less information from their oncologist which may reinforce minority patients stereotypes about nonminority physicians as not interested in or biased against them thus we posit that this intervention will have cascading positive influences on racially discordant medical interactions helping patients to ask more questions is expected to elicit greater responsiveness from oncologists which in turn should undermine patients negative stereotypic perceptions at least with respect to this particular healthcare provider that is greater responsiveness in the encounter by oncologists may serve to individuate the oncologists to the patients and thus reduce the impact of the patients racerelated thoughts and feelings on the interaction itself and the treatment decisions patients make note that this intervention would not really address the general attitudes and stereotypes that either oncologists or patients bring to the interactions but it might reduce the relevance of these feelings and thoughts to communication during their immediate interactions and the decisions each party makes of course one could simply provide physicians and patients with large amounts of information about one another prior to the interactions which might also serve to individuate them however promoting individuation by providing patients and physicians detailed information about one another may not be practical physicians may not be willing or able to invest great amounts of their very limited time exchanging individuating information with their patients similarly patients may not be willing or able to learn about their physicians as individuals furthermore the stressful aspects of racially discordant interactions and the time pressures and heavy workload for many physicians who treat minority patients may increase the cognitive load on such physicians under these conditions attempts at individuation via increased information may actually have counterproductive effects for example phillips northcraft and neale studied homogeneous and diverse groups working on a complex problem they found that individuating members of diverse groups with information about similar attitudes and values did not increase attraction among them and in fact actually resulted in poorer performance relative to diverse groups that did not receive this information3 these findings suggest that one might be cautious in providing large amounts of individuating information during already cognitively taxing racially discordant medical interactions because this information may further increase the cognitive load under such circumstances physicians may actually fall back onto racial stereotypes to reduce the cognitive load creating a common identity in medical interactionsanother possibly more productive way to improve the outcomes of racially discordant medical interactions might be to try to change patients and physicians perceptions of one another as us versus them social psychological research has shown that it possible to do this by creating a common group identity in which members of disparate groups are induced to focus on their common interests and goals they share in common the creation of a common group identity has been found to reduce intergroup bias and increase intergroup trust in a recent study we attempted to improve the outcomes of racially discordant medical interactions by creating an intervention to promote common group identity between the low ses black patients and their nonblack physicians in our samples in the detroit clinic prior to their appointment with their primary care physicians 72 black patients completed all the baseline measures described above and then were randomly assigned to a treatment group or control group the 42 patients in the treatment group received written instructions that introduced the concept of being on a team with their doctor they were asked to sign a contract stating that they would be partners in a team that is working to solve your medical problems to reinforce this message treatmentgroup patients were given buttons and pens with the team name and team colors patients also received 10 suggestions for being part of a team which were posted on the wall of the room in which the treatmentcondition patients saw their physician the 30 patients in the control group received their usual standard of care the 7 physicians randomly assigned to the treatment condition received similar instructions at the beginning of the study and wore the same kind of buttons during the interactions each physician interacted with multiple patients across the course of the study patients completed the measure of physician specific trust and the two team items immediately after the interaction 4 and 16 weeks later they completed the trust measures again and the adherence measures in all the tests of treatmentcontrol differences we controlled for baseline trust and adherence measures as illustrated in figure 5 we found that relative to the control group patients who received the common identity manipulation showed increased trust in their physicians and in physicians in general at four and 16 weeks after the interactions perhaps more importantly 16 weeks after the interactions members of the intervention group adhered to physician recommendations significantly more than did members of the control group these findings reveal the important role of changing the way physicians and patients think of each other during their medical interactions from us and them based on their racial or ethnic group memberships to we in terms of their relationship in this medical context on healthcare success understanding the psychological mechanisms that underlie intergroup bias can thus help guide the development of interventions to improve the effectiveness of medical encounters in ways that particularly benefit minoritygroup patients thereby reducing healthcare disparities as we close this section we might consider which of the two kinds of interventions holds the greatest promise for reducing healthcare disparities ultimately of course it is those interventions that target general negative racerelated thoughts and feelings however for the immediate future it may well be most practical and efficacious to target specific medical interactions and focus attention on improving interactions between racial minority patients and their physicians thus the most practical and realistic goal is to reduce the impact of racerelated thoughts and feelings on how patients and physicians interact with one another and thus improve the outcome of these interactions summary and conclusions around the world members of racialethnic minorities almost invariably experience poorer mental and physical health than do racialethnic majorities racialethnic disparities in healthcare play an important role in these disparities in the health of different racialethnic groups societal intrapersonal and interpersonal level processes involving racerelated thoughts feelings and actions play important roles in healthcare disparities we presented a social psychological analysis in the exposition of the healthcare disparities model to do this we focused more on processes at intrapersonal and interpersonal levels than on the societal level and primarily considered the impact of these processes on racially discordant medical interactions at both levels we saw that a social psychological analysis provides considerable insight into the reasons why these interactions are typically less positive and productive than racially concordant interactions while healthcare disparities have a long history and are pervasive throughout the world they are not inevitable and can be reduced if not eliminated social psychological theories have much to offer in this regard some healthcare disparity interventions directly derived from social psychological theories have already been tested and seem to hold great promise of improving both communication during and the outcomes of racially discordant medical interactions moreover there are other untested interventions also derived from social psychological theory that hold promise as means to address healthcare disparities we believe there is a special benefit to developing such theorydriven interventions presently many of the interventions directed at healthcare disparities are largely atheoretical and may often simply apply an intervention that was shown to be effective in one context to another context without much consideration of why it was successful one important practical drawback of such approaches is that if the intervention succeeds it is very difficult to identify the mechanisms responsible for the outcomes thus the investigator has little guidance on how to improve the intervention or apply it to other settings however theorydriven interventions which specify and test the presumed causes of the expected outcome and the mediational processes associated with the outcomes are likely to provide valuable heuristic and practical information for future efforts whether or not the specific intervention is successful we note that there are two excellent reasons for bridging social psychological theory and racial and ethnic disparities in health and healthcare first this pervasive social problem provides an exciting natural laboratory in which to test theories of intergroup relations and racial bias at the same time psychologists have a potentially important role to play in applied practical research intended to reduce health disparities thus this article represents an argument for a melding of basic and applied research thus addressing the problem of healthcare disparities may be another example of kurt lewins wellknown axiom nothing is as practical as a good theory a multilevel model of the causes of healthcare and health status disparities copyright © 2013 elsevier racial attitudes social control and adherence in racially discordant medical interactions hagiwaran et alsocial science and medicine87 123 124 125 126 127 128 129 130 131 figure 3 caption overall physicians talked more tan patients the larger this ratio the more physicians talked relative to patients

around the world members of racialethnic minority groups typically experience poorer health than members of racialethnic majority groups the core premise of this article is that thoughts feelings and behaviors related to race and ethnicity play a critical role in healthcare disparities social psychological theories of the origins and consequences of these thoughts feelings and behaviors offer critical insights into the processes responsible for these disparities and suggest interventions to address them we present a multilevel model that explains how societal intrapersonal and interpersonal factors can influence ethnicracial health disparities we focus our literature review including our own research and conceptual analysis at the intrapersonal the racerelated thoughts and feelings of minority patients and nonminority physicians and interpersonal levels intergroup processes that affect medical interactions between minority patients and nonminority physicians at both levels of analysis we use theories of social categorization social identity contemporary forms of racial bias stereotype activation stigma and other social psychological processes to identify and understand potential causes and processes of health and healthcare disparities in the final section we identify theorybased interventions that might reduce ethnicracial disparities in health and healthcareethnicityrace health and healthcare disparities explicit and implicit bias intergroup processes across a broad spectrum of mental and physical illnesses members of socially disadvantaged groups typically experience poorer physical and mental health than members of socially advantaged groups this is a persistent social problem in at least 126 countries which include 944 of the worlds population dorling mitchell pearce 2007 there are two general classes of explanations of this pervasive public health problem the first is that these differences reflect biological and genetic differences in the populations to which

introduction intimate relationships are linked with better mental and physical wellbeing across the lifespan 1 2 3 for people with chronic illness or disease in particular intimate relationships can greatly impact their ability to selfmanage their condition illnessrelated quality of life coping responses posttraumatic stress and growth among many other factors 4 5 6 7 the downstream impact of intimate relationship quality can thus be substantial especially for partners struggling with the daytoday manifestations of their condition or disease 8 when the condition or disease specifically impacts sexuality intimate partner support is especially critical sexual intimacy and sexual satisfaction are crucial components of relationship quality 9 and are directly linked to relationship stability 10 longitudinal studies of married couples have shown that sexual satisfaction at time of assessment is related to later relationship satisfaction even in studies spanning more than a decade 11 in fact a recent study employing machine learning to the study of over 11000 romantic couples found that sexual satisfaction was one of the top five predictors of higher relationship quality 12 although scholars are in disagreement over the true direction of the association between relationship satisfaction and sexual satisfactionmeaning which distinctly drives the otherthese concepts have consistently been highly correlated in crosssectional and longitudinal research 13 unsurprisingly changes to sexual intimacy are among the most predominant concerns for people undergoing treatment for breast colon or reproductive cancers 51415 such changes could leave one or both partners with unfulfilled sexual needs and potentially pose a threat to relationship longevity in the current study we examined sexual satisfaction and distress in the context of chronic vulvovaginal pain cvvp is vulvar andor vaginal pain that is unexplained by underlying physical trauma medications or any known medical conditions 1617 this pain can occur during daytoday mundane activities such as sitting for long periods of time or wearing tight clothing that can cause prolonged vulvar pressure cvvp can also occur during menstruation with the use of menstrual products during gynecological pelvic exams and during sexual activity both with and without vaginal penetration 1819 although prevalence estimates are based on incomplete data around 13 million people are likely experiencing cvvp in the united states at the time of this writing 16 research on cvvp has shown that the pursuit of diagnosis and treatment is an arduous journey many participants report that healthcare providers have insisted that their pain is psychosomatic and thus not real 20 21 22 other studies have shown that people with cvvp typically have to see multiple healthcare providers before they reach one who has the expertise needed 23 prolonged healthrelated uncertainty and navigating multiple healthcare environments is likely to produce high levels of stress for people with cvvp as with any other chronic condition social support is essential 24 social support is defined as information leading one to believe that heshe is cared for and loved esteemed and a member of a network of mutual obligations social support generally includes the exchange of encouragement validation and resources 26 and is intended as a catalyst enhancer or buffer 27 in particular emotional support is defined as providing care love empathy and support 262829 the receipt of emotional support has been shown to buffer stress particularly in situations beyond a persons control 30 likewise the receipt of emotional support reduced the odds of posttraumatic stress disorder symptom emergence in people who had experienced a physical assault 31 in the context of chronic diseases including cancer diabetes and lupus emotional support contributes substantially to better psychological adjustment and subsequently to better overall wellbeing 32 33 34 furthermore for women experiencing chronic illness emotional support received from a romantic partner has been associated with better adjustment to the illness less occurrence of depressive symptoms and higher levels of marital satisfaction 24 unlike many other chronic conditions however cvvp impacts not only psychological and physical wellbeing but romantic relationship functioning while intimate partners are typically among the main sources of social support for adults 35 people may be reluctant to seek support from their partners when it relates to cvvp this is because the presence of cvvp can complicate the maintenance of sexual intimacy as previously detailed sexual intimacy and resulting sexual satisfaction are especially important for perceptions of relationship quality but cvvp may prevent typical engagement in sexual behaviors 36 this may lead some people who have a cvvp condition to choose not to disclose their condition to their partner in order to avoid their partner viewing them differently studies have shown that women with cvvp feel shame because their pain interferes with their ability to sexually please their partnersomething that many women feel makes them incapable of being the perfect girlfriend or worthy romantic partner 37 thus women and others may hesitate in seeking support for their cvvp from intimate partners because doing so would communicate their ongoing discomfort with sexual activity and highlight their perceived shortcomings which could in turn harm the relationship in the current descriptive study we examined the prevalence of disclosure to romantic partners in a sample of over 300 women experiencing cvvp for women who had disclosed their condition to their romantic partners we further investigated the extent to which they perceived their partners as providing relevant emotional support and how that support was associated with sexual dissatisfaction and distress longitudinal studies involving control groups of women without cvvp are needed to provide the most rigorous and causally informative understanding of how cvvp impacts romantic and sexual intimacy and overall wellbeing however the literature in this area is still emerging and the existing library is small here we conducted a descriptive and correlational investigation to provide needed foundational information for future hypothesisdriven work 38 39 40 a better understanding of healthrelated disclosure and partner support in the context of chronic pain conditions like cvvp can help to advance research and therapeutic intervention on physical psychological and social wellbeing although there is a small but active literature on the experiences of women with cvvp the great majority of work in this area has been conducted with samples mostly comprising white women a clear limitation of the existing knowledge base is in the experiences of people of color who have cvvp conditions studies examining lifetime prevalence of chronic vulvar pain in racially diverse communities have found no difference in lifetime rates for black versus white women but findings have suggested that hispanic women are between 14 and 18 times more likely than women of other racesethnicities to experience chronic vulvar pain 1823 rates of lifetime prevalence may be relatively stable across racial groups but studies have indicated that women of color have unique struggles with cvvp one study examining racial differences in the experience of provoked vestibulodyniapain localized at the vulvar vestibule 41 found no difference in black versus white womens pain ratings but black women had higher rates of functional impairment caused by their vestibulodynia 42 the disparity in impairment is especially disconcerting considering the nearly twenty percent difference in diagnostic rates for black versus white women with chronic vulvar pain 18 we know of no research on cvvp in the context of romantic relationships that focused or specifically mentioned people who identify as a race or ethnicity other than white however work conducted with patients navigating other chronic diseases has shown the significance of sexual intimacy in the lives of women of color for example in a qualitative study of black women breast cancer survivors under the age of 45 lewis and colleagues reported that half of the sample believed that their cancer negatively affected their relationships and particularly their partners emotions 43 in this study participants identified sexual side effects as a paramount issue in their cancer prognosis relatedly another study found similarly negative romantic and sexual relationship outcomes for black asian and white breast cancer survivors but latina survivors experienced additional challenges due to cultural conceptions of femininity and reconciling those conceptions with the mastectomies they had received 44 though sourced only from a very small review of the literature these findings make clear the likely impact of sexuallyor reproductively relevant health conditions on sexual intimacy for women of color outside of the illness context recent work has further demonstrated the importance of sexual intimacy on these womens romantic relationships townes and colleagues conducted a study of black womens perceptions of sex satisfaction within the context of relationships and found that nearly 80 of the sample considered aspects of sexual intimacy to be essential for relationship functioning 45 in the current study we expand the existing literature focusing specifically on the experiences of women of color in our investigation of cvvp partner support sexual satisfaction and distress the current study focused on social support specifically aspects of emotional support and its impact on individuals with chronic vulvovaginal pain this study also specifically examined people of colorpredominantly black womenwhich was unique from previous studies on this topic that either lacked participants of color or failed to report on racialethnic categories at all 46 47 48 49 in addition this study sought only to examine the proposed associations for individuals who were partnered in longterm committed romantic relationships based on previous literature to analyze the current sample our research questions were how emotionally supportive are the intimate partners of the participants who have disclosed their chronic vulvovaginal pain is more support from partners associated with lower sexual dissatisfaction andor distress and aside from emotional support from ones partner what sources are the most helpful in providing emotional support to participants who experience chronic vulvovaginal pain materials and methods measures demographics demographic questions were asked to obtain information about the participants age gender identification relationship status and sexual orientation partner support emotional supportiveness from the participants partner was measured with the item how supportive was your partners response when you told them that you have chronic vulvovaginal pain with choices ranging from very unsupportive to very supportive dissatisfaction about sex life dissatisfaction was measured with the item how often do you feel dissatisfied with your sex life from the female sexual distress scalerevised 50 and participants answered on a 5point likert type scale ranging from never to always distress about sex life stress was measured with the item how often do you feel distressed about your sex life from the female sexual distress scalerevised 50 and participants answered on a 5point likert type scale ranging from never to always emotional support sources participants were asked what information source is the most helpful for emotional support and were allowed to select up to three choices from the following options medical professional general medical information website vulvarvaginal painspecific medical information website healthrelated forums and social media friends or family members newspapers or magazines government health agencies radio or podcasts religious organizations or leaders lifestyle websites or blogs or none of the options they were then asked what information source is the least helpful for emotional support and were allowed to choose up to three choices from the same list provided above procedure participants were recruited via the internet standardized messages including a recruitment flyer were posted on various social media sites and were subsequently shared widely by other social media users all research procedures were approved by the universitys institutional review board furthermore this study was deemed exempt as it presented no more than minimal risk to subjects and followed the guidelines for ethical research presented in the belmont report 51 recruitment for this study included several eligibility requirements age of 19 to 55 no experience of perimenopause or menopause identifying as a person of color and having experienced vulvar vaginal andor pelvic pain for at least three to six months participants who failed the survey attention check items or the recaptcha item and participants with duplicate ip addresses were also removed from the dataset to ensure data quality in addition this report examined only the data of eligible participants who reported being in a form of longterm committed relationship after data cleaning 333 participants were included for statistical analysis eligible participants reported demographics and whether they had been formally diagnosed with a chronic vulvovaginal or pelvic pain condition participants who did not have a formal diagnosis reported whether they suspected they had a chronic vulvovaginal or pelvic pain condition to capture individuals who had not yet sought care or who had not yet found an appropriate healthcare specialist that could provide a diagnosis participants also responded to ad hoc survey items regarding their informationseeking behaviors and their experiences in deciding to disclose their chronic pain to relationship partners these data were part of a larger study on the multifaceted experiences of people of color living with chronic vulvovaginal andor pelvic pain the larger study included data on a host of health and behavioral aspects of cvvp unrelated to the current study here we discuss only variables related to participant demographics partnered social support sexual dissatisfaction distress and other sources of support identified by participants as helpful to their experiences with cvvp data analysis spss version 28 was used to analyze the data statistical significance was determined by pvalues less than 005 descriptive statistics were run in order to answer the research questions posed in the study to determine percentages of participants two separate linear regression models were used to determine if partner supportiveness was associated with less sexual distress andor less sexual dissatisfaction results to answer our proposed research questions we examined descriptive statistics to determine how supportive intimate partners were after their partner disclosed their chronic vulvovaginal pain our results showed that partners were rated as largely supportive on a sevenpoint scale only 25 of the sample selected the midpoint or lower corresponding with neither supportive or unsupportive or worse furthermore no one reported that their partner was very unsupportive one in four participants reported that their partner was very supportive 386 reported that their partner was supportive and 344 reported that their partner was somewhat supportive next a linear regression was run to examine the relationship between partner supportiveness and dissatisfaction about the participants sex life the results yielded a significant negative relationship between partner supportiveness and dissatisfaction indicating that increased partner support was associated with lower levels of dissatisfaction therefore h1 was supported by the data next a linear regression was run to examine the relationship between partner supportiveness and distress about the participants sex life the results yielded a significant negative relationship between partner supportiveness and distress indicating that increased partner support was associated with lower levels of distress therefore h2 was supported by the data lastly descriptive statistics were run in order to determine what sources of emotional support participants found to be most and least helpful as related to their chronic vulvovaginal pain the most helpful emotional support sources were medical professionals followed by healthrelated forums and social media family members or friends and vulvarvaginal painspecific medical information websites the least helpful emotional support sources were none of the options provided followed by vulvarvaginal painspecific medical information websites and medical professionals all of the values for each source for both least and most helpful are reported in tables 1 and2 as participants were allowed to select up to three of the choices provided percentages did add up to over 100 discussion in the current study we investigated the presence of social support from romantic partners for participants experiencing chronic vulvovaginal pain we also examined associations between that partnered support sexual dissatisfaction and distress in the context of this type of pain our results provided evidencealbeit of the crosssectional varietyfor the positive role that social support plays for individuals who experience cvvp although the role of a romantic partners social support has been explored in several other contexts this was the first study to examine its role in individuals who experience cvvp the current study should help provide encouragement to individuals who experience cvvp to disclose their diagnosis as very few participants received unsupportive responses from their partners and most experienced very positive supportive responses additionally higher levels of partner supportiveness were associated with lower sexual dissatisfaction for the participant as well as less distress surrounding their sex life because of the intimate relationship that participants shared with their partners and the difficulties cvvp may cause in the experience of sexual intimacy it is reasonable to believe that having ones partner being supportive would be of the utmost importance in how the participant views their sex life and sexual experiences this finding also suggests that additional research should aim to examine disclosure strategies for individuals with cvvp which could assist in finding the best way to discuss this sensitive topic with sexual partners within future studies researchers should examine how these relationships between emotional support and sexual dissatisfaction play out for individuals who are single or in the early stages of a relationship as singles may be more hesitant to reveal their diagnoses to sexual partners who are not consistent or new because of the lack of trust which takes time to establish beyond the role of partner support in cvvp we also endeavored to identify the most helpful sources of emotional support for people experiencing cvvp two choices emerged when examining what sources of emotional support participants found the most and least helpful these choices for both the most and least helpful respectively were medical professionals and vulvarvaginal painspecific medical information websites this suggests that medical professionals play a key role in not only providing their patients with medical information and diagnoses but being people that patients can turn to for emotional support specifically for individuals who experience cvvp and may not feel that others fully understand what they are experiencing imploring medical professionals to listen to their patients and provide patientcentered care particularly for patients who are experiencing cvvp may assist with their patients overall sexual and mental wellbeing previous research has shown that patients with chronic pain have better outcomes when their medical providers are able to use personcentered messages and develop a supportive connection with their patients 52 in addition to medical providers vulvarvaginal painspecific medical information websites were also identified as a most and least helpful source of support for many of the participants there may be more nuanced reasons as to why some individuals with cvvp find these websites more or less helpful such as a lack of specific information that individuals are searching for or a lack of certain desired features further research is needed to analyze the content of these websites in order to identify what can be improved in order to assist individuals with cvvp limitations though we have expanded the literature on the understanding of social support and its impact on racial and ethnic minority people with chronic vulvovaginal pain the current research was not without limitations first we relied exclusively on selfreport data collected from the internet though it would be difficult to collect perceptions of support in the context of cvvp beyond the selfreport future research could employ more innovative research designs to ensure consistency in findings furthermore online studies have their own limitations including sample restriction due to accessibility of the internet and associated technology online surveys also remove the researchers ability to control the environment in which people answer survey questions the survey environment has the potential to affect how willing people are to be truthful in their responses to sensitive questions for example people may spend less time onand subsequently provide lower quality data forquestions related to sexuality if they are in the presence of other people who may be able to see the survey items second our sample for this particular inquiry was restricted the overall sample from the larger study included a wider array of participants but our specific research inquiry necessitated a focus on people in established romantic relationships however people with cvvp who are single or not in stable romantic relationships need to be included in future research work with these populations would provide insight into how their sexual and romantic desires are impacted by pain how they pursue partners and where they derive support from with regards to their cvvp those transitioning into a romantic relationship would also provide valuable insight into how couples navigate disclosure of their condition and subsequent support dynamics additionally our participants all resided in the united states but we did not have data on where our participants were raised this limited our knowledge of potential cultural differences we could not ascertain the extent to which partners were willing to discuss gynecological issues with their partnersincluding vaginal painor if their cultural expectations drove their likelihood to share or withhold this type of information from their partners future work focusing on a larger population should collect information on socialenvironmental factors that may impact the magnitude of observable effects we had intended to compare participants who had been formally diagnosed with a cvvp condition with those who had not received a formal diagnosis this type of comparison would potentially uncover differences in sexual dissatisfaction distress or partner support based on whether a healthcare authority had declared ones symptoms to be reflective of an authentic condition unfortunately only 16 of the sample reported not having a formal diagnosis 68 of the sample did report a formal diagnosis and an additional 16 did not answer this survey question the distinct imbalance between diagnosed and undiagnosed groups made comparisons less informative than ideal we recommend that future researchers work to collect adequate samples of both groups to be able to examine indirect or unexpected benefits associated with receiving a formal cvvp diagnosis we had little variance to examine with regard to differences between participants who had and had not disclosed their pain condition to their romantic partner the great majority of our participants had disclosed their cvvp to their romantic partner this finding was in line with prior work on the role of romantic partners in the experience of endometriosis although this work found a largely negative impact of endometriosis on the romantic relationship over 90 of women in the study reported that their partners were interested in being informed of their health and the status of their condition 53 suggesting that disclosure would likely be appreciated by most partners however it should be noted that good communication skills are important for navigating longterm impacts of any chronic condition an investigation of canadian and american women with provoked vestibulodyniaa type of chronic vulvar painfound no consistent pattern in womens dyadic sexual communication scale scores 54 thus having a condition that directly impacts ones partnered sexuality does not inherently make one better at working with a partner toward constructive solutions future research on partnered communication in the context of cvvp would be useful for therapeutic interventions future researchers may also wish to delve into the present topic with more specificity examining particular facets of distress or satisfaction in the realm of sexual intimacy in particular studies focused on partner communication in relation to feelings of shame or of guilt around not being able to normally engage in sex would be highly valuable for therapeutic interventions involving couples other covariates such as number of children desire to have more children and frequency of sexual intercourse before and after cvvp diagnoses may be of use to include in future studies alternatively research examining nonvaginal forms of sex that couples with cvvp may utilize to navigate sexual pain while enhancing mutual satisfaction is an important avenue of future study needed to further understand the multifaceted nature of these dynamics finally the present research was crosssectional giving us only a snapshot of support dynamics in the context of cvvp and an inability to prove causal relationships future research should examine the evolution of intimacy support and sexual expression as it unfolds over time within the confines of romantic relationships and beyond perhaps through the use of longitudinal studies conclusions in the present paper we investigated the role of social supportspecifically emotional supportand its impact on 333 people of color with chronic vulvovaginal pain our results suggested that social support is essential for those who are navigating cvvp and that disclosing their cvvp diagnosis to partners frequently yielded positive and inherently supportive responses additional research could benefit from finding suitable strategies to disclose and discuss cvvp with sexual partners to encourage positive interpersonal and sexual health outcomes taken together these findings highlight the importance of emotional support in the context of navigating a sexual partnership while managing cvvp and indicate potential routes to more satisfaction and less distress in the realm of sexual connection data availability statement the data presented in this study are available on request from the corresponding author the data are not publicly available because of privacy concerns informed consent statement informed consent was obtained from all subjects involved in the study

within the social support literature individuals who experience chronic pain have shown many positive outcomes and benefits when receiving the appropriate level of emotional support in the current study individuals who experience chronic vulvovaginal pain cvvp were asked about their partners supportiveness other sources of emotional support and their satisfaction and stress surrounding sexual activity the participants n 333 also identified as people of color with a majority identifying as african american or black n 227 the participants indicated that their partners were overall supportive of their diagnoses and found other emotional support sources through medical professionals vulvarvaginal painspecific medical information websites and family or friends after conducting linear regressions results showed the partner supportiveness was associated with less distress and less dissatisfaction surrounding sexual activity future research is suggested to further examine social supports role for minority patients who experience chronic vulvovaginal pain

introduction the thalassaemias are recessively inherited disorders of haemoglobin synthesis common in people of mediterranean middle east indian subcontinent and asian origins thalassaemia is considered the most common genetic condition worldwide and about 3 of the worlds population carry the β thalassaemia genes in malaysia approximately 45 of the population are carriers of beta thalassaemia and 340 are hbe carriers recent online data from the malaysian thalassaemia registry as of september 2011 showed a total of 5115 registered patients of which 2207 have β thalassaemia major and 1594 have hbeβ thalassaemia patients with thalassaemia major require lifelong regular blood transfusions which necessitate burdensome and expensive chelation agents in malaysia patients have free access to blood transfusions in government hospitals nationwide from the year 2005 chelation agents in the form of subcutaneous deferoxamine and oral deferiprone are also offered free to patients the newer oral chelator deferasirox will become accessible especially for the younger patients from the year 2012 the only curative option is by allogeneic haemopoietic stem cell transplant in malaysia from the year 1987 to 2008 a total of 144 transplants were performed for haemoglobinopathies with an overall diseasefree survival of 875 however the majority of malaysian thalassaemia patients will still undergo treatment with regular blood transfusions and iron chelation in the form of subcutaneous deferoxamine the huge economic and emotional burdens of thalassaemia are important public health issues leading to the need for an effective prevention programme many of the thalassaemia prevention programmes that were successful in various countries employed population screening prenatal diagnosis and selective termination of pregnancy consequently the birth rate of children born with thalassaemia major fell dramatically by 96 in cyprus 94 in sardinia and 70 in iran those countries were however homogenous with regard to ethnic and religious composition and employing similar preventive strategies in other countries and cultures may not yield equivalent success due to various dissimilar sociocultural religious economic technical and ethical perspectives additional factors may need to be accounted for in a multiethnic country such as malaysia malaysia has a multiethnic population of 283 million consisting of 501 malays 226 chinese 118 indigenous peoples and 67 indians and the remainder are noncitizens and minority groups data from the department of statistics in malaysia also revealed the followingthe malays are all muslims whereas 87 of the chinese population practises a mix of beliefs with influences from traditional chinese religions such as buddhism confucianism and taoism the majority of indians practise hinduism and christianity is embraced by 46 of indigenous people especially those from the states of sabah and sarawak as well as 11 of chinese 6 of indians and other minority groups based on data from the malaysian thalassaemia registry in 2009 the main ethnic background of malaysian thalassaemia patients was recorded as malay chinese and kadazandusun the kadazandusuns are the indigenous people of the state of sabah compared to the background population demographics thalassaemia appeared to affect more kadazandusuns and malays compared to the chinese and indians this may be contributed by a higher prevalence of consanguineous marriages as well as carrier rates among the kadazandusuns where a recent study revealed carrier rates of 336 and 128 for alpha and beta thalassaemia respectively about 45 of malays and chinese are beta thalassaemia carriers but more malays are affected by the homozygous states and failure of preventive strategies among the malays could have contributed to the ratio seen the success of preventive strategies depends largely on the acceptance of the targeted communities most of the successful thalassaemia preventive strategies incorporated prenatal diagnosis and selective termination of affected foetuses into their programmes studies addressing the acceptance of these measures have been done in muslimmajority countries such as iran pakistan lebanon and saudi arabia but are relatively scarce in malaysia a malaysian survey among the general lay public documented not only a low level of knowledge about thalassaemia but it revealed that only 366 of participants accepted selective termination of affected foetuses with the malays less likely to accept abortion compared to the chinese and indians although the reasons were not explored further it was perceived that cultural and religious restrictions contributed to the malay participants rejection of abortion our study addressed the attitudes of malaysian parents who already have children affected by thalassaemia these data represent the first such study in the country and we hope it will provide insights that can contribute towards successful prevention in a multiethnic country methodology this crosssectional study was conducted over 4 months in the state of johor which has the fourth largest number of thalassaemia patients among the 14 states in malaysia as there were no published questionnaire surveys in this area we conducted a focus group discussion with five parents of thalassaemic children to assist the development of survey items a structured questionnaire using laymans terms was developed in english and then translated to malay and mandarin chinese which is the commonest form of chinese language used by the malaysian chinese each version of the questionnaire then underwent rigorous pilot testing before it was finalized the selfadministered questionnaires were then distributed to parents of children with thalassaemia major participation was voluntary and all responses were anonymous and returned in sealed envelopes to the attending staff that was also trained to clarify survey items should parents encounter difficulties comprehending them we used a convenience sample of parents attending the daycare centres in three major hospitals in johor as well as parents attending a statelevel thalassaemia seminar organised in june 2011 in johor bahru the state capital where both partners were approached the questionnaires were administered separately demographic details were recorded such as sex age religion ethnic group highest education attained and number of children with thalassaemia as many chinese practise a mixture of buddhism taoism and confucianism this is categorised under buddhism and catholics were included in the christians category each parent was asked if heshe was in favour of antenatal diagnosis at the early stage of pregnancy participants who favoured antenatal diagnosis were then asked if they would choose to terminate the pregnancy if the foetus was confirmed to have thalassaemia major at an early stage of pregnancy reasons for their responses to both items were further explored where the participants were asked to choose the single most important reason out of a list of predefined choices a space for freetext comments was also allocated if the reason was not among the predefined choices all the data were analysed using spss and results were presented using descriptive statistics we compared the responses of our participants using chisquare tests via crosstabulation for categorical data or t test for independent groups for continuous data this study was reviewed and approved by the malaysian ministry of health research and ethics committee and performed in accordance with the ethical standards in the 1964 declaration of helsinki results all 117 parents approached agreed to participate in the survey one participant did not respond to questions on antenatal diagnosis and termination of pregnancy and was excluded from the analysis thus we achieved a 991 response rate of completed surveys the demographic details of the participants are depicted in table 2 out of 116 parents who completed the survey 83 were in favour of antenatal diagnosis no significant factors were associated with a preference for antenatal diagnosis the 33 who declined antenatal diagnosis gave the main reasons as condition not serious enough to warrant a termination of pregnancy emotional reasons and termination of pregnancy is forbidden by my religion out of 83 parents who were in favour of antenatal diagnosis only 33 were agreeable to terminate a pregnancy carrying a foetus with thalassaemia major for the remainder 50 respondents who declined termination of pregnancy is forbidden by my religion condition not serious enough to warrant a termination of pregnancy and emotional reason were the main reasons given out of the 38 parents who refused to terminate the pregnancy based on religious grounds 36 were malay muslims and the remainder 2 participants were chinese religion was significantly associated with a decision to terminate an affected pregnancy among parents who agreed for antenatal diagnosis with 734 of muslim participants against termination compared to 25 of christians and 133 of buddhists comparing different ethnic groups a greater proportion of malays compared to chinese declined termination there were no difference among the respondents who were in favour of termination versus those who were against termination in terms of gender age highest education level and number of children affected with thalassaemia chinese •buddhist 17 •christian 2 •muslim 1 indian •hindu 2 a the total response is less than 116 due to missing data discussion in a crosssectional survey among 3723 members of the general public in malaysia only 366 were supportive of selective termination of foetuses diagnosed with thalassaemia major as these households have no affected children many may assume that parents with thalassaemic children will be more inclined to terminate affected pregnancies having personally raised a thalassaemic child which leads to greater awareness of the suffering that this condition can where most women wanted prenatal diagnosis as they wish to know their childs condition but they did not necessarily agree to the termination of affected foetuses in our study religious consideration was the main reason offered for declining selective abortion and this mainly affects the malays who are all muslims in malaysia the muslims family and religious practices are guided by authorities like the national council of islamic religious affairs which oversees religious decrees at the national level however in states where there are reigning sultans religious affairs by legislature are under the purview of the various state islamic religious councils the national council decrees are legally nonbinding and serve as guidance to be adopted upon consent of the sultan in relation to thalassaemia the fatwa committee at the councils 52nd muzakarah in july 2002 has decreed that termination of pregnancy before 120 days is permissible if the foetus is disfigured ill and can harm the life of the mother as a foetus affected with thalassaemia major does not fully qualify the above prerequisites this affects the malay muslims full acceptance of termination of thalassaemic foetuses with regard to the islamic stance on termination of a foetus with a serious disorder a number of islamic countries like kuwait and saudi arabia have ruled that termination is permissible before ensoulment at 120 days of gestation in pakistan two renowned islamic scholars ruled that a pregnancy can be terminated if the foetus is affected by a serious genetic disorder and if termination is before 120 days of gestation in iran abortion was illegal when premarital screening was first introduced but based on systematic feedback by the population screened intensive and widespread ethical discussions were held which led to a fatwa issued in 1998 which allowed pregnancy termination up to 16 weeks for some genetic disabling disorders including beta thalassaemia most of the religious edicts do not permit abortion after 120 days unless the mothers life is harmed muslims are committed to comply with religious teachings and religious permissibility in these countries has led to acceptance of antenatal diagnosis and termination of thalassaemic foetuses the acceptance rate was 903 in iran and 752 in pakistan recent studies on muslim populations revealed that education about the religions stance on termination of pregnancy improved uptake of prenatal diagnosis and termination of pregnancies affected by thalassaemia and sickle cell anaemia for example in saudi arabia alkuraya and kilani found that 28 out of 32 muslim participants refused abortion but 13 changed their minds after they were given the fatwa on abortion in egypt where previously there was a poor uptake of termination among pregnant mothers with affected foetuses a recent study showed that with comprehensive indepth counselling addressing the islamic aspects of termination uptake of selective abortion increased significantly these studies highlight the importance of religious permissibility as well as education of the target population to enable a successful prevention programme besides religious teachings other factors which may affect a muslim womans decision on abortion are the perceived severity of the disease and family support in our study 867 of the chinese in malaysia accepted termination most of the malaysian chinese practise a mixture of buddhism taoism and confucianism and a smaller minority embraces christianity the lack of strict religious guidelines on abortion issues less compulsion to follow religious guidelines within the community as well as a more pragmatic approach in life most likely led to the higher acceptance rate of abortion as for the christians who made up 68 of our study population 25 were against termination and those who were roman catholics appeared to decline abortion as this is forbidden among them in our cohort of 116 parents 33 parents have declined prenatal diagnosis and the most cited reason was that the condition is not serious enough even amongst parents who accepted antenatal diagnosis but declined abortion this was the second most cited reason after religious restrictions this viewpoint reflects the improvement in the malaysian health care services for patients with thalassaemia prior to 2005 patients were only provided with free access to blood transfusions and the majority of them succumbed to severe iron overload in their teens however since 2005 the government provides free iron chelation and survival rates together with quality of life have improved leading parents to view that thalassaemia is not a serious condition we did not study the age of the affected children amongst parents surveyed but most of the children were likely to be relatively young as the mean age of their parents in the survey was only 404 years old as most complications tended to set in during adolescence or adulthood parents of these young children might have regarded thalassaemia major as a condition not serious enough to warrant abortion it is likely that these parents have not been adequately informed of the longterm complications management and the effects on quality of life of this condition hence the importance of providing this information during counselling sessions to atrisk couples should be emphasized in the future since year 2005 the malaysian ministry of health has launched a national programme to prevent and control thalassaemia nationwide best possible care in the form of free iron chelation as well as public awareness and health education campaigns are carried out screening however is offered only to interested parties who present to the medical facilities on a voluntary basis and premarital carrier screening in general is still not mandatory after an affected child is diagnosed retrospective genetic counselling is offered as well as cascade screening to relatives prenatal diagnosis and termination of pregnancy for thalassaemia is available since 20 years ago in malaysia this approach which has led to successful prevention in many countries has yet to be actively incorporated into our malaysian national programme partly due to the current conservative and cautious stand on abortion by the consensus decision of the fatwa council members however as exemplified in other muslim countries and precedents from other medicalrelated decrees the consensus opinion may change to accommodate new evidences or other mitigating circumstances that would allow termination of pregnancy in selected cases preimplantation genetic diagnosis which may be more acceptable is still not feasible due to financial and technical reasons we recognise the following strength and limitations in our study the high response rate we achieved to our survey was most likely due to the convenience sample gathered in a single sitting the anonymous manner in which it was conducted as well as the items which were concise and easily understood by our participants who received at least a primary school education as the survey was conducted in settings where their childrens health care providers were present the parents may have been compelled to accede to the request to participate in the survey furthermore in such settings participants responses might be biassed towards giving socially desirable responses despite the anonymised nature of our survey for instance the opinions on prenatal diagnosis and abortion might have been skewed towards what they perceived the health care providers were in favour of when exploring the reasons parents chose a certain reproductive option we provided predefined choices and limited the response to a single selection this approach was useful in standardizing responses but it might not have encompassed the breadth and depth of possible responses which might be obtained had we chosen to explore this in focus group discussions further clarification should have been sought for parents who chose emotional reasons so that their values beliefs or feelings could be identified we used early stage of pregnancy in our survey without specifying the gestational age and this might have led to some uncertainties in the participants responses additionally our study was conducted in the daycare centres of three referral hospitals where two thirds of the patients in johor state sought treatment as well as among parents who attended a thalassaemia seminar in the state capital therefore parents staying in the smaller districts or those who lacked the motivation or opportunity to attend the seminar may be underrepresented lastly the findings in the state of johor cannot be generalised to the borneo state of sabah which carries the highest burden of thalassaemia among all the states in malaysia most of the sabahan patients are from the kadazandusun ethnic group where a sizeable proportion of them are catholics who may reject abortion for thalassaemia major based on religious restrictions conclusion this study highlighted a number of important observations with farreaching implications for the prevention of thalassaemia in a multiethnic country we have shown that even among parents of children with thalassaemia major there is a low acceptance rate for prenatal diagnosis and termination of affected pregnancies acceptance rates for abortion vary markedly depending on the ethnic and religious backgrounds where perceived religious nonpermissibility is an important factor leading to a high rate of nonacceptance among the malay muslims in a country with such a diverse cultural background and religious beliefs like malaysia it is essential for us to understand the issues in depth so that we can implement effective strategies towards successful prevention this study suggests that scholarly deliberations among the malaysian muslim religious authorities that result in a supportive stance in prenatal diagnosis and selective abortion may contribute to a more successful prevention programme but this issue should be approached with a lot of tact and sensitivity besides that education should be improved among parents with affected children and this should include adequate information on the longterm morbidity and mortality associated with thalassaemia they can thus acquire a balanced viewpoint and an informed decision may then be made with regard to their reproductive options our survey seeks to address the views of thalassaemia carriers although their views might not necessarily translate accurately into actual behaviours we therefore suggest that future studies should employ a more objective approach by observing and reporting the actual choices made by participants when offered genetic counselling and prenatal diagnosis last but not the least the health authorities will need to explore various other strategies such as public education an effective national screening programme as well as the accessibility of counselling genetic and antenatal services so as to ensure an effective prevention programme which will be sustainable in the long run

thalassaemia is a public health problem in multiethnic malaysia which mainly affects the malays kadazandusuns and chinese this study the first in malaysia aims to evaluate the acceptability of prenatal diagnosis and abortion among malaysian parents who have a child or children with thalassaemia major and the sociodemographic factors affecting their decisionmaking a prestructured questionnaire was distributed to parents of children with thalassaemia major response rate for completed surveys was 991 out of 116 respondents the majority 83716 were agreeable for prenatal diagnosis but only 33 284 agreed to both prenatal diagnosis followed by termination of affected foetuses of parents who declined abortion 776 cited religious restriction as the main reason and their religious background was a significant factor p0001 with 734 of muslim participants against termination compared to 25 of christians and 133 of buddhists gender age highest education level and number of children affected with thalassaemia were nonsignificant predictors in decisionmaking regarding abortion the acceptance rate for termination of foetuses with thalassaemia major in malaysia is low especially among the muslims due to religious nonpermissibility therefore scholarly deliberations among the malaysian muslim religious authorities that result in a supportive stance in this issue may contribute to a more successful prevention programme

introduction aboriginal and torres strait islander knowledge and wisdom has long recognised the role of social and cultural factors on health and wellbeing aboriginal and torres strait islander holistic health philosophy describes social and emotional wellbeing as the interconnection of social emotional spiritual cultural factors on health and wellness of not just individuals but communities social and emotional wellbeing as conceptualised by gee et al recognises the ongoing influence of historical political and social factors on health and social outcomes these social factors are internationally described and recognised as the social determinants of health and are estimated to contribute to 34 of the overall burden of disease experienced by aboriginal and torres strait islander people both internationally and crossculturally peerreviewed literature has established associations explored pathways and biological mechanisms providing a critical knowledge base on the role of social factors on health despite these understandings there is limited evidence on effective intervention strategies that address how these social factors influence health outcomes within the population recent government consultations highlight the importance of selfdetermined and timely action on the social determinants of health for aboriginal and torres strait islander communities incorporating system responses that are coordinated culturally relevant and strengthsbased health systems face challenges in responding to the complex nature of the social determinants of health with collaborations required across health and social services nonetheless the clinical frontline workforce have been recognised as a potential catalyst for change in any systems response clinical workforce approaches that include screening clients for social and emotional wellbeing facilitate the early identification and management of needs planned and coordinated responses and the monitoring of progress and outcomes in a current context aboriginal community controlled health services and primary health care services are doing whatever it takes to meet the social and emotional wellbeing needs of aboriginal and torres strait islander people which includes addressing the social determinants of health in service delivery consultations with acchos have highlighted key principles which inform holistic approaches to the social determinants of health including selfdetermination accessible and culturally safe care and strong partnerships that support clients to navigate social services a recent document analysis of 67 accho annual reports found that all services were working to improve clients intermediary social determinants of health specifically material circumstances biological behavioural and psychosocial factors whilst structured and funded aboriginal and torres strait islander health assessments for preventative care are widely implemented these assessments are limited by a biomedical focus that inadequately addresses social and cultural factors across organisations there are varied responses depending on the capacity of the primary health care service furthermore service delivery protocols for addressing the social determinants of health and more broadly data systems for monitoring their actions are not well established strengthsbased person centred and empowerment approaches are often used synonymously to describe the delivery of health care for aboriginal and torres strait islander people these approaches promote individuals control over their own lives and focus on abilities and resources to enable selfdetermination aboriginal and torres strait islander people who have increased control and mastery over their lived experiences are empowered in their engagement with social and health services health care services commonly describe intentions to deliver strengthsbased approaches yet the practical and genuine implementation with aboriginal and torres strait islander people is still emerging in practice holistic case management models are well suited for strengthsbased practice which focuses on empowering people to take charge of their own lives and to support the identification of existing strengths and resources case management approaches whilst diverse across disciplines and in different contexts usually include the following core functions assessment planning linking monitoring advocacy and outreach services case management approaches in primary health care with aboriginal and torres strait islander people report improvements in selfrated health status reduction in depression and improved measures of diabetes control these findings suggest that patientled case management has the potential to enhance holistic approaches to social and emotional wellbeing the effects of colonisation and the continuing social and political oppression and dispossession of aboriginal and torres strait islander communities have contributed to significant socioeconomic and health inequities persistent and disproportionate inequalities experienced by aboriginal and torres strait islander people highlight the need to better understand and respond to social and emotional wellbeing needs which includes the social determinants of health there is a pressing need for coordinated best practice responses to social and emotional wellbeing screening and management dedicated resources training and ongoing monitoring existing evidence has not yet described approaches that collectively inform health care responses for aboriginal and torres strait islander social and emotional wellbeing to address this gap a pilot program has been designed within a research setting and includes the following key elements i identifying unmet needs ii strengthsbased case management iii document and monitoring iv culturally relevant supervision and v evaluation the aim of this manuscript is to describe and critically explore the programs key elements from an aboriginal and torres strait islander perspective as part of strengthening practicebased evidence on social and emotional wellbeing discussion program context the cultural pathways program is implemented by wardliparingga aboriginal health equity research team in the south australian health and medical research institute adelaide south australia wardliparingga undertakes research that is of relevance to south australian aboriginal and torres strait islander communities through partnerships collaboration respect reciprocity and for the benefit of community the cultural pathways program is designed and implemented by aboriginal and torres strait islander people as a response to community identified needs the program is implemented within an indigenous methodological framework and from inception to implementation the program has been underpinned by aboriginal and torres strait islander ways of knowing being and doing priority areas for research were established through extensive consultation and engagement with the community all programs of work implemented by wardliparingga have aboriginal and torres strait islander leadership and governance through these structures the community consistently highlighted that more holistic responses which included the social determinants of health were required the research team is predominantly aboriginal and torres strait islander researchers who bring wisdom and experience to the development of the program approach and implementation ensuring consistent alignment with aboriginal and torres strait islander ways of knowing being and doing the program described in this manuscript was approved by the aboriginal health research ethics committee of south australia the program approach includes comprehensive screening utilising a specifically developed holistic screening tool to identify unmet social and emotional wellbeing needs following screening facilitators implement strengthsbased case management through goal setting prioritisation and brokering connections to services program structures embed documentation and monitoring of the programs social and emotional wellbeing responses actions taken to address needs and outcomes for participants these elements are underpinned by culturally relevant supervision reflective practice and evaluation the program approach critically explores the benefits cultural relevance and responsiveness of common practices in case management through a combined understanding of these approaches the program seeks to inform the evidence base for strengthened and coordinated responses to aboriginal and torres strait islander social and emotional wellbeing program delivery is undertaken by male and female facilitators with workforce roles informed by a navigator approach to assist individuals engagement with the health care system and to overcome any barriers to care referrals are received from a largescale populationbased biomedical cohort study of aboriginal and torres strait islander south australians as part of the study all participants receive a comprehensive health assessment that includes questions regarding their social and emotional wellbeing further to this community engagement and consultations highlighted that poststudy followup responses for participants would require addressing social and emotional wellbeing needs such as psychosocial health financial literacy food security and material circumstances participants are offered a referral to the cultural pathways program if unmet social and cultural needs are identified during the assessment the implementation setting replicates realworld service delivery models where presentation may initially be for a physical health need upon receipt of referrals from the study team the cultural pathways program facilitators connect with participants and implement the flexible participant led case management process program elements informing a social and emotional wellbeing response have been detailed within the following sections providing the theoretical underpinnings cultural pathways program approach embedded aboriginal and torres strait islander ways of working and opportunities for strengthening practice identifying unmet needs screening and assessment is a common first point of engagement in health settings and appropriate screening delivered as part of routine practice can enhance the timely and effective identification of needs and accordingly inform responses or prompt a more comprehensive assessment indigenous specific health assessments are associated with improved preventive care for a range of health needs however a greater focus is needed on social and cultural factors cultural pathways program facilitators implement a modified social needs screening tool to identify unmet social needs of participants developed through an aboriginal and torres strait islander researcher led process with community input to ensure cultural relevance and responsiveness the adapted holistic tool covers wellbeing domains including mental health and cultural and community connection and social domains including financial and food security transport employment housing and social isolation the process of cultural development ensures the questions are relevant asked the right way with cultural meaning and are best able to identify the unique needs of aboriginal and torres strait islander participants screening processes for the social determinants must be accompanied by plans for action and as part of the programs case management approach the screening process assists the facilitator to understand participant needs and enables the identification and prioritisation of participant goals by implementing a structured and consistent approach identifying and documenting unmet needs enable the measurement of actions activities and the monitoring of participant outcomes strengthsbased case management the programs case management approach includes goal setting prioritisation and brokering connections to services facilitators work in partnership with participants and tailor responses to individual circumstances and needs a strengthsbased approach to case management ensures facilitators focus on clients abilities talents and resources to enable clients selfdetermination skills develop resilience and the ability to respond or navigate similar situations in the future goal setting is a common step in the case of management process with theoretical concepts highlighting the importance of collaboration for effective goal setting an individuals sense of control and autonomy influence their willingness to set goals and efforts for achieving them the australian integrated mental health initiative is an existing framework that uses strengths based story telling the cultural pathways program implements a goal and priority setting framework utilising the aimhi pictorial care plan to explore physical emotional spiritual cultural family social and work contexts to identify worries strengths and resources consistent with aboriginal and torres strait islander ways of working facilitators work in partnership with participants to identify and prioritise issues of most importance that will support improved wellbeing as part of the strengthsbased empowerment and personcentred approaches participants define their own priorities contributing to enhanced autonomy control and selfefficacy as part of the brokering approach to case management facilitators connect participants with services to meet their needs making a referral to other services organisations or agencies are widely implemented in health and social services social and emotional wellbeing and social determinants of health needs span across sectors with often multiple services and agencies involved this requires coordination to minimise the burden on service users and to enable referrals and connections brokering connections relies on relationships understandings of what is available across the breadth of health and social needs and understandings of culturally relevant services to support this approach facilitators undertake service mapping exercises to identify the available services and will proactively seek the most appropriate service to connect a participant to and reduce barriers to access these services facilitators actively support participants to access services by contacting services on behalf of participants supporting participants when they contact services themselves and follow up contact with participants to monitor progress if necessary facilitators address any challenges or barriers to support the best possible outcome the active and coordinated approach to brokering connections enhances service access for participants and enables the program to also monitor brokerage outcomes documentation and monitoring program monitoring involves measuring and reporting on progress and creates opportunities for continuous quality improvement currently health services rarely systematically collect data about or measure activity on the social determinants of health and require a mechanism to monitor and evaluate the impact of social and emotional wellbeing services they provide to address health outcomes comprehensive understandings of the most appropriate measures for aboriginal and torres strait islander social and emotional wellbeing and the social determinants of health are still emerging existing national measures of wellbeing include psychological distress positive wellbeing anger life stressors discrimination cultural identification and removal from natural family measures for the social determinants of health as described by the world health organization conceptual framework and outlined in the aboriginal and torres strait islander health performance framework include domains such as connection to country education employment health system housing income and transport the cultural pathways program combines social and emotional wellbeing and social determinants of health measures as part of the programs monitoring framework the program utilises redcap a secure web platform for managing online databases the platform collects participant information demographics and activity data which include when and how people are contacted and the services provided by socialhealth domain the program measures factors such as unmet needs identified goals whether they have been achieved and the service connections made the program utilises routine data for ongoing monitoring quality improvement and as part of funding requirements and obligations the data collected by the program was informed by aboriginal and torres strait islander understandings of health and wellbeing and the wisdom and expertise of the research team and community the process included the collective development of culturally relevant measures in relation to social and emotional wellbeing specifically practical ways to measure progress towards addressing complex social and cultural factors this process enabled the program to capture information that is useful and relevant for aboriginal and torres strait islander people a structured and consistent approach to identifying needs and a specifically designed monitoring framework enables the program to measure progress or outcomes which can be used to understand the needs of service users to plan responses and to advocate for resources culturally relevant supervision reflective practice and clinical supervision are recognised by many professions for their role in supporting enhanced clinical practice as well as the health and wellbeing of the workforce this is particularly important for aboriginal and torres 4 tina brodie et al strait islander health workers and practitioners who have complex experiences including burnout and vicarious trauma the aboriginal and torres strait islander health workforce and nonindigenous workers in aboriginal and torres strait islander health contexts require access to highquality cultural and clinical supervision which supports cultural safety improved practice and wellbeing available frameworks for culturally appropriate supervision with aboriginal and torres strait islander people include considerations for working with community looking after self understanding of roles and professional practice koivu et al 2012nelson et al 2015scerra 2012 the cultural pathways program utilises these existing frameworks as well as the knowledge and experience of program staff to implement a culturally relevant reflective practice and supervision model an experienced aboriginal clinician supports facilitators through a range of structures including weekly clinical yarning one to one yarning and debriefing opportunities as required facilitators share perspectives feelings challenges barriers and enablers in relation to both clinical practice as well as system policy and organisational factors which impact the participant facilitator or the program fundamentally the supervision and reflective practice model are culturally grounded in relationships and yarning to support the cultural safety for aboriginal and torres strait islander participants whilst also enabling the retention and wellbeing of the aboriginal and torres strait islander workforce developmental evaluation evaluating health programs and initiatives supports implementation across different contexts utilising insights into how and why they work and whether they have been effective there is an increasing recognition of the important role of evidencebased programs featuring high quality and culturally relevant evaluation the cultural pathways program is underpinned by an indigenous methodological evaluation framework which utilises developmental evaluation an approach to evaluation that supports innovation and adaptation in complex environments and is consistent with indigenous methodology and participatory approaches requiring partnerships trust and shared decision making the key to developmental evaluation is that the evaluator works with the team in realtime asking evaluation questions examining and tracking implications of adaptations and providing timely feedback as the program is implemented and modified or adapted as needed the evaluator as an aboriginal woman is immersed in as an insider drawing heavily on reflective practice and utilising the cultural knowledge and expertise of the evaluator as part of the evaluation method the aim of the evaluation is to understand the process including what was delivered how it was implemented and the experiences of program participants the evaluation through reflective and formative methods supports further understanding on the interactions between facilitators program participants and the broader health and social service contexts the evaluation framework includes community engagement governance and approaches which have been purposely selected for their consistency with indigenous methodologies this framework ensures that the participation and voice of the community are therefore embedded throughout implementation to support tangible benefits to the community conclusions there is a knowledge to action gap on how to assess and address the social determinants of health within clinical practice to inform the development of coordinated culturally relevant and strengthbased responses to meet the holistic social and emotional wellbeing needs of aboriginal and torres strait islander people and communities primary health care services often as the entry point for accessing health services are well positioned to implement coordinated health equity responses which include addressing the social determinants of health the absence of a readily applied model creates challenges for the provision of coordinated resourced and systemic responses to the social determinants of health routine screening for unmet needs implementing strengthsbased practice connecting people to what they need monitoring service provision and providing clinical and cultural support for the aboriginal and torres strait islander workforce align to existing practice and are transferable across contexts continuous quality improvement and monitoring enables primary health care services to embed new practices into services systems and routines the ability to implement holistic approaches to aboriginal and torres strait islander health through the intersection of health and social services requires adequate resources training and support to clinical workforce including consideration of roles responsibilities scope of practice and readiness to implement strengthsbased approaches these changes cannot be implemented without addressing the ongoing impacts of racism and oppression of aboriginal and torres strait islander people allowing for culturally safe systems which are able to meet holistic social and emotional wellbeing needs the cultural pathways program builds on existing approaches to contribute to practicebased evidence of culturally relevant case management approaches which can be utilised as part of routine care to strengthen the systematic identification and response in primary health care delivery the combined understandings of the elements outlined in this manuscript provide a framework to inform service planning and tailored implementation which can strengthen social and emotional wellbeing responses for aboriginal and torres strait islander people policy health systems and inequity comprises a unique comprehensive skillset relevant to existing and emerging complexities of aboriginal health and wellbeing specifically odette seeks to understand how institutional policies and practices drive health and social inequities experienced by indigenous populations her novel approach is the use of communitylevel information to show and explore the reasons for variations in disadvantage both within the aboriginal community and between the aboriginal and nonaboriginal community integral to her research is the inclusion of aboriginal communities in defining their health and wellbeing and how indigenous data can be governed in the future to derive greater benefit for the population luke cantley has family connections to the gunditjmara nation of victoria and is a research associate located within flinders university through his research luke is determined to solidify aboriginal culture as a protective factor within the child protection system whilst exploring the nuances between child safety and cultural safety luke holds extensive knowledge on the role unmet social and cultural needs have on positive health outcomes within the aboriginal and torres strait islander community and holds a strong passion for advocating for increased health care utilisation for health care consumers luke has gained extensive experience working as an aboriginal health worker within a strengthsbased approach across diverse sectors including prison health primary health care public housing and mental health services developing expertise in 1 culturally appropriate and ethical ways of engaging within the community 2 health and wellbeing assessment methods fostering participatory action research and 3 social inequities generated by reduced access to services or resources peita cooper has a bachelor of social work and currently works within the justice sector peita commenced as a graduate in wardliparingga aboriginal health equity theme at the south australian health and medical research institute as a program facilitator peita contributed to the delivery of strengthsbased case management and developing culturally responsive practice with aboriginal and torres strait islander peoples and communities her previous experience includes working in the disability sector seth westhead has family connections to the awabakal and wiradjuri nations of nsw and is a research associate with wardliparingga aboriginal health equity theme south australian health medical research institute through his research work seth strives to better understand how social and cultural determinants drive health and social inequities within society particularly as it relates to the indigenous population he seeks to better equip communities and young people with tools and evidence for public health advocacy and enable communities to translate health research into meaningful action specifically seth has expertise in the 1 conceptual development of aboriginal specific social determinants and wellbeing frameworks and tools 2 implementation of projects involving community engagement and communityled governance structures 2 and 3 undertaking of qualitative research methodologies and community and stakeholder participation interpretation of findings alex brown is an aboriginal medical doctor and researcher he is the theme leader of wardliparingga aboriginal health equity and professor of medicine at the university of adelaide he grew up on the south coast of new south wales with family connections to nowra wreck bay and wallaga lake on the far south coast of nsw over the last 20 years alex has established an extensive and unique research program focused on chronic disease in vulnerable communities with a particular focus on outlining and overcoming health disparities he leads projects encompassing epidemiology psychosocial determinants of chronic disease mixed methods health services research in aboriginal primary care and hospital settings and randomised controlled trials of pharmacological and nonpharmacological chronic disease interventions alex has been heavily involved in engaging government and lead agencies in setting the agenda in aboriginal cardiovascular disease management and control and chronic disease policy more broadly he sits on a range of national committees and cochairs the indigenous research health fund through the mrff natasha howard is the wardliparingga platform lead implementation science the platform incorporates a systems view and privileges indigenous knowledge to deliver mixedmethod interdisciplinary perspectives which aim to generate policy and practicebased evidence on the social determinants of health her experience spans both the health and social sciences applying population approaches to investigate how the social and built environment enables and promotes cardiometabolic health and wellbeing notably for priority populations she has been active in advocacy and mentoring of the local population health community in both research and practice conflict of interest none ethical approval this program was approved by the aboriginal health research ethics committee of south australia

aboriginal and torres strait islander holistic health represents the interconnection of social emotional spiritual and cultural factors on health and wellbeing social factors education employment housing transport food and financial security are internationally described and recognised as the social determinants of health the social determinants of health are estimated to contribute to 34 of the overall burden of disease experienced by aboriginal and torres strait islander people primary health care services currently do what it takes to address social and emotional wellbeing needs including the social determinants of health and require culturally relevant tools and processes for implementing coordinated and holistic responses drawing upon a researchsetting pilot program this manuscript outlines key elements encapsulating a strengthsbased approach aimed at addressing aboriginal and torres strait islander holistic social and emotional wellbeing the cultural pathways program is a response to community identified needs designed and led by aboriginal and torres strait islander people and informed by holistic views of health the program aims to identify holistic needs of aboriginal and torres strait islander people as the starting point to act on the social determinants of health facilitators implement strengthsbased practice to identify social and cultural needs eg cultural and community connection food and financial security housing mental health transport engage in a goal setting process and broker connections with social and health services an integrated culturally appropriate clinical supervision model enhances delivery of the program through reflective practice and shared decision making these embedded approaches enable continuous review and improvement from a program and participant perspective a developmental evaluation underpins program implementation and the proposed culturally relevant elements could be further tailored for delivery within primary health care services as part of routine care to strengthen systematic identification and response to social and emotional wellbeing needs

moving furniture in the context of tango dancing only became clear to me five months later according to a common way of evaluating female performance in tango dancing women who deploy the ability to respond immediately and effortlessly to their dancing partners movements with the complementary ones are considered to be light women in this context light means kinetically imperceptible and predictable so as to allow for male choreographic improvisation trying to understand the selfimage of latin american women many anglophone studies have turned to the influence of catholic feminine images especially the virgin mary following the analysis of emily stevens in female and male in latin america albeit later studies have criticized this emphasis on marianismo for providing a passive image of women the prevalence of gender images of catholic origin continues to dominate research on the continent studies continue to discuss womens interpretation of these images the moral lessons derived from them and how they use them to maintain valued selfconcepts based on 12 years of participant observation in tango milonguero lessons first as a student of the womans role then of the mans role and finally as a teacher and at nighttime milongas in downtown buenos aires i take here a different stance analysing the image of the light women as an allegorical rendition of heterosexual relationships originating in tango dance halls this analytical frame is inspired by cultural critiques viewing feminine figures elsewhere as the product of the allegorization and feminization of the relationships of colonizers with the colonized and conquerors with uncultivated lands at a difference with this literature it considers the image under study as emerging from the immediate context where it is exchanged thus this work aims to make a twofold contribution to sociological knowledge on feminine images first it seeks to enlarge knowledge on the diversity of feminine imagery in latin america by depicting a feminine figure that shows no connection to catholic imagery second by showing the resonance of the image of the light woman and the characteristics of heterosexual relations in tango social dance events this article suggests the possibility that gender images may be understood as the feminization and allegorization of relations involving men and women in the very contexts where such images circulate milongas and tango milonguero lessons in buenos aires the word milonga designates either a musical genre or a public social event where people dance tangos milongas and valses criollos i here employ the term in the latter sense as a dance event with few exceptions while saturday night milongas are traditionally attended by couples who go to dance with each other and their common friends those taking place from sundays to fridays are attended by people who go alone or with tango classmates and friends to dance with partners they meet there among the latter there is a small but growing number of milongas where homodancing prevails throughout this article i refer to milongas taking place on sunday to friday nights in downtown buenos aires where heterodance prevails regular attendants called milongueros distinguish orthodox or traditional milongas from relaxed ones milongas relajadas sometimes called practices orthodox milongas is a native term that indicates dance events that are regulated by strict codes accordingly men and women sit opposite each other on either side of the dance floor there is a strict dress code of smart clothes and leather shoes and no jeans or trainers are allowed men invite women to dance by fixing their gaze on those who are watching them and then moving their heads upwards and sideways a move called cabeceo if the woman nods acceptingly the man will go up to her table and then escort her to the dance floor after the dance he will accompany her back to the table the couples dance lasts four tangos four milongas or four waltzes depending on each specific tanda as these sets of music are called in these milongas the dancing tandas only include these rhythms played in succession and divided by cortinas that is excerpts of other musical genres that nobody dances to at the beginning of each tango the couple spends a few seconds in small talk and then starts dancing anticlockwise without overtaking or touching other couples and only stopping to make some steps for no more than two or three counts if the space allows or else they keep moving forward the couples feet do not lift high from the floor specially to avoid movements that may hurt nearby dancers once the tanda is finished the man walks the woman back to her chair and returns to his in order to invite another partner when the following set starts the distribution of the places where one can sit is dictated by the time and frequency a person has been attending the milonga or others within the same circuit when people are sitting at the tables they do not talk or only do so in a low voice in order not to disturb the dancers the music played is mostly the recordings made by the typical orchestras in the 1940s these orchestras are known by the names of their directors each tanda usually pays tribute to one of these artists thus providing rhythmic homogeneity generally speaking the orthodox milongas are more populated by older people than the relaxed ones although there may be a few younger dancers especially women in the former there is a criteria based on dance standards when choosing a partner the evaluation of these standards is related to the years spent in the milonga and the reputation of the dancers there is a tendency to choose partners who have the same dance level although young women can quickly climb up or skip the hierarchy because of their beauty most of the codes respected in the orthodox milongas do not exist in the prácticas and relaxed milongas here people attend in mixed groups and share the same table talk while others are dancing and pay less attention to what happens on the dance floor except when a new tanda begins and invitations are made to dance besides tangos waltzes and milongas it is common to have a tanda of other rhythms during the night the dance floor is not as clearly separated from the walking areas and there are verbal invitations to dance as well as cabeceos on the dance floor figuras on the spot are frequent with legs unfolding upwards backwards or sideways contact with other couples is if not welcomed at least tolerated and excused with a smile as long as it is followed by an apology the circulation is still anticlockwise but it becomes slower as each couple stops to make more intricate movements taking up more space and time often couples of women or men dance together and in some though it is still rare women lead and men follow many of these milongas include tandas of live music and recordings that would be unsuitable in an orthodox milonga either because of their nature far from the typical orchestras from the 1940s and their compositions for piano bass violins and bandoneones or because they include more recently composed tangos in general in these prácticas or relaxed milongas the entrance fee is lower than in the orthodox ones and occasionally the fee is a la gorra that is at the discretion of the attendees who contribute with what they can despite the differences regarding codes both orthodox and relaxed milongas forbid any erotic gesture beyond the limits established by the dance itself with rare exceptions dancers leave the room on their own with a person of their own gender or in the relaxed milongas in a group there is no apparent sign of attraction or desire beyond the dances embrace and the couples are renewed in each tanda it is still rare to see the same couple dancing more than a tanda in the same milonga as this is considered a sign of mutual attraction the organizers of orthodox milongas make sure the codes are respected and warn newcomers who may challenge them they may even expel them if their warnings are not followed the exclusion of any sign of heterosexual attraction beyond the dances embrace also characterizes the relaxed milongas albeit without a direct control from the organizers during my fieldwork i attended both orthodox and relaxed milongas first with my teachers and classmates and then with my tango students and fellow teachers with them i also shared and organized dinners birthday and christmas parties paid and received visits attended shows looked for places to offer tango lessons and participated in negotiations with their owners and administrators travelled on long weekends and trained new teaching assistants and teachers because of the secrecy surrounding affairs originating in milongas the close friendship relations that i established with many of them along the past 12 years were central to gathering data for this article although at the beginning of my fieldwork i attended a number of tango classes in diverse styles i finally opted for remaining in tango milonguero ones which i took in four different schools tango milonguero is a style created by the codification and commodification of the dance of the milongueros as practised in downtown buenos aires it was developed by two female teachers and one male teacher at the beginning of the 1990s susana miller ana maría schapira and cacho dante old milongueros from the city centre had always considered their way of dancing tango impossible to teach collectively as they had acquired their knowledge in secret practices with more experienced dancers and by constant participation in the milongas after collaborating with dante however miller started creating with ana maría schapira a method to teach the dance in this way they appropriated the only recognized knowledge in the tango dance the mans role and codified it as part of the process they selected elements coming from various movement techniques and they codified the combinations of steps made by many different milongueros thus they created the milonguero style and developed a teaching method from these milongueros they inherited the concept of the light woman as the ideal dancing partner and then they spread it among their students once this method came into being the tango milonguero classes in the city as well as in various european and north american countries multiplied due to their teachings and that of their collaborators students and assistants there were also some old milongueros who with less success decided to start their own classes and obtain the financial benefits that these produced the tango milonguero classes were added to the other preexistent styles the tango salón escénico and nuevo classes that professional dancers and milongueros from the neighbourhood of villa urquiza and its surrounding areas had been delivering in buenos aires before the 1990s therefore these classes became part of a growing process of commodification and collectivization in the teaching of the tango dance that had some precedents in previous decades but never enjoyed the success and growth that this decade would bring because of the sustained direct and frontal contact between the upper part of the torso of both members of the couple the milonguero style in general is still considered by present dancers as the most obviously erotic experience within tango dancing it is often stated that milongueros created this style in the sweet shops of the city centre in order to hold tight or grope the women they met there who were far from the family control exercised in the neighbourhood clubs following the tradition started by miller and schapira tango milonguero teachers use a vocabulary that makes reference to changes of weight balances stretches flexions muscles and also torso hips legs knees and feet positions that remain unknown to most dancers who were dancing it socially before the 1990s in the lessons the use of technical and anatomical vocabulary somehow blurs the erotic connotations of the close embrace and of the chest to chest body contact that characterize both the milonguero dance of the city centre and the milonguero style the language taken from classes in other dance genres like ballet or contemporary dance makes tango lessons similar in appearance to them light women dancing tango older milongueros attending buenos aires downtown milongas often criticize and dismiss as potential dance partners women who intentionally or not perform moves of their own or at their own rhythm as it hinders the development of the choreography the male dancers are creatively improvising professors who inherited and teach their art during tango lessons also transmit these expectations regarding the dance of women so both at traditional milongas and during social tango lessons it is said that women who move without their companions indication are like truckdrivers this figure stereotypically associated with lack of good manners and delicacy conveys the idea that by leading instead of letting their partners lead they become masculine women who delay their response to the males moves are said to be heavy women pieces of furniture or refrigerators that hinder the creative freedom of their male companions each tango step is initiated with an almost imperceptible movement of the mans torso known as la marca this movement announces for the woman what his next step will be then ideally she will perform the expected complementary movement at the same time that he performs his step the more precisely and on time a woman responds to her partners movements the less he has to worry about what she is doing if he knows the music by heart as is usually the case he can create a choreography of various movements in advance for the couple to perform being sure that she will answer as expected or as tango dancers usually say that she will follow him he will then conclude that she is a light woman instead when he has to stop the performance of his ideal choreography and adapt it to his partners rhythm because she does not respond as fast or precisely as he expected he will assert that she is a heavy woman or a piece of furniture the heaviness or lightness of female dancers is therefore independent of their body weight tango lightness does not relate either to the ethereal quality of movement expected from ballet performers since the 19th century thus in the context of tango lessons and milongas womens lightness is a necessary complement to the males creative freedom creativity improvisation and the ability to surprise their dancing partners are central attributes of the esteemed male dance tango dancing in downtown milongas allows for advancing and retreating stopping and going around left and right displacements sudden stops and rhythm changes doubling beats and skipping beats changing from following the rhythm of the bandoneón to the melody of the violin initiating advances that will end up in backward movements long walks and long pauses the ways milongueros move around the dance floor resonate with the ways buenos aires dwellers drive and once played football it is full of amagues minimal movements indicating they will go in one direction to suddenly change to the opposite so each milonguero dances adapting his own movements to a moving scene that changes all the time in unpredictable ways while each milonguera dances adapting to a partner who moves all the time in unpredictable ways in the film tango bayle nuestro director jorge zanada includes a scene in which a group of milongueros watch the performance of a group of tango stage dancers who are being filmed for an english television programme at the end almost unanimously the milongueros remark with disgust that the dances were previously choreographed tango according to their own way of describing their art should always be improvised spontaneous never planned or repeated every tango danced by a milonguero is in their own eyes a transient creation freely invented at every instant product of the moments inspiration for them like de certeaus tactics tango dancing neither follows nor leaves footprints creatively solving the many problems they may encounter on the dance floor a couple that suddenly stops in front of them another one that quickly approaches from the side a third one pushing from behind while they interpret with their bodies the variation played by a violin the sudden dash of a piano or the slowing movement of a bandoneón at the end of a tango milongueros see themselves as free creators who improvise their dance following the moments inspiration and are proud of this ability to experience this freedom what they call a light woman as their dance partner is considered a necessary requirement a light partner is for these social tango dancers one that relaxes and allows herself to be carried through the floor never responds to their cues with an impromptu movement never stops unexpectedly never generates by herself a movement that will surprise them with a light woman the milonguero can feel that he freely creates the dance in her body as a young and famed professor likes to say a light woman is a stradivarius as legendary dancer juan carlos copes calls his equally renowned partner maría nieves or a ferrari allowing a swift ride through the dance floor in the words of a student of the school where i teach as a canvas that absorbs paint in a constant fashion or a violin that produces exactly the desired sound the light woman always moves as expected in response to the improvised imaginative inspired move of her partner thus contributing to his creative freedom feminine images in latin america following the analysis of emily stevens in female and male in latin america a considerable number of anglophone studies addressed the issue of the influence of catholic feminine images especially the virgin mary on the selfimage of latin american women while subsequent studies criticized the passivity that the author attributed to them in her study of marianismo as a latin american ideology of womens spiritual superiority the prevalence of images of catholic origin continues to dominate this body of literature thus studies continue to discuss how women interpret these images what moral lessons they derive from them and how they use them to maintain valued selfconcepts or legitimize their choices some studies on masculinities in latin america have also analysed how men label women with categories derived from images such as saints and virgins argentine social scientists studying the field of music have departed from the assumption that feminine imagery necessarily derives from the catholic church but not always from the one that assumes this imagery as inspired mostly or exclusively by the behaviour of women thus martín suggests that images of women in the lyrics of a local genre called cumbia villera may indicate transformations in the female role in intimate relations following her lead vila and semán argue that the frequent labelling of women as whores and of performing explicitly sexual practices in this genre is a reaction to what the authors call the sexual activation of women images depicting women seeking sex are a result of the infantile attitude with which men dominant but besieged contemplate the lively sexual activity of some women and fantasize that most of them exhibit this behaviour accordingly the masculine voice heard in cumbia villera lyrics no longer describes women as passive objects instead it describes them as powerful thus for vila and semán through name calling lyrics men try to keep control of womens sexuality when they have already lost it feminine images are for these authors a masculine reaction to changes in womens practices these changes are in turn indicative of a subversion of heterosexual power relations archetti has made a similar argument in relation to the frequent mention of the figure of the milonguita in tango lyrics during the first decades of the 20th century around 1920 the daughters of recently arrived european immigrants ventured to public entertainment places that constituted a new presence in downtown buenos aires dancing tangos in public places sharing embraces that were neither approved nor controlled by their families and establishing heterosexual relations with men on the basis of personal preferences these young women inspired tango composers themselves descendants of immigrants to create an impressive amount of lyrics portraying female figures they named milonguitas for archetti these tangos were a masculine reaction to womens escaping the close control exercised by their parents at a time when the vision of a nonaccompanied woman in a public place constituted a rare occurrence and to watch one embracing a man was downright inconceivable influenced as they were by romantic literature tango writers did not call them sluts but their lyrics attributed to those milonguitas characteristics that bear a strong resemblance to those associated with whores these include their demeanour they were always depicted as laughing and drinking champagne an interest in acquiring luxury symbols as a result of their relationships with men and a marked disposition to abandon true love in the pursuit of a good catch thus both archettis and vila and semáns analyses argue that lyrics either labelling women as sluts or attributing them whorelike traits are male reactions to novelties in female behaviour women dancing in new more sensual ways and establishing heterosexual relations in ways that were until then considered improper other authors have analysed stereotypical feminine figures in tango lyrics as controlling images which have pedagogical effects on women armus interpreted a widespread tango image women dying from tuberculosis as the feminization of illness for the author this feminization served moralizing purposes along the same lines campodónico and gil lozano have analysed the contrasting figures of the milonguita and the mother both in tango lyrics and films as constructions also having moralizing effects over women some studies on gender images in latin america have departed from the assumption that these are reactions to changes in womens behaviour and primarily affect them authors have made efforts to show that recurrent female and male images reflect not only gender but also class and ethnic inequalities savigliano takes a similar stance asserting that in tango gender is a metaphor condensing racial class and colonial inequities but in other sections of the same book she also considers that tango lyrics reflect the real behaviour of women describing their abilities to subvert gender relations both while dancing and loving a man the author states that milonguitas are apparently docile women but they finally leave men who oppress them based on 12 years of participant observation in tango lessons and milongas in downtown buenos aires i take a different stance and analyse the image of the light women as an allegorical rendition of heterosexual relationships originating in milongas etymologically allegory means other speech it conveys an open declamatory act that contains another layer of meaning in western painting and sculpture the female form has been very frequently used to allegorically represent a variety of concepts such as freedom justice revolution youth and death among many others rarely used by sociologists the concept of allegory has sometimes been employed by cultural critics to analyse colonial relationships jenny sharpe has used it to analyse narratives of rape written by colonizers in india she argues that the images of the white innocent woman and the indian rapist are allegories of the colonizercolonized relationship elaborated by the former when the continuity of the empire was threatened by rebellion in turn rebecca blevins faery has noticed that images of naked women and virgins were produced by colonizers and conquerors as allegories of america to depict it as a vacant and uncultivated land with a slight twist on this literature i consider the image of the light woman as emerging from the immediate context where it is exchanged showing the resonance of the image of the light woman in dance and the characteristics of heterosexual relations in tango social dance events heterosexual relations in buenos aires downtown milongas the dance floor as a place of transient and generalized eroticism tango is almost universally defined as an erotic sensual or passionate dance by those who watch it and by those who advertise it for international consumption however the way social dancers and teachers refer to it in buenos aires does not match this description old milongueros publicly state that they dance for the pure joy that it brings them and thus hide from novices any possible erotic attraction a link that however they will acknowledge in a whisper when they are among friends the majority of those who started dancing from the 1980s onwards clearly distinguish between the pleasure that the dance produces from that associated with sexuality or with any other emotional link they frequently state that there are partners they like dancing with because of the way they dance that there are others who dance badly but feel sexually attracted to and that there are partners with whom they enjoy dancing because they are funny or have a good vibe or are friends this feeling of friendship is particularly encouraged in tango classes finally whatever pleasure one may derive from a particular partner most milongueros consider this should only be articulated within the couples inner sphere and never made evident to those around thus even if social tango dancing may seem erotic to the onlooker this eroticism appears to be evenly distributed between all the dancers with no special liaisons arising between any of them but for a brief moment tango eroticism also seems extremely mobile for couples reshuffle as soon as a musical tanda ends when tango dancers experience pleasure or erotic attraction during the dance the signs used to indicate this are usually subtle and only understood by the partner a touch delayed for a few seconds a hand that slides upwards to reach the flesh in the neck above the shirt collar or dress cleavage some unavoidable contact that is a bit longer than the music concedes or the imperceptible repetition of certain movements that allow more and sustained contact an example of the expected limits of such signs happened when several advanced students teachers and assistants of a milonguero tango school were watching the organizer of one of the socalled relaxed milongas at the same place where they taught and learnt once a week because of the unusual explicitness of the erotic contact he displayed when dancing with his partner the women nicknamed him the groper lara carina camila andrés and i were looking at the groper dancing with one of his friends he invited her to open her legs wide and he put one of his legs between hers embracing her around her waist and making both bodies go upwards and downwards then he put his hand with his fingers downwards on her bottom and he slid it upwards slowly but surely we all watched from our chairs with our bodies and heads together moving from side to side in order not to miss any of the scenes that the column that separated us from the dance floor hid from us lara put her hands in her stomach and made a painful face its like watching porn andrés says yes answers carina i dont have a problem with porn movies but this is like watching one at home in the living room with your family martín another teacher ironically asks do you know the name of that guys dance style uruguayan tango its the one walter and waldo taught in chachacha making reference to a tv comedy in which a pair of men parodied tango classes through grotesque performances we all laughed until the moment luciano said no its called erect tango this unanimous censure when confronted by visible and openly sensual movement as displayed by the organizer shows the preference for invisible and subtle tactile and only perceptible to the occasional partner demonstration of attraction and erotic pleasure during the tango dance it also explains why for many milongueros explicit demonstrations of passion associated with stage tango look ridiculous and become the object of parody and jokes within the context of social tango as a result of this subtlety when watching the dance floor in a milonga no special attraction appears to link the members of any given couple this impression is still more vivid since all couples are reshuffled every set of four pieces of music when a musical tanda finishes everybody goes back to their seats searching for a new transient dance partner as soon as the music resumes thus no special liaisons appear to arise between any of them tango eroticism also seems extremely mobile since those who seemed attracted to each other moments before are likely to be showing identical interest in new dance partners as soon as they begin to dance with them however every milonguero or milonguera recognizes that occasionally they have experienced an exceptional connection during the dance that developed into erotic encounters beyond the confines of the milonga when sexual encounters recur milongueros refer to the relationship as a story a native term i will use from now on there are as we will see hidden liaisons involving sex between those attending the milongas and that remain unnoticed by others or when noticed unspoken in the common milonguero language this concealment is reinforced by statements such as you go to the milonga to dance and i choose my partners because of their dance though they may add afterwards in a whisper and if i also like them all the better light heterosexual relations everybody knows that there is flirting in a milonga but how you hit on someone is still a mystery to me since the rules of conduct in milongas differ markedly from those applying in the world outside los códigos de la milonga the milonga codes keep the limit between those in the know and those who do not know between oldtimers and newcomers keeping the latter away from the dance floor and making their initiation into a very gradual process although everybody in the milonga knows that there are códigos and milongueros like to convey some of them to newcomers they never mention rules organizing sexual encounters among them the prospective milonguero has to discover this implicit aspect of the code by observation spending time in milongas catching words and attitudes and especially by listening to the warnings and secret anecdotes of close friends as a general rule in the milongas of the city centre that take place from sunday to friday dates are arranged without any public display of affection or attraction beyond the tangos embrace for unknowing watchers and newcomers milongas appear as a space clearly divided between a dance floor where the dance evolves in all its erotic flair and its surroundings where eroticism is completely absent thus most of the stories born in the milongas remain publicly hidden except to the most intimate friends of those involved who in turn will never acknowledge knowing even while interacting with the participant in the story who is not the one that revealed it only a fraction of those attending a milonga regularly get to know some of the stories through whispers or gossip that on the other hand is always suspected of being made up since further evidence is very difficult to gather the evaluation of the gossips veracity will depend on the intimacy between the listener the teller and those involved a dramatic illustration of this invisibility regarding relationships took place at a milonga where i used to go weekly and involved a woman who used to sit next to my table we had always greeted with a hug and we used to exchange a few words during the night on one of these occasions she started crying when i asked her what had happened she told me that one of the regulars in the milonga whom i also knew had died she then told me that she had had a story with him for over two years but had never told anyone because he did not want others to know another friend then confirmed this revelation while adding that the man in question had forbidden her to tell because he was a womanizer and did not want other women to know about their affair throughout the night the woman revealed her relationship with her deceased partner to each person who greeted her with a hug after seeing her crying and she remained sitting at her usual table and without concealing her grief without such drama there were several occasions on which i got to know by chance about stories that involved friends and acquaintances and even students and classmates i used to meet regularly either i would see them together in the street after they had parted their separate ways or after a fight one of the partners would reveal the story or a close friend could tell in revenge after an argument with a member of the couple i have also helped cover up stories of close friends by leaving the milonga with them so that they could meet their partner later outside the occasional couple who has met during the context of a dance will hardly ever leave the room together or at the same time on the contrary it will be during the initial musical phrases that start each tango that the date will be set then they will return to their respective tables and they will meet again in another place at another time far from the other participants gaze these meetings can either be set for the same night at a specified time establishing who leaves the milonga first and in which bar or street corner nearby they will meet or it may be set for a different night if it is not possible to agree on a date and time telephone numbers will be exchanged in the corridors in discreet and coordinated visits to the toilets or at the door in the entrance hall on the balconies or when going out to smoke or take fresh air always depending on the hidden and empty spaces that the milonga may offer in milongas attended by younger people where social gatherings outside the dance floor are more common there is another unwritten code that enables the possibility to coordinate secret dates friends will never approach a man and a woman when they are speaking privately unless both of them belong to a group of intimate friends classmates generally and they are certain that there is no possible story between them though as i have realized sometimes that certainty may not match the reality of the situation i remember the shock of a female tango student who worked as producer of a rock band and had just started attending milongas when her teacher got angry with her because she had approached him while he was talking to another woman in the entrance hall i just cant understand this she said in disbelief in the rock environment these things dont happen on the other hand stories do not have visible consequences in the way their main protagonists will interact in future milongas and thus remain invisible they may dance together in the future or not if she ignores the males cabeceo or if he disregards her enticing stare if they do dance again they may arrange a new date or not if one of them suggests meeting on the same night the other can always make up an excuse i have to work early im knackered or i have to take my mum to the hospital tomorrow this excuse may allow a secret meeting with another person from the same milonga on that very night thus secrecy allows milongueros and milongueras to be involved in several stories at the same time and to choose the person they want to leave with on each night it also allows them to try and start other affairs with new partners as one of them once illustrated if i let other people know that i have a story with a woman in a milonga i am stupid because i am missing out on pulling all the other ones in general the few women who publicly proclaim their stories either verbally or in gestures in the milonga confines are either described as clumsy or crazy moreover those involved will spread the idea that they imagine things on the other hand those men who show their attraction towards a woman through gestures are called slimy this is more common when they are newcomers generally speaking most people who attend milongas learn quickly the code of secrecy and respect it however in private conversations women complain more often than men about keeping their stories secret especially when they continue over time though both men and women sometimes exercise the right to this free sexual circulation guaranteed by secrecy it is as far as i know much more common for men than for women to be involved in several long stories developing at the same time this practice is not absent among women but especially those above 30 tend to finish a long story before starting a new one since women more frequently complain about events regarding stories one could argue that milongueros are more suited to this way of sexually relating than milongueras but it can also be the case that these complaints reflect more closely the gender distribution of what can and must be said about the number and variety of ones own sexual experiences than that of actual experiences to be sure during my fieldwork i heard men loudly bragging about the richness and variety of their sexual encounters in front of their friends while women just whispered about the same subject in the ears of a very close friend i must point out that though the usual endings of stories originated in the milongas are to give birth to new ones a few of them become official and develop into public relationships however only some of these relationships imply giving up the emergence of new secret stories especially if one or both members continue dancing in the milongas the secrecy code allows couples to initiate new relationships and set dates without being noticed even if their partners are present in the same room occasionally a new serious relationship may mean the abandonment of those milongas where they used to interact and so the new couple will start going dancing together in other places or they may stop dancing altogether the secrecy that milonga practices impose on the erotic relationships that take place in its realm allows for free sexual circulation and the development of multiple stories that can happen at the same time and that may or may not be resumed during any given night depending on chance and the will of the moment the unbearable heaviness of women who fall in love the most oftenstated reason by my milonguero friends to finish a liaison that started in a milonga is that she fell in love and started getting heavy as i heard this reason time and again as an excuse for the termination of several of their involvements or of their friends i finally asked one of them but dont you ever fall in love he answered i might fall in love but i never tell them because if i do they start getting heavy men going to milongas therefore seem to establish a close connection between falling in love and female heaviness the diagnosis of falling in love made by the men is not always acknowledged by the women involved on more than one occasion i have learned of women who were very much surprised to learn that they were being dumped because they were falling in love i have heard male milongueros diagnose infatuation and foresee increasing heaviness of the women they were seeing in the following circumstances • when they found out that a woman had told other women in the milonga that they had a story with them • when a woman asked that they go together to a milonga • when a woman demanded that the man not leave the milonga with another woman if she was present • when a woman engaged in public demonstrations of affect in the context of a milonga • when a woman after a period of not seeing them said she missed them • when a woman called asking to see them or to chat the first three of these behaviorus entail a breach of the implicit code of secrecy that regulates relationships in the milongas the last two involve an attempt on the part of the woman to have a say in the frequency of encounters and in the development of an affective link the limits of specific milongueros are variable and some may take certain behaviours listed above and not others as proof of unwarranted female love many regular milongueros have told me that when they see a woman repeatedly they consciously deploy tactics to prevent their falling in love these vary from individual to individual some avoid any word that may suggest a romantic relationship miss love want even like are forbidden words that they force themselves not to utter during sex some even confided that they do not tell a woman that she is pretty to prevent her from falling in love other tactics include abstaining of meeting in a public place even if it is outside the milongas so that the woman does not think they want to officially acknowledge their story or not going out on saturday nights which would also give the relationship unwanted recognition and perhaps provide fuel for love interestingly all these tactics construct female sentiments and love as a consequence of the males actions i have heard them express their surprise when women fell in love without them doing anything to warrant it for these men frequent sexual encounters over long periods of time with women they met in the milongas do not seem to lead to the development of sentimental feelings romantic words public demonstrations of affection seeing each other on saturdays or being introduced to their friends however are considered possible causes for women to fall in love and thus turn into heavy ones i must emphasize that i have rarely heard women complain because men they were seeing had fallen in love quite to the contrary a frequent complaint is that they could only have onenight stands with milongueros the male version is that they only do this if women become heavy immediately afterwards for example if they call them during the week to chat or ask how they are doing if not they are willing to repeat the experience each time there is no other more desirable choice at hand this may happen for an unlimited amount of time as long as the woman shows no signs of falling in love foreign women known to social dancers as las extranjeras are an interesting exception to the taboo of romance in the milongas as one of my milonguero friends put itmuch to the approval of others present a foreigner can become your girlfriend because she is leaving anyway milongueros often explain that they can treat foreign women differently express their love to them or show themselves together publicly because their eventual and inevitable departure ensures the fleetingness of the relationship foreign women are seldom considered heavy and are allowed to fall in love as long as they do not plan to put down roots in the city their impending departure makes them extralight women an identical exception holds for tourist women in relation to their ability to dance differently from argentine women blond lighteyed or very darkskinned foreign women are frequently invited to dance as soon as they arrive to the milonga independently of their dancing skills however if they plan to stay in the city they lose their foreigner identity and they are judged as harshly as their porteñas counterparts their falling in love is avoided by the same tactics already discussed the exceptional lightness attributed to foreign women show the intimate relation linking the attribution of that trait to the fleetingness of stories although as our analysis of heavy women has shown this fleetingness should not be considered identical to briefness a story continues to be light even when composed of many episodes as long as recurrent occurrences do not imply any obligation to be repeated at any given moment in the future conclusions the secrecy that milonga practices impose on the erotic relationships that originate within the milonga allows the free sexual circulation and the development of multiple stories that can happen at the same time and that may or may not be resumed during any given night depending on chance and the will of the moment they are as light women in dance relationships that allow for the creative freedom of the participants and do not impose any obligations on them they are characterized by secrecy detachment multiplicity and freedom conversely public recognition affective attachment and the obligation to meet at any given moment are enemies of this free circulation they turn heterosexual relations heavy but in the milonga context lightness and heaviness are not depicted as attributes of stories and love relationships they become feminine images they acquire an anonymous female form as did justice or liberty when statues were made to represent them thus the light woman can be understood as an allegory of those ways of heterosexually relating that milongueros call stories while the one that becomes heavy allegorizes monogamous affective attachments in this process of gendered allegorization the role of men in heterosexual relationships is erased one could wonder if a similar process is not involved in the making of the figure of the slut in cumbia villera or of milonguitas in early tango lyrics couldnt they be understood as allegories of heterosexual relations established in the social contexts where these genres are or were publicly performed in order to answer the question much more information of how relationships develop beyond the limits of dance halls would be needed no doubt when attributed to specific persons images of women can become a social identity such attributions have observable consequences for women and they develop diverse tactics to deal with them they can sometimes choose to contextually identify with them embodying them through kinetic behaviour clothing and demeanour reject them or even use them to their advantage but here i wished to emphasize that in the context of the milongas the image of the light woman gives a feminine form to a prevailing way of heterosexually relating that engages both men and women être envisagées comme la féminisation et lallégorie des relations impliquant les hommes et les femmes dans les contextes mêmes où ces images circulent motsclés cours de danse images des femmes milonga sexes tango resumen tratando de entender la auto imagen de las mujeres latinoamericanas muchos estudios anglófonos han recurrido a la influencia de las imágenes femeninas católicas especialmente a la virgen maría aunque estudios recientes han criticado este énfasis en el marianismo por proporcionar una imagen pasiva de las mujeres la preeminencia de las imágenes de género de origen católico continúa dominando las investigaciones sobre el continente basado en doce años de observación participante en clases de tango milonguero primero como alumna del papel de la mujer luego del papel del hombre y finalmente como profesora y en milongas nocturnas en el centro de buenos aires asumo una postura diferente sobre esta cuestión analizando la imagen de la mujer liviana como una versión alegórica de las relaciones heterosexuales originadas en los salones de baile de tango este marco analítico está inspirado por las críticas culturales que observan las figuras femeninas en otros lugares como la alegorización y feminización de las relaciones de colonizadores y colonizados y de conquistadores con las tierras sin cultivar sin embargo en contrapunto con esta literatura este artículo considera la imagen estudiada como emergiendo del contexto inmediato donde es intercambiado al mostrar la resonancia de la imagen de la mujer liviana y las características de las relaciones heterosexuales en los bailes y eventos de tango social este artículo sugiere la posibilidad que las imágenes de género serían entendidas como la feminización y alegorización de las relaciones que involucran hombres y mujeres en los propios contextos donde dichas imágenes circulan palabras clave clases de danza género imágenes de género milonga tango author biography maria julia carozzi got her phd in anthropology from the university of california los angeles she is a tenured professor of ritual and performance at the institute of higher social studies national university of san martin and tenured researcher at the national council for scientific and technological research argentina her latest book is entitled las palabras y los pasos etnografías de la danza en la ciudad résumé dans leurs tentatives de comprendre limage de soi des femmes latinoaméricaines beaucoup détudes anglophones se sont tournés vers linfluence des images féminines catholiques en particulier de la vierge marie malgré des études plus récentes qui ont critiqué laccent mis sur le marianisme dans la formation de cette image passive de la femme la place importante accordée aux images féminines dorigine catholique continue à dominer la recherche sur le continent basée sur douze années dobservation participante menée lors de leçons de tango milonguero afin détudier en premier lieu le rôle de la femme puis le rôle de lhomme et enfin celui du professeur et lors de séances nocturnes de milonga dans le centre de buenos aires cet article propose une approche différente de la question celle de lanalyse de limage des femmes légères comme une interprétation allégorique des relations hétérosexuelles dans les salles de danse de tango cette grille danalyse est inspirée des critiques culturelles qui considèrent dautres figures féminines comme le produit de lallégorie et la féminisation des relations entre les colonisateurs et les colonisés et entre les conquérants et les terres incultes cependant à la différence de cette littérature cet article analyse cette image directement dans le contexte immédiat où elle est échangée en montrant les relations entre limage de la femme légère et les relations hétérosexuelles dans les endroits où lon danse le tango cet article suggère que ces images féminines puissent

trying to understand the selfimage of latin american women many anglophone studies have turned to the influence of catholic feminine images especially the virgin mary albeit later studies have criticized this emphasis on marianismo for providing a passive image of women the prevalence of gender images of catholic origin continues to dominate research on the continent based on 12 years of participant observation in tango milonguero lessons and at nighttime milongas in downtown buenos aires the author take a different stance on the issue analysing the image of the light woman la mujer liviana as an allegorical rendition of heterosexual relationships originating in tango dance halls this analytical frame is inspired by cultural critiques viewing feminine figures elsewhere as the product of the allegorization and feminization of the relationships of colonizers with the colonized and conquerors with uncultivated lands however at odds with this literature it considers the image under study as emerging from the immediate context where it is exchanged by showing the resonance of the image of the light woman and the characteristics of heterosexual relations in tango social dance events this article suggests the possibility that gender images may be understood as the feminization and allegorization of relations involving men and women in the very contexts where such images circulate

background an extensive amount of research has consistently found associations between childhood socioeconomic status and mental health functioning 1 2 3 with marital conflict and parenting practices seeming to mediate these associations ses is a construct that consists of multiple dimensions of social position 45 previous related empirical and theoretical research has focused on economic and educational aspects as ses indicators family income has been associated with childrens developmental outcomes as have parental educational levels 6 7 8 9 10 11 12 however despite the many studies conducted in this area few have simultaneously investigated the influence of family income and maternal and paternal education levels as predictors in the relationships between ses family processes and child mental health functioning additionally despite extensive studies concerning the relationships between ses family processes and child mental health functioning most have only minimally considered the effects of the positive dimensions of marital conflict and parenting practices rather than the negative dimensions thereof as mediators in the link between ses and child mental health functioning 7 13 14 15 16 moreover a limitation of previous empirical work concerning these associations is that these studies focused on negative developmental outcomes 1718 further studies examining positive dimensions of child mental health functioning especially the issue of social competence are needed social competence which is defined as an individuals ability to act in a socially appropriate manner 1920 has received comparatively less attention as a mediator in the link between ses family processes and child behavioral adjustment despite preliminary evidence suggesting it may be an important indicator when considering the complex relationships between these variables it is important to consider independent associations while controlling for other variables however previous studies have primarily examined individual relationships between different types of ses marital conflict and parenting practices as well as child social competence and behavioral adjustment without considering these associations in a comprehensive model therefore this study examined mediators of the associations between ses and childrens functioning in greater detail specifically destructive and constructive marital conflict negative and positive parenting practices and child social skills were investigated as mediators in the associations between ses indicators including family income and parental education levels and childrens internalizing and externalizing behaviors in a unified model regarding social skills we especially focused on the mediating role of social competence in the relationships between family factors and child behavioral problems from preschool to the first grade socioeconomic status and child adjustment research in the past decade has shown that ses is an important contextual factor that strongly predicts child outcomes 1 2 3 extensive research has shown that ses affects the wellbeing and development of children including their internalizing and externalizing symptoms as well as their cognitive and language development 13 21 22 23 24 25 26 27 it has been well documented that economic problems such as low income and financial instability adversely influence interparental and parentchild interactions which in turn are related to a range of harmful outcomes for child development 28 studies have shown that economic problems are associated with destructive parental interactions that predict increased domestic problems and lower levels of marital quality furthermore it has also been shown that economic problems place children at an increased risk of exposure to family conflict 7 29 30 31 32 economic problems are also predictors of negative parenting including lack of warmth and involvement parental harshness and authoritarian parenting methods 28 33 34 35 36 the family stress model which was proposed by conger et al explains the relationships among ses marital conflict and parenting style while also providing solid evidence for the negative effects of family economic problems on both parents and children 1537 the fsm proposes that economic hardship predicts economic pressure which in turn exacerbates emotional distress for both parents 37 in turn parental emotional distress has a direct negative impact on the parents relationships with each other as indicated by conflict this conflict then spills over into parentchild relationships in the form of negative parenting resulting in harsh uninvolved and or inconsistent childrearing practices these parenting styles are associated with an increase in negative outcomes for children 29 37 38 39 educational status and economic aspects are typical quantitative ses indicators 45 many previous studies have focused on the educational aspects of ses in the relationship between ses and child development with parental educational levels being associated with child developmental outcomes 1 2 1012 25 26 however despite the many studies completed in this area few have simultaneously investigated the influence of multiple components of ses including family income and maternal and paternal education levels as predictors in the relationships among ses family processes and child mental health functioning in several studies that include both educational and economic aspects of ses indicators educational status has often either previously been used as a control variable or it has been combined with income in the construction of an overall index of ses indicators 67 furthermore a limitation of previous empirical work on the fsm is that studies have also focused exclusively on the economic aspect of ses in the relationship between ses and family processes dedicating little research attention to the educational aspects of ses 28 it is well known that education is an important predictor of family income across the life course 40 therefore it may be reasonable to expect the influence of educational status on parental interactions and parent child interactions to be indirect and mediated by economic wellbeing education is an important component of ses that helps identify a social class or position and has been linked to individual competence 4 higher education is likely to enhance various individual skills for competent functioning such as problemsolving skills cognitive skills and capacity to cope with change people with higher levels of education tend to be able to solve problems that are more complex and perform jobs with more autonomy and creativity 41 42 43 44 moreover educational achievement provides persons with more employment opportunities enhances their ability to make significant contributions to their fields and demonstrates significant positive associations with occupational prestige and income 40 45 46 47 furthermore according to human capital theory the education level of an individuals spouse also helps accumulate human capital and has an important impact on economic outcomes 4849 for example a spouse with a higher education might provide constructive advice and information that can affect career and decision making in the family such as consumption fertility and where to live 50 51 52 additionally spouses are likely to affect each other through values attitudes and other abilities associated with education many studies have revealed common findings that the education level of an individuals spouse is positively correlated with the individuals earnings especially numerous studies have suggested that a wifes education affects her husbands earnings 51 52 53 54 55 56 and vice versa additionally other studies have shown that an individuals earnings are positively correlated with their spouses education level 5357 this correlation might be due to marital matching as individuals that are more productive are more likely to marry bettereducated individuals however despite the fact that parental education levels strongly interact with income education levels and economic conditions could have different effects on family processes and child mental health functioning possibly acting through different pathways regarding the relationship between educational level and marital relationship higher education is likely to help parents to strengthen their communication and analytical skills allowing for more effective problem solving between parents 445058 moreover higher education is also likely to enhance selfcontrol and coping mechanisms of parents possibly increasing the positive association between education and psychological wellbeing 58 consequently parental education levels might positively affect marital relationship through parental psychological wellbeing 44 59 60 61 a large amount of evidence for the beneficial nature of education on marriage exist as studies have demonstrated a negative relationship between parental educational levels and marital conflict 62 a positive association between educational attainment and greater marital satisfaction 3063 and higher levels of educational attainment are associated with greater marital stability 6465 in addition previous research has suggested that parental education is the strongest and most important predictor of parenting behavior 66 regarding the relationship between educational level and parent child interactions higher education is likely to promote the ability to process information and enable parents to acquire more knowledge and skills about childrearing and child development allowing parents with higher education to use more effective strategies for childrearing 66 67 68 moreover as mentioned above a higher level of education is likely to boost parental psychological wellbeing which in turn could positively influence parenting style 69 70 71 many studies found that higher maternal education levels are associated with more supportive parenting 7273 which is also associated with positive cognitive behavioral emotional and physical child outcomes 74 75 76 77 while few studies have investigated the influence of paternal education levels on fathers involvement in childrearing some studies have found paternal education levels to be somewhat associated with parent child interactions for example several studies revealed that fathers with higher educational attainment tend to be more involved show more positive engagement and be more accessible to their children than fathers with a lower education level 78 79 80 however other studies have found little association between paternal educational attainment and fathers involvement after controlling for factors such as family income and maternal education level 6 7 8 9 as there are conflicting results in the literature regarding the influence of paternal education level on parental involvement it is possible that parental education levels may influence parenting attitudes directly or they may do so indirectly through family economic factors or other ses indicators given this information we are unable to form strong expectations regarding the possible pathways of how both maternal and paternal education levels may influence childhood mental health problems when considering the complex relationships in the abovementioned variables it is important to consider independent associations while controlling for other ses variables however few previous studies have primarily examined individual relationships between ses including family income and parental educational levels interparental interactions parentchild interactions and or child mental health functioning taking into account associations in a comprehensive model therefore investigations into ses including family income and parental educational levels are needed to clarify how each ses indicator flows through the family processes to influence child development studying individual markers of ses including family income and maternal and paternal education enables us to study the unique and combined contributions of family income and parental education towards family functioning and child adjustment family processes and child adjustment as mentioned earlier the fsm has shown that economic hardship predicts greater economic pressure in turn exacerbating emotional distress among parents which then negatively affects their relationship with each other as indicated by parental relationship conflict 2939 this marital conflict spills over into parentchild relationships which are characterized by more hostile harsh emotionally neglectful parenting and less warmth these types of relationships are associated with more negative outcomes in childhood and adulthood 71516 the spillover hypothesis has been proposed to explain this relationship between marital conflict and child outcomes according to this hypothesis the negativity and positivity experienced in the interparental relationship transfer to the parentchild relationship affecting child outcomes 1718 81 82 83 the hypothesis further posits that destructive marital conflict such as verbal and physical aggression requires excessive energy that makes parents less emotionally available and less sensitive to the needs of their children the negative interactions spill over into the parentchild relationship resulting in an increase in negative parenting practices such as poor monitoring inconsistency and harsh discipline in contrast constructive marital conflict such as satisfaction support and positive interaction spills over into the parentchild relationship which is characterized by increased availability to meet childrens needs and results in more positive parenting practices such as involvement and praise moreover several studies examining the effects of conflict on childrens emotional and behavioral outcomes have also demonstrated ways of categorizing conflict into destructive and constructive marital conflict 84 85 86 87 88 these studies suggest that destructive marital conflict make children more vulnerable to developing adjustment problems including aggression conduct disorders anxiety and depressive symptomatology conversely these studies also suggest that constructive marital conflict including progress towards the resolution of the conflicts and explanations about how conflicts were resolved is likely to be beneficial to children helping them learn effective problemsolving and communication skills therefore the findings illustrate the need to examine marital conflict as a multidimensional construct to understand how conflict affects children however despite the extensive research completed in this area studies have minimally considered the impact of positive dimensions of marital conflict and in turn parenting practices rather than negative dimensions as mediators in the link between ses and child mental health functioning previous studies have consistently found that destructive marital conflict fosters negative spillover resulting in more negative parentchild interactions 18 furthermore a limitation of previous empirical work is that studies have focused exclusively on negative outcomes 1718 further studies examining a positive association between family factors and child mental health functioning including positive outcomes have been called for therefore investigations into positive spillover practices are needed to clarify how family functioning affects child development in a comprehensive model social competence and child adjustment school maladjustment is one of the most prevalent and significant health problems threatening children previous studies have suggested that one of the factors related to child maladjustment is a childs inability to adjust socially as a result of a lack of social competence 89 social competence has been broadly defined as effectiveness in social interactions 20 social skills are discrete abilities that contribute to social competence 19 specifically these skills have been defined as socially acceptable learned behaviors that enable children to interact effectively and avoid unacceptable responses from others 90 in short social competence refers to an individuals overall ability to act in a socially appropriate manner 19 whereas social skills refer to specific and distinct behaviors representing social competence 91 social skills are some of the most important accomplishments in childhood aspects of social skills such as cooperation selfcontrol and assertion which were clustered by gresham and elliott 90 affect social adaptation in later life social skills help children initiate positive peer interactions which help them learn positive behaviors through peer modeling and provide them with resources such as support and acceptance 92 93 94 95 conversely children who fail to develop social skills in early developmental phases often display social problems children who persistently exhibit deficits in social skills experience both shortand longterm negative consequences which may often be precursors to more severe social problems later in life 9697 children who lack social skills may experience emotional difficulties and tend to have trouble interacting with their peers teachers and families 97 98 99 100 furthermore social skill deficits frequently demonstrate a negative association with behavioral adjustment 99 100 101 102 behavioral adjustment is generally associated with two broad symptom dimensions internalizing and externalizing behaviors internalizing behaviors include worry anxiety depression and somatic complaints while externalizing behaviors include hyperactivity inattention aggression toward peers and management problems 103 104 105 106 107 108 109 110 internalizing and externalizing behaviors consistently influence each other over time with prior studies showing that internalizing behaviors predict later externalizing behaviors and vice versa 111 112 113 114 115 116 further there is evidence of comorbidity with internalizing and externalizing behaviors later in the life course social competence predicts internalizing and externalizing behaviors across longer periods in childhood adolescence and adulthood additionally lower social competence forecasts higher levels of both internalizing and externalizing problems 99102 117 118 children who lack social skills have difficulties in expressing themselves and understanding others such as sending appropriate social messages and responding to their peers teachers and families they have fewer positive interactions and have more trouble interacting with others consequently these individuals are more prone to be disliked and deemed socially incompetent by others 119 therefore children with social skill deficits are at an elevated risk for social isolation including anxious solitude and peer rejection social isolation is associated with behavioral adjustment for instance increased childhood social isolation longitudinally predicts depressive symptoms 120 121 122 therefore early peer difficulties with social skill deficits are predictive of later maladjustment the crosssectional and longitudinal associations between social competence deficits and internalizing symptoms have been well documented from preschool to adolescence 123 124 125 similarly several studies suggest childhood peer rejection longitudinally predicts externalizing behaviors including aggression conduct disorders involving peers and other undercontrolled behaviors during the schoolage years and into adolescence 101102126 however several social skill abilities among children that are associated with externalizing behaviors such as abilities in emotion regulation verbally expressing emotions and selfregulation of behavior generally increase with age 127128 therefore as social skills improve with age the rates of externalizing problems tend to decrease in comparison to internalizing problems 127 128 129 eventually the failure to develop social skills and successful childhood interpersonal relationships could promote mental health difficulties and both internalizing and externalizing problems over time early childhood is a pivotal period for social development the transition period from early childhood to elementary school first grade is a pivotal period for social development that leads to school readiness previous research has indicated that the preschool years are a sensitive period for the acquisition of social skills and related abilities 130 131 132 133 134 135 preschoolaged children learn and frequently display various prosocial behaviors 136 therefore this period is an important developmental stage during when children are expected to acquire social skills to prepare them for broader social activity social skill deficits in early childhood gradually become permanent over time are related to poor academic performance and are predictive of social adjustment problems and serious psychopathology in adolescence understanding the factors that influence these developmental processes in early childhood may enable the prevention of later socioemotional difficulties there is an extensive body of literature demonstrating that the development of social competence among children is significantly affected by environmental factors in childhood 137 138 139 for example family functioning has been shown to predict childrens social competence positive parenting such as emotional expressiveness responsiveness and support has been shown to enhance empathy and social functioning in children 140 141 142 143 while negative parenting behavior such as harsh discipline emotional neglect or rejecting behavior is often associated with lower sociability social competence and increased problem behaviors in children 1625143 many previous studies have also shown that destructive marital conflicts negatively affect social competence 144 this type of marital conflict may put children at risk of developing adjustment problems including internalizing and externalizing disorders due to their inability to control their emotions moreover they may learn through these interactions to solve problems through aggressive behavior 18 145 146 147 since research has primarily focused on destructive marital conflict few studies have investigated constructive marital conflict which may foster social competence constructive marital conflict may also aid in the development of problemsolving coping and conflict resolution abilities by teaching children how to effectively communicate with others to solve issues 148 149 150 previous studies consistently suggest that destructive conflict increases the risk of adjustment disorders whereas constructive conflict may positively influence adjustment despite the differential effects of destructive and constructive conflict on child development there is no distinction between these two types of conflict and their implications for social development within the literature moreover even though marital conflict and parenting practices affect social competence 144151 few studies have addressed the various ways that this may occur within a comprehensive model as mentioned previously a limitation of empirical work on the fsm is that studies have focused exclusively on negative outcomes such as internalizing and externalizing problems 715 this myopic focus leads to a strong need for the examination of positive associations such as positive developmental outcomes among children the current study highlights the ways that family processes within the fsm promote desirable child outcomes specifically focusing on the development of social competence various studies have demonstrated the significant effects of family processes on social competence primarily examining the individual relationships between different types of ses marital conflict parenting practices and child mental health functioning without considering associations in a comprehensive model when considering the complex relationships among these variables it is also important to consider independent associations while controlling for other variables for a more detailed exploration of the early protective factors potentially influencing diverse developmental maladjustment the purpose of this preliminary study was to examine in greater detail social competence as a mediator of the relationships between ses family processes and childrens adjustment present study although several studies have demonstrated a significant impact of ses and family processes on general adjustment among children few have considered the relationship between child behavioral problems and ses including family economic and parental educational levels negative and positive aspects of marital conflict and parenting practices and child social competence in conjunction with one another most prior studies including the fsm have focused little attention on the educational domain of ses or the positive aspects of family functioning and child outcomes when considering the complex relationships between these variables it is important to consider independent associations while controlling for other variables in a comprehensive model most studies have examined these complex relationships in a more piecemeal fashion rarely integrating them into a unified conceptual model within the risk and resilience research framework relational risk or protective factors are thought to make either additive or contingent contributions to adjustment based on the observations above the aim of this study was to clarify the roles of ses marital conflict parenting practices and child social competence and behavioral problems by analyzing these relationships in a comprehensive model in the present study we used longitudinal assessments of childrens externalizing and internalizing behaviors to evaluate the hypothesis that ses marital conflict and parenting practices predict childrens social competence which is then related to later child adjustment the mediational model in fig 1 was tested to estimate the direct effects of time 1 ses marital conflict and parenting practices on time 2 behavioral problems and to examine the indirect effects of t1 variables through their effects on t1 social competence on t2 behavioral problems as a result our study provides theoretical contributions to the fsm by incorporating additional critical factors investigating the role of social competence as a mediating process in the link between relational risks such as ses and later child adjustment will enable important theoretical contributions to the understanding of processes involved in the development of adaptation among children with higher relational risks and will provide implications for prevention and intervention efforts we hypothesized the following pathways ses indicators are as predictors differentially associated with family processes and child mental functioning through distinct pathways both negative and positive aspects of family processes will mediate the relationship between ses and child mental health functioning and social competence in preschool which is influenced by multidimensional family factors will reduce the risk of behavioral problems in the first grade hosokawa and katsura child adolesc psychiatry ment health 1162 methods ethics statement the childrens parents and teachers were informed of the studys purpose and procedures and they were made aware that they were not obligated to participate the teachers provided their written informed consent and the parents submitted the same on behalf of their children prior to participating in this research ethical approval for this study was obtained from kyoto universitys ethics committee in kyoto japan measures all the questions used for the selfdeveloped questionnaire were questions translated into japanese predictors socioeconomic status at t1 ses was defined as information about family income levels as provided by the parents and parental education parents were asked to report their total yearly family income their education in years and their completed education levels by choosing one of the following response options compulsory education vocational uppersecondary schoolgeneral uppersecondary school less than 4 years at collegeuniversity and over 4 years at collegeuniversity each of the ses scores were converted to z scores mediators marital conflict at t1 the quality of coparental communication scale a 10item selfreport questionnaire was used to assess each parents feelings or behaviors within the context of the coparenting relationship 120 this measure is composed of the following two subscales coparental conflict and coparental support items are rated on a 5point likert scale ranging from 1 to 5 the conflict and support subscales assess parents perceptions of the coparenting relationship the conflict subscale measures the negative aspect of the coparenting relationship with higher conflict scores indicating more coparental communication conflict 152 in the current study we con sidered coparental conflict as destructive conflict conversely the support subscale measures positive aspects of the coparenting relationship with higher support scores indicating more supportive coparental communication 152 specifically the support subscale measures general support including helpfulness resourcefulness and cooperation 152 as opposed to the constructive aspects of conflict however in the current study we considered coparental support as constructive marital conflict the scales have adequate internal consistency and construct validity 152 153 154 the internal consistency was 88 and 74 for conflict and support scales respectively 152 the current study found internal consistencies of 77 and 86 for the conflict and support scales respectively each qccs total score was converted to a z score parenting practice at t1 the alabama parenting questionnaire a 42item selfreport questionnaire was used to assess various aspects of parenting behavior 155156 the measure is composed of the following five subscales poor monitoringsupervision inconsistent discipline corporal punishment positive parenting and involvement items are rated on a 5point likert scale ranging from 1 to 5 participants selfreported their own parenting behavior the developers have reported that the measure has adequate internal consistency and construct validity 156 the internal consistency of the subscales ranges from 46 to 80 156 in this study the subscales internal consistency ranged from 71 to 76 in this study we standardized the separate positive and negative parenting composite scores 157 scores on the poor monitoringsupervision inconsistent discipline and corporal punishment subscales of the apq were combined to form a negative parenting composite score whereas scores on the positive parenting and involvement subscales were combined to form a positive parenting composite score the negative parenting composite score was calculated by converting the poor monitoring supervision inconsistent discipline and corporal punishment subscale scores to z scores and then averaging them with higher scores indicating more negative parenting similarly the positive parenting composite score was calculated using the same method for the positive parenting and involvement subscale scores with higher scores indicating more positive parenting child social competence at t1 the social skills questionnaire was used as an index of observer ratings of child social competence in the current study the childrens teachers evaluated their social skills using this scale the ssq is a 24item measure of childrens social competence in relation to cooperation selfcontrol and assertion 158 159 160 as factors affecting social adaptation in later life 90 these clusters of social behaviors can briefly be characterized as follows cooperationbehaviors such as helping others sharing with a peer and complying with rules such as sharing and obeying selfcontrolbehaviors that emerge in conflict situations such as responding appropriately to teasing or corrective feedback from an adult and assertionbehaviors such as asking others for helpinformation and responding to others actions the ssq has the following three subscales cooperation selfcontrol and assertion these factors are based upon and positively correlated with the social skills rating system 90 which is one of the most widely used social skills scales and was used in the national institute of child health and human development study 161162 the ssqs items are rated on a 3point scale ranging from 0 to 2 yielding total scores for cooperation selfcontrol and assertiveness the ssq has adequate internal consistency and construct validity the subscales internal consistency has previously ranged from 91 to 93 158 with a range from 84 to 94 in the current study furthermore the present study combined total scores for cooperation selfcontrol and assertiveness to form a social skills score with higher scores indicating better social skills the social skills score was calculated by converting scores on the cooperation selfcontrol and assertion subscales to z scores and then averaging them criterion variables child adjustment the strengths and difficulties questionnaire is a 25item measure of parents perceptions of their childrens prosocial and difficult behaviors and it is designed to assess general internalizing and externalizing emotional and behavioral problems 163 in this study childrens mothers evaluated their behavioral adjustment using this scale at both t1 and t2 the measure is composed of the following five subscales emotional symptoms conduct problems hyperactivityinattention peer problems and prosocial behavior items were rated on a 3point likert scale ranging from 0 to 2 the scales internal consistency and construct validity were reported as adequate 164 165 166 in this study the emotional symptoms and peer problems subscales of the sdq were combined to form an internalizing problems scale while the conduct problems and hyperactivityinattention subscales were combined to form an externalizing problem scale as suggested by goodman et al 167 with higher scores indicating more behavioral problems each sdq total score was converted to a z score procedure to conduct our study we asked the kindergartens and nursery schools with 50 or more students in nagoya city to participate as a result principals of 130 facilities gave us permission to conduct our survey and meet with participating parents to recruit families at t1 selfreported questionnaires were distributed at the participating facilities to all parents of 5 year olds participants received an information sheet and questionnaires on childrearing in relation to family factors and child behavioral adjustment participants provided written informed consent and agreed to participate the parents completed the questionnaires at a single time point and returned these to participating facilities in sealed envelopes to prevent teachers from seeing the questionnaires then the teachers evaluated the childrens social skills using the ssq all sealed envelopes containing questionnaires and ssq evaluations were returned to the researcher from the respective principals at t2 12 months later participants were contacted again when the children were in the first grade at t1 the researcher obtained the address of participants and at t2 the researcher mailed the participants questionnaires on childrearing in relation to family factors and child behavioral adjustment participants who completed the questionnaires returned them to the researcher by mail access to the data was restricted to the researchers of the current longitudinal study data analyses first prior to developing a model of the relationships among ses parental relationship parenting practices and child social competence and adjustment correlation analyses were utilized to determine the associations among ses marital relationship parenting practices child social competence and child adjustment second path analyses were conducted to estimate direct and indirect paths between ses parental relationship parenting practices and child social competence and adjustment structural equation modeling analyses were conducted using full information maximumlikelihood estimation in the presence of missing data the hypothesized model is presented in fig 1 in the models ses was specified as a predictor of the marital relationship parenting practices child social competence and behavioral adjustment we estimated how family factors and child social competence in preschool influenced the childrens behavioral adjustment in the first grade the model also included t1 behavioral adjustment as control variables through controlling for initial levels of maladjustment the model would appropriately address changes in behavioral adjustment based on previous findings in the literature we expected the effect of t1 ses indicators on t2 behavioral adjustment to be mediated by the t1 parental relationship parenting practices and social competence moreover we expected an inverse effect between t1 social competence and t2 adjustment to assess fit we examined the comparative fit index 168 the incremental fit index 169 and the root mean square error of approximation 170 good model fit is reflected in cfi and ifi values above 90 168169 regarding the rmsea good fit was represented by a value smaller than 05 and reasonable fit was represented by values ranging from 05 to 08 171 all the statistical analyses were conducted using spss version 230 and amos version 230 results preliminary analyses ses indicators are shown in table 1 other descriptive statistics for all variables measured by the scales are presented in table 2 a correlation matrix of the ses indicators marital conflict parenting practices and child social competence and behavioral adjustment is shown in table 3 analyses in study composites showed that all correlations of the study composites were statistically significant the indicators of ses marital conflict parenting practice and child social competence and behavioral adjustment were interrelated supporting our hypotheses and previous empirical findings each ses variable was negatively related to destructive marital conflict negative parenting and the childrens externalizing and internalizing behavioral problems conversely it was positively related to constructive marital conflict positive parenting and childrens social skills in turn social skills inversely correlated with childrens externalizing and internalizing behavioral problems mediational models for ses marital conflict parenting practices child social skills and child adjustment longitudinal models examined the impact of ses marital conflict and parenting practices on child social competence and behavioral adjustment figure 3 depicts the final path models and the path diagram specifies both direct and indirect paths linking t1 ses indicators to t2 child behavioral adjustment the standardized coefficients are shown in fig 3 model fit was tested with multiple indices the model provided a good fit to the data χ 2 3189 p 023 cfi 99 ifi 99 rmsea 02 in the model several statistically significant direct and indirect paths were found between the predictors and criterion variables family income was found to be a significant predictor of lower levels of destructive marital conflict lower levels of negative parenting practices higher levels of constructive marital conflict higher levels of positive parenting practices higher levels of child social skills and lower levels of t2 internalizing problems and t2 externalizing problems the indirect paths from family economy to child mental health functioning through marital conflict and parenting practices were also significant maternal education level was found to be a significant predictor of lower levels of negative parenting practices higher levels of constructive marital conflict higher levels of positive parenting practices and lower levels of t2 internalizing problems and t2 externalizing problems the indirect paths from maternal education level to child mental health functioning through marital conflict and parenting practices were also significant paternal education level was found to be a significant predictor of lower levels of destructive marital conflict lower levels of negative parenting practices higher levels of constructive marital conflict and higher levels of child social skills the indirect paths from paternal education level to child mental health functioning through marital conflict and parenting practices were also significant notably in terms of the negative dimension of family processes t1 destructive conflict was directly negatively related to social skills and indirectly negatively related to t1 social skills through t1 negative parenting practices t1 negative parenting practices were directly negatively related to social skills regarding the positive dimension of family processes t1 constructive conflict was directly positively related to social skills and indirectly positively related to t1 social skills through t1 positive parenting practices t1 positive parenting practices were directly positively related to social skills in turn t1 social skills were found to be a direct and significant predictor of lower levels of t2 internalizing problems and t2 externalizing problems while controlling for behavior problems at t1 therefore consistent with the hypotheses each ses indicator was significantly and independently associated with child mental health functioning through positive and negative dimensions of marital conflict and parenting practices notably t1 social skills in preschool which were affected by t1 family factors predicted lower levels of t2 behavioral problems in the first grade discussion our longitudinal study explored in a comprehensive model marital conflict parenting practices and social competence as mediators of the association between ses in preschool and child behavioral adjustment in the first grade our extension of previous research investigating the relationships between ses and child behavioral adjustment comprised the following three points we included both family income and maternal and paternal education levels as ses indicators and as predictors of family processes and mental health functioning of children in a unified model we expected each ses indicator as predictors to be differentially associated with family processes and child mental functioning through distinct pathways we included not only negative mediators but also positive mediators as mediating mechanisms in the link between ses and child mental health functioning we expected both negative pathways and positive pathways in the family process model we included not only negative child developmental outcomes but also desirable child developmental outcomes in the relationship between family factors and child mental health functioning moreover we focused on social competence as a mediator of the relationship between family factors and child behavioral problems we expected social competence in preschool which was affected by different types of family factors to be inversely related to the symptoms of behavioral problems in the first grade our main findings were the following family income and parental education levels were differentially associated with child mental health functioning through distinct pathways this result provides evidence that lower ses is both directly and indirectly associated with more destructive marital conflict more use of negative parenting practices less constructive marital conflict less use of positive parenting practices poorer social competence and more symptoms of behavioral problems this suggests that by contrast higher ses is both directly and indirectly associated with less destructive marital conflict less use of negative parenting practices more constructive marital conflict more use of positive parenting practices higher social competence and fewer symptoms of behavioral problems we identified both negative and positive pathways between ses and child mental health functioning positive mediators included constructive marital conflict and positive path of family economic situation family processes and child mental health functioning in this study family income was directly linked to marital conflict parenting practices and in turn child mental health functioning this result is consistent with previous research findings identifying a direct path of family income to destructive marital conflict and negative parenting practices and in turn child outcomes 7 2830 35 36 63 furthermore this result supports the fsms prediction that family income affects childrens socioemotional development through its influence on parents psychological wellbeing and therefore the interparental relationship and parentchild interactions 15 the result also supports the notion of negative spillover effects and is consistent with family systems theory 1718 conversely we found a positive pathway within which a higher family economic status was associated with more constructive marital conflict and in turn more use of positive parenting practices resulting in higher mental health functioning this result supports the notion of the positive spillover effect with the positive interparental relationship spilling over into the parentchild relationship resulting in more positive parenting practices similar to negative spillover effects and consistent with family systems theory 18 positive emotions from interparental relationships may transfer to parentchild relationships 8283 this result that there is a positive spillover effect in the family process model is an extension of previous studies additionally we found that family income was directly related to child mental health functioning while controlling for other variables there are likely to be other factors that were not accounted for in our model for example the family investment model which is concerned with the advantages reaped by the developing child because of family wealth 28172173 may explain this association the fim proposes that families with more economic resources can make significant investments in the development of their children whereas those with lower incomes must invest in more immediate family needs 17174 income enables families to invest in building their childrens human capital these investments in children involve several dimensions of goods and services including parents direct and indirect stimulation of learning the familys standard of living and living in a more advantaged neighborhood environment that fosters a childs development 7175176 according to this perspective children in disadvantaged families tend to fare worse because they have limited access to resources that help them develop mayer demonstrated that children in disadvantaged families lived under worse conditions owned fewer stimulating materials and were less likely to engage in stimulating activities 176 after controlling for other family background characteristics these resources were associated with childrens developmental outcomes 176 therefore the apparent direct effect of family economic status found in the current study could possibly be mediated by factors that were not accounted for in our model future studies should investigate this possibility by including more family factors related to child mental health functioning in their models path of parental educational level family processes and child mental health functioning as mentioned earlier despite the many studies completed in this area few studies have simultaneously investigated the influence of family income and maternal and paternal education levels as predictors in the relationships between ses family processes and child mental health functioning 6728 although most of the previous fsm studies have focused primarily on economic conditions we suspect that they tend to capture a limited hosokawa and katsura child adolesc psychiatry ment health 1162 scope of the influence of educational achievement in this study both maternal and paternal educational levels were independently linked with parental functioning and parentchild interactions and in turn with child mental health functioning in a unified model while controlling for economic conditions in addition this result also supports the notion of both positive and negative spillover effects 1718 as educational levels were positively related to higher levels of constructive marital conflict and in turn higher levels of positive parenting resulting in better developmental outcomes therefore the results regarding the effects of multiple components of ses including family income and maternal and paternal education levels on child mental health functioning through distinct pathways are an extension of those found in previous studies in terms of the relationship between educational level and marital conflict the results of the current study are consistent with those of previous research showing educational attainment to be inversely related to destructive marital conflict 62 and parental educational attainment to be positively related to greater marital satisfaction and marital stability 30 63 64 65 more precisely paternal education was linked to both destructive and constructive conflict however maternal education was linked to only constructive conflict this might be due to difference of effect of maternal and paternal education on decisionmaking in the home as mentioned earlier previous studies have suggested that higher education helps parents strengthen their communication and problemsolving skills and promotes effective problem solving between parents 5058 in addition higher education tends to make fathers positively participate in decisionmaking in the home whereas fathers with lower education negatively participate 177 178 179 therefore in this study paternal education might more strongly affect both destructive and constructive than maternal education furthermore in terms of the relationship between educational level and parental involvement we found that maternal education was associated with positive parenting practices but not paternal education however both maternal and paternal education were linked to negative parenting practices this result might indicate that the effects of parental education on involvement is larger for maternal education than for paternal this might be due to mothers tending to be the main provider of care within the households of japan many studies suggest that mothers assume the primary parenting role in that mothers were found to be more intrusive toward fatherchild interactions 180 181 182 in addition this result is consistent with previous research findings a large number of studies suggest higher maternal educational attainment to be positively related to positive parenting attitudes such as talking to children warmly or supportively 7273 whereas lower educational levels have been found to be predictors of negative parenting such as harshness and physical disciplinary tactics 3334 183 184 185 however although many studies suggest maternal educational attainment is related to parenting attitudes few studies have comparatively investigated the influence of paternal education levels on parental involvement these results imply the possibility that both maternal and paternal educational levels are independently related to parenting attitudes one of the important mechanisms in the effect of parental education levels on family processes and childrens development is likely to be parental knowledge about childrearing and child development lower levels of parental education are associated with negative parenting attitudes such as physical and authoritarian disciplinary tactics 3334 183 184 185 it has been suggested that this is due to a lack of knowledge concerning the counterproductive outcomes of severe disciplinary responses and appropriate alternatives to harsh discipline 33183 higher levels of parental education have also been positively associated with sensitivity positive regard and cognitive stimulation of children 186 further it has been suggested that higher educational levels are associated with increased knowledge about childrearing and child development and more supportive parenting 7273 therefore both maternal and paternal education levels may influence parenting attitudes even when controlling for family income whereas educational attainment affects parenting attitudes through the adverse effects of poor family economic situations on parents mental wellbeing therefore we assume that findings related to economic predictions based on the fsm are likely to reflect educational differences in ses as well educational levels are likely to play an important role in the relationships among ses family processes and child mental health functioning in addition we found a direct association between parental education levels and child mental health functioning while controlling for other variables there are likely to be other factors that were unaccounted for in our model the fim may also explain this mediating pathway to provide evidence for the plausibility of parental education level as an important aspect of the investment process 17 the model proposes that similar to family income parental education level has an influence on parental investments and that these investments in turn will have a positive relationship with child development parents with higher education levels acquire more knowledge hosokawa and katsura child adolesc psychiatry ment health 1162 about child development have a greater understanding of strategies to encourage social competence and may be more effective in teaching children 7273187 families with higher educational levels and more knowledge about childrearing and child development may be more willing to make significant investments in their childrens development despite the reasonableness of this hypothesized mediating process there have been limited investigations into the impact of parental education level in terms of the fim however some evidence is consistent with the aforementioned ideas for example a previous study found education level to be positively correlated with parental investments involving a more enriched and positive childrearing environment characterized by the availability of play and learning materials and the organization and diversity of the physical environment 188 investment in this regard is not only material but also emotional 189 for example more highly educated parents create a richer and more complex language environment for their children 190 they also spend more time communicating with their children 173191 a previous study found parental education to be positively related to childrens language skills including vocabulary and reading skills 192 the richness of the language environment in interparental and parentchild interactions may mediate the association between parents education levels and a childs productive vocabularies and enhance the childrens social competence therefore there are likely to be other factors in family processes that were unaccounted for in our model this result is likely to support the fim including its suggestion of parental educational attainment as an ses indicator more precisely regarding the path between parental education and social competence we found that paternal education was directly linked to social competence but maternal education was not there are likely to be other factors of paternal characteristic roles that were unaccounted for in our model in addition to factors of the fim for instance paternal involvement tends to be more physical and challenging than maternal 193194 physical and challenging play is an important component of human socialization 195196 fatherchild physical play is likely to help children learn to regulate their own behavior and practice coping with failure or frustration and interpreting others emotions this is because father child physical play has been linked to childrens emotionregulation and peer competence 196 197 198 199 the positive association between fatherchild physical play and child social competence is a common empirical finding 195 200 201 202 203 in addition several studies have suggested that fathers with higher educational levels tend to be more involved have more positive engagement and are more accessible to their children 78 79 80 therefore fathers with higher educational levels might promote child social competence through not only factors of fim but also characteristic parental involvement such as physical and challenging play moreover regarding the path between parental education and behavioral problems we found that maternal education was both directly and indirectly linked to t2 internalizing behavior and externalizing behavior however the link for paternal education was only indirect there are also likely to be other factors of maternal characteristic roles that were unaccounted for in our model for instance mothers with higher education tend to have higher quality of motherchild interactions such as sensitivity and responsiveness 188204 past researchers have found that maternal sensitivity and responsiveness significantly shape childrens cognitive development furthermore cognitive competence deficits have also been reported as a vulnerability factor in causing behavioral problems 205 206 207 208 therefore maternal educational achievement might affect behavioral problems through the effect of specific motherchild interactions future studies should investigate the possibilities of the direct effect of parental education levels as found in this study being mediated by factors not accounted for in our model this could be done by including more factors in future models the role of social competence in the relationships among ses family processes and adjustment we focused on both negative child developmental outcomes and desirable child developmental outcomes in the relationship between family factors and child mental health functioning we also highlighted the ways that family processes within the fsm promote positive developmental outcomes in the current study social competence mediated the association between family factors and childrens behavioral adjustment in a comprehensive model ses was positively related to social competence and inversely related to internalizing and externalizing symptomatology through positive and negative dimensions of parents marital relationships and parenting styles this result is an extension of those of previous studies in which multidimensional family factors were related to both negative and positive outcomes in a comprehensive model this result is consistent with several previous research findings identifying the direct individual path within which marital conflict and parenting practices are associated with child mental health functioning in terms of parenting practices and child mental health functioning in this study negative parenting practice was directly linked with poorer mental health functioning by contrast positive parenting was directly linked to higher mental health functioning previous studies have suggested that negative parenting behaviors such as harsh discipline being emotionally neglectful or demonstrating rejecting behaviors are often associated with lower sociabilitycompetence and increased problem behaviors in children 1625143 while positive parenting behaviors such as emotional expressiveness responsiveness and support have been shown to predict better empathy and social functioning in children 140 141 142 143 additionally in terms of marital conflict and child mental health functioning in this study marital conflict was not only indirectly related to child outcomes through parenting practices but also directly related to child outcomes parents destructive marital conflict was directly linked with poorer mental health functioning by contrast parents constructive conflict was directly linked to better mental health functioning and in turn fewer symptoms of behavioral problems these results are consistent with previous studies indicating that exposure to marital conflict is associated with different responses in children depending on the type of interparental relationship 146209 many previous studies have shown that destructive marital conflict negatively affects social competence 144 in addition the relationships between interparental destructive conflict and negative psychological adjustment among children are well established 146149 209 210 211 that is destructive marital conflict has been shown to adversely influence childrens social competence 212 213 214 215 internalizing symptoms 211216 and externalizing problems 210211 however limited research has investigated the impact of constructive marital conflict on child mental health functioning therefore the current result is an extension of those in previous studies which demonstrated constructive marital conflicts direct association with child social development one of the important direct mechanisms of the effect of interparental relationship on childrens development is likely to be modeling according to social learning theory childrens social development can be influenced by modeling the behaviors and attitudes of significant persons in their lives such as parents 217 child social development may be both positively and negatively related to parents social development due to the effects of modeling 218 219 220 consistent with the modeling mechanism proposed by the spillover hypothesis children may directly model conflict behavior exhibited by their parents in the case of destructive marital conflict children whose parents resolve their problems through aggressive behavior are more likely to learn that aggression is an acceptable way of dealing with disagreements and thus may act aggressively when interacting with their peers 149221222 therefore destructive marital conflict is likely to directly limit childrens social development by contrast in the case of constructive marital conflict children whose parents resolve problems through supportive cooperation are more likely to learn from the negotiations between their mothers and fathers during the decisionmaking process allowing them a blueprint to communicate more effectively and efficiently when interacting with their peers 150 therefore constructive marital conflict is likely to directly enhance social development in addition in this study social skills in preschool which were affected by family factors inversely predicted later internalizing and externalizing symptomatology in the first grade after controlling for preschool behavioral symptomatology this result is consistent with previous research a number of studies have shown negative correlations between social competence and behavioral problems early social competence among children is an important predictor of later social adjustment and psychopathology 223 224 225 226 for example social competence promotes child development in a number of domains including social adjustment and interpersonal relationships 223227228 conversely social competence deficits have been linked to social maladjustment and several problem behaviors including aggression and delinquency 105223 229 230 231 232 233 234 previous studies have primarily examined individual relationships between different types of ses marital conflict parenting practices social competence and child outcomes without considering these associations in a comprehensive model however when considering the complex relationships between these variables social competence was adversely related to later behavioral problems as a mediating mechanism in the link between ses and child adjustment preschool social competence played a potential protective role in preventing later behavioral problems in the first grade this result is an extension of previous studies in which social competence was found to influence later adjustment as shown in the complex relationships among these variables the prevailing model of prevention holds that reducing risk factors associated with adverse outcomes and increasing protective factors that moderate the effects of exposure to risk will reduce the possibility of later maladjustment 235 the effectiveness of this approach towards prevention rests on the extent to which identified risk and protective factors are actually causal therefore the current study findings which focus on multidimensional family factors simultaneous promotion of social competence among preschoolers may provide an effective strategy for promoting later social adjustment among children limitations and future directions our findings should be interpreted in light of several limitations first although this studys design was longitudinal the design was partially crosssectional identifying the relationship between family factors and social competence at t1 the crosssectional design poses several restrictions that make it difficult to assume causality among the factors statistical evidence from studies using a crosssectional design may not be as informative as longitudinal data 236237 prior studies have found that childrens mental health functioning influences interparental relationship and parenting styles as well as the influence of interparental relationship and parenting styles on childrens mental health functioning 238 239 240 241 childrens mental health functioning and family factors are likely to influence each other furthermore followup period of the current study was only 1 year although the transition period from early childhood to elementary school is an important period of mental development for children 1 year may not be enough followup time to estimate the effects that have taken place leading to the possibility of underestimating the impact of ses future studies should primarily focus on longitudinal research to examine the effects of family factors on later social competence specifically it is necessary to have longitudinal research with surveys distributed at least three different time points and more long term to clarify the extent to which family factors flow through social competence to affect later behavioral problems second the majority of the data in this study was obtained from only mothers therefore there is a risk of reporting bias this vulnerability to reporting bias can pose a serious potential problem to interpretation of the findings 242 243 244 245 single respondents views toward family factors and child mental health functioning may be skewed either more positively or negatively thus resulting in misleading findings the arguments for the examination of the complex relationships between components of ses family processes and child mental functioning would seem to be not fully realized with data provided only from mothers paternal and maternal education levels or other background information may also influence their views of family factors and childrens adaptive functioning several studies have showed there are discrepancies between the views of fathers and mothers 246247 therefore this studys data may obscure the extent to which paternal education is associated with the interparental relationship parenting styles and childrens adaptive functioning since information from the point of view of fathers was absent furthermore other factors may also influence the views of the informants for example regarding the interparental relationship prior studies have shown that views of conflict vary across men and women women tend to report more conflict episodes than men do whether for the better or worse 248 in addition regarding parenting styles the data provided by only maternal reports did not reveal information concerning fathers involvement generally fathers and mothers each have their own parenting styles many studies have shown that fathers and mothers play similar or complementary roles in terms of parenting behavior simultaneously suggesting that their qualities of parenting behavior differ in particular concerning the amount of physical play fathering may prove to be more challenging 249 250 251 views of childrens adaptive functioning behavior may vary across fathers mothers and childrens teachers many study findings indicate that there are several discrepancies among informants including fathers mothers and childrens teachers these discrepancies are particularly prevalent between childrens parents and teachers in terms of their assessment of the childrens psychological wellbeing 242 243 244 245 252 the discrepancies may reflect childrens symptoms or the opportunities to observe them generally it is not easy for parents to assess early maladaptive behaviors in particular parents have difficulty identifying behavior that is indicative of internalizing problems in young children for instance it is difficult for parents to distinguish behavior that is reflective of underlying psychopathology from behavior that is reflective of immaturity in selfregulatory competence conversely teachers have the advantage of having the opportunity to observe the behavior of many other children simultaneously furthermore behavioral problems are likely to be more apparent at school than at home therefore obtaining teacher reports may be particularly important for young children to aid in the assessment and forecasting of their school maladjustment and mental health problems 253 furthermore several studies have suggested that the combination of teacher and parent reports with independent assessments is more sensitive than either assessment alone 254 therefore in future studies reports from several dissimilar informants including those from fathers and teachers in addition to mothers will be needed to more precisely evaluate how family factors affect child mental health functioning third in the current study we did not consider the interplay between maternal and paternal education or the interplay between positive and negative aspects of interparental functioning we studied the independent contributions of both maternal and paternal education and those of the positive and negative aspects of interparental functioning the framework used in this study does not lead to an examination of the actual interplay among any of these factors regarding parental education we included the independent contributions of both maternal and paternal education level as we expected each ses indicator as a predictor to be differentially associated with family processes and child mental functioning through distinct pathways however the argument is incomplete and not generally consistent with theoretical perspectives including family systems and developmental systems theories 1 2 3 4 5 theoretical perspectives suggest there is a more dynamic interplay than the simple additive contribution of maternal and paternal education not modeling the interaction between maternal and paternal education achievement may mislead the influence of each maternal and paternal education achievement regarding interparental functioning we also included the independent contributions of both positive and negative aspects of interparental functioning as there are reasons we expected each positive and negative aspect of interparental functioning to be differentially associated with other variables through distinct pathways most studies empirically investigating the fsm have focused exclusively on the negative aspect of interparental functioning 1537 previous research suggests the interplay between the positive and negative aspects of interparental functioning is more complex than simply looking at the independent contributions of each 1537 previous research also suggests that it is not easy to distinguish the positive and negative aspects of interparental functioning and that children respond to the whole instead of just the parts 29 37 38 39 the model including the independent contributions of both the positive and negative aspects of interparental functioning may not precisely assess the influences of each therefore the inclusion of maternal and paternal education and the positive and negative aspects of interparental functioning are both strengths and weaknesses of this study fourth we could not exactly assess the positive aspects of interparental functioning as a constructive marital conflict as mentioned earlier we used the quality of coparental communication measure to assess the positive and negative aspects of interparental functioning the qccs captures two aspects of the interparental relationship coparental conflict and coparental support 152 the support subscales of this scale measured only general support it has not precisely measured the constructive aspects of conflict however in the current study we treated coparental support as measured by the support subscales as constructive conflict thus the constructive conflict we used may not precisely assess the influence of the positive aspects of interparental functioning on the other variables future studies should investigate this possibility further by using other scales to more precisely assess the constructive aspects of conflict fifth there are likely to be other factors that were not accounted for in our model as mentioned earlier we found a direct association between ses and child mental health functioning while controlling for other variables there are likely to be other family environmental factors furthermore although we found the effects of certain hypothesized family environmental factors on child mental health functioning we did not consider genetic factors in our model it is important to realize childrens behavioral problems may be influenced by genetic risks as well as their familys environmental factors a large body of evidence supports the conclusion that childrens behavioral problems are moderately heritable 255 256 257 258 several studies have suggested the extent to which childrens mental health functioning is affected by family environmental factors depends on genetic and early temperamental characteristics environments help determine how genes express themselves 259 260 261 children with different genetic attributes will respond differentially to the same environmental circumstances therefore it is difficult to distinguish genetic effects from the effects of family environmental factors on child mental health functioning because genetic factors were not examined in this model consequently there are likely to be other family environmental and genetic factors that need to be included in this model future studies should investigate this possibility further by including more family environmental factors related to child mental health functioning specifically these studies could include a genetically informative design as these types of studies would be useful in accounting for the interplay between individuals and environmental circumstances furthermore although we described earlier that the fim contends that family ses is associated with neighborhood conditions as one aspect of parental investment our studies did not assess areal characteristics familys socioeconomic resources are likely to largely determine the kind of neighborhood in which they reside 262 wealthier parents are expected to reside in areas that have a positive community environment which provides resources for the developing child such as parks good schools community involvement among residents and access to conventional friends conversely poor parents are constrained in their choice of neighborhoods children reared in neighborhoods without these resources experience a number of negative consequences lower income may lead to residing in extremely poor neighborhoods which are characterized by few resources for child development such as playgrounds childcare health care facilities and afterschool programs children who live in areas of disadvantaged neighborhoods tend to have poor physical and mental health 263264 furthermore several studies suggest that the affluence of neighborhoods is associated with child outcomes over and above family poverty 265 thus future studies will need to include an assessment of neighborhood quality finally these findings may not be generalizable to all families because there is a risk of attrition bias and the sample was drawn from a limited geographical area in an urban metropolis of japan as mentioned earlier the retention rate from t1 to t2 was 516 and the t2 returning participants tended to be relatively higher in ses than the nonreturning participants this indicates there is a risk of attrition bias therefore there is the possibility that our analyses could not exactly evaluate the mechanism of children with lower ses and our analyses may underestimate the influence of ses furthermore some characteristics of japanese society such as low levels of economic disparity and high education levels among the general population may have contributed towards the current results the reproducibility of the current results should be confirmed using data from other regions in a variety of settings in summary future research on these topics would benefit from longitudinal designs and samples with higher retention rates and greater demographic and clinical diversity conclusions despite the abovementioned limitations our findings help advance our understanding of the relationships between different types of ses marital relationships parenting styles and child social competence and behavioral problems this study highlights the need to simultaneously explore the interrelations between multiple family factors to further our understanding of child mental health functioning emphasis is placed on the importance of examining both family income and educational levels of parents as ses indicators to elucidate the relationships between family factors and child adjustment additionally consistent with a developmental psychopathology perspective this study emphasizes the need to explore both positive and negative aspects of family processes with a particular focus on the positive dimensions of family functioning this study also emphasizes social competence as a potential protective factor that prevents later behavioral problems the current study advances the understanding of ses marital conflict and parenting utilizing a family systems explanation for child development this study adds to previous literature concerning the relationship between ses and child mental health outcomes by demonstrating that both family income and parental education levels simultaneously and independently influence child mental health outcomes through marital conflict and parenting practices in addition the current study adds to previous literature concerning the relationship between ses and child mental health functioning by demonstrating the positive pathway where constructive marital conflict was shown to be related to higher levels of affirmative parenting and in turn more positive outcomes the current study supports not only the notion of negative spillover effects but also of positive spillover effects in addition social skills which were affected by multidimensional family factors adversely influenced later internalizing and externalizing behaviors therefore our study suggests the possibility that theoretical models including the fsm should be included with parental educational levels and positive aspects of family functioning and child outcomes when examining the effects of ses these findings offer preliminary evidence for the need to explore ses by including family income and parental educational levels and both negative and positive aspects of family functioning they advance our understanding of ses marital conflict and parenting practices using a family systems explanation for child development therefore our results suggest that we should be sensitive to social inequalities in childrens mental health problems and developmental outcomes and strive to reduce social inequalities in the longterm it may be necessary to focus not only on economic support but also on education as providing equal access to suitable educational opportunities can positively affect the next generation and is likely to have a more permanent impact on the childrearing environment than a temporary increase in income if more parents can become better educated through an improved social system it might lead to better developmental outcomes for children in addition simultaneously focusing on the marital relationship and parenting style in negative and positive domains may be an effective strategy for developing social adjustment among children the current study suggests that marital relationships and parenting skills in negative and positive domains may be appropriate for interventions promoting social competence among children to prevent later social maladjustment among parents and children who are socioeconomically disadvantaged our findings have important clinical and policy implications abbreviations qccs the quality of coparental communication scale apq the alabama parenting questionnaire ssq the social skills questionnaire sdq the strengths and difficulties questionnaire competing interests the authors declare that they have no competing interests

objective using a shortterm longitudinal design this study examined the concurrent and longitudinal relationships among familial socioeconomic status ses ie family income and maternal and paternal education levels marital conflict ie constructive and destructive marital conflict parenting practices ie positive and negative parenting practices child social competence ie social skills and child behavioral adjustment ie internalizing and externalizing problems in a comprehensive modelthe sample included a total of 1604 preschoolers aged 5 years at time 1 and first graders aged 6 years at time 2 515 male parents completed a selfreported questionnaire regarding their ses marital conflict parenting practices and their childrens behavioral adjustment teachers also evaluated the childrens social competencethe path analysis results revealed that time 1 family income and maternal and paternal education levels were respectively related to time 1 social skills and time 2 internalizing and externalizing problems both directly and indirectly through their influence on destructive and constructive marital conflict as well as negative and positive parenting practices notably after controlling for time 1 behavioral problems as mediating mechanisms in the link between family factors ie ses marital conflict and parenting practices and behavioral adjustment time 1 social skills significantly and inversely influenced both the internalization and externalization of problems at time 2the merit of examining ses marital conflict and parenting practices as multidimensional constructs is discussed in relation to an understanding of processes and pathways within families that affect child mental health functioning the results suggest social competence which is influenced by the multidimensional constructs of family factors may prove protective in reducing the risk of child maladjustment especially for children who are socioeconomically disadvantaged

introduction since 1990 interculturality has been an important concept worldwide it has progressively gained prominence in the public social and political spheres as the focus of interest of educational improvements at both national institutional and intertransnational levels 12 if we focus on the educational field schools have become an important part of intercultural action 3 interculturality is increasingly used as a strategy to promote reflection and a culture of dialogue in educational institutions there is a clear orientation towards changing certain hegemonies of legitimization of the knowledge of what is taught and how it is taught in schools the aim is to transform those organizational and structuring routines of the school institution that reproduce exclusion this circumstance which can be linked to the historical struggles of social movements and their demands for social justice can also be seen at the same time from another perspective the one that links it to the global designs of power capital and market 1 it is therefore necessary to understand the current complex situation surrounding the concept of interculturality in formal education in this sense given that the term interculturality seems to have been used in multicultural neoliberal discourses policies and strategies in an assimilationist and bureaucratic tone it is useful to understand that functional interculturality unquestioningly complies with the established hegemonic rules on the other hand critical interculturality as a political social epistemic and ethical project suppresses the causes of social asymmetry and cultural discrimination that hinder the possibilities of authentic cultural inclusion in the field of education the influence of the neoliberal discourse has tinged the battles for social justice that emerged in the pedagogies of the oppressed 4 and later of hope 56 those that 78 were later raised as banners concerning the transformation of the established system refs 12 highlighted the usefulness of most educational reforms and pointed out that these reforms coinciding with neoliberation policies at different historical moments and in contexts close to globalization which recognize the multiethnic and multilingual character of countries introduced specific policies for the different as part of this multicultural logic of transnational capitalism the critical approach to interculturality in different contexts based on this sociocritical historical perspective it is useful to point out the divergences different nuances and particularities in the way in which each context has developed policies and instruments of public action to respond to the intercultural phenomenon 9 conceptions of interculturality differ substantially depending on the countries on which the analysis is focused on as it was pointed out in 10 the notion of interculturality and intercultural education is not the same in countries that have been created thanks to the migration of diverse cultures such as canada as it is in other european countries and the united states which have migrations from other countries with a lower socioeconomic level or status the author also discussed other countries such as mexico where multiculturalism is part of their history and where cultural differences between the dominant group and the indigenous cultures have led to everything from extermination attempts to concerted national assimilation efforts 10 in analyzing intercultural education in terms of the paradoxical closeness between the european and latin american contexts ref 11 argued that in both territories coexist different models and approaches to tackle cultural diversity which far from contributing to the transformation of schools and society tend to deepen social inequalities 11 this has happened in many countries because the effectiveness of intercultural proposals depends not only on how much the actions generated are consistent with the needs of each educational context but also on other structural measures that transcend the school environment if these conditions are not complied with the socalled intercultural initiatives could be used as a camouflage for inequalities as an alibi to avoid the adoption of initiatives that are genuinely respectful of cultural diversity or as a mere showcase for the most touristy and superficial vision of cultural manifestations 12 in this respect it is believed that the european unions policy initiatives have focused less on the positive effect of improved schooling or on the political and social participation of immigrant students but rather on cohesion the logic governing european policy documents is based on achieving better integration of immigrants into society and more specifically into the labor market 13 in this sense the authors pointed out that at these governmental levels the empowerment of the social and political participation of this group through a more inclusive education is only addressed as a side effect of the policies developed this is consistent with 14 analysis of the clear inconsistencies between the statements of european rhetoric which stress democracy and human rights and what is emphasized by national educational policies basically focused on the acquisition of language and national values to fit in migrants these policies which supposedly promote social justice may fail to achieve inclusive citizenship if while acknowledging demographic changes they neglect everyday injustices and the european historical imprint of racism and xenophobia 1516 until recently it would seem that what has prevailed is to find channels different in each country to integrate the different from the educational system and making them adapt to the majority however there are other indications that their potential can contribute very much to the development of intercultural competence of all citizens due to their capacity for resilience acceptance and openness to novelty especially in secondand thirdgeneration migrant citizens 17 as 18 stated the potential of the individual to demonstrate intercultural competence increases as the experience of cultural diversity becomes more sophisticated moving from ethnocentrism to ethnorelativism it is in this sense that situations of cultural dialogue can be fostered based on the empathy and flexibility that are associated in many cases with the development of intercultural competence as 19 defines intercultural competence as the ability to interact effectively and appropriately in intercultural situations based on ones intercultural knowledge skills and attitudes what leads to intercultural competence is intercultural learning in this regard cortazzi and jin stated that intercultural learning refers to how we understand other cultures and our own culture through interaction generating a cultural synergy that yields a holistic benefit that is larger than separated elements it suggests the importance of peer dialogue as well as teacherstudent discussion about ways of learning to develop local contextualized ways of learning 20 evolution of the concept of intercultural education all this conceptualization emerged in the field of analysis that has been forged around the central subject of this study which is intercultural education the expression intercultural education first appeared within the european context in 1983 when the european legislative framework emphasized the intercultural dimension of education in a resolution for the schooling of immigrant children 21 since then as developed by 22 there has been a clear evolution in the conception and approach given to the expression since 2015 research on intercultural education begins to move towards a more dynamic ethical and transcultural perspective which is brought to educational practice through interaction and cultural dialogue 2324 the static view of intercultural education as a skill in dealing with other cultures ethnicities or languages has been disregarded it has become increasingly evident that cultural diversity itself promoted by national education systems is not appropriate for intercultural learning and dialogue to take place 2526 always in a living process of formation in this field where discourses and training practice sometimes unrelated have multiplied worldwide a rallying point is extracted intercultural education supported by inclusion and social justice should address the entire school community fostering dialogue and democratic coexistence going beyond the mere recognition and acceptance of differences 2728 the authors of 22 highlight an important contradiction the national education system and the teaching and learning approach it fosters is precisely what raises obstacles to intercultural dialogue thus it is easy to understand that the school recognizes this intercultural approach in declarative terms but maintains an assimilationist logic in its praxis 29 the conflict between the official discourse on intercultural education and its actual application in school practice should not be overlooked in specific areas where social coexistence with diverse cultures has significantly intensified publications have also increased significantly in the last two decades 30 31 32 one of the fundamental reasons concerns the interest in caring for the intercultural coexistence that has developed given the high rate of immigration in spain according to 12 there is a clear definition of the concept of intercultural education that emphasizes the perspective of interaction and the benefit of cultural pluralism typical of democratic societies as a pedagogical resource intercultural pedagogy is understood as a reflection on education based on the recognition of cultural diversity value 12 what is important about this proposal is that it is based on a model of analysis and intervention that includes all the dimensions of the educational process at the time when intercultural education was taking shape in spain a clear vision was provided showing the existing gaps in the research carried out up to that time in relation to both structural and curricular measures the academic centers had a limited margin to put faith in an educational project based on a mediumlongterm consolidated center where interculturality was hardly existent at that time it became clear that organizational and curricular changes do not usually affect the general curriculum but rather have a compensatory character 12 from the results of these studies important recommendations were drawn regarding the grouping and selection of students it was aimed at the need for flexible groups adapted to teachinglearning processes in relation to formative and evaluative activities cooperative learning was emphasized to favor interaction regarding another critical dimension the participation of families and students in the center it was suggested that it is not so much a matter of continuing to facilitate familyschoolcommunity bridges but rather of creating educational spaces where all those involved have a role to play in the definition and development of the educational model 12 until 2003 intercultural education was an illusion rather than a reality it was necessary to state and support actions towards the creation of models of educational projects in schools that would build a solid and consistent proposal for intercultural education later in their systematic review ref 33 point out two fundamental lines that have marked a trend between 2009 and 2019 the one related to the perceptions and beliefs of teachers in relation to ethnocultural diversity and on the other hand the concern to offer a consistent and sustained response to this diversity in schools and communities 3435 bearing in mind the crucial role of the family in the important dynamics of change both inside and outside the classroom towards an inclusive approach to intercultural education in schools since 2015 there has been a certain abundance of studies emphasizing an inclusive and dynamic conception of intercultural education based on quality interactions generated in schools however it is necessary to review what has happened in the last five years analyzing whether this approach has permeated organizational and curricular processes and pedagogical practice in schools and whether the terrain marked by political discourse on the inclusion of cultural diversity 25 has developed from the perspective that has been reflected beyond neoliberal slogans a review is proposed on the way educational institutions and school communities may be succeeding in inclusive practice and process practice towards creating an authentic intercultural education this review considers that an inclusive intercultural approach must be supported by an involved and collaborative institutional organization the progress of which is achieved through the construction of a sense of belonging to the educational community 36 37 38 39 40 the need for collective responsibility in a climate of exchange between educational agents for the improvement of competent learning for all students 41 derives from this principle the importance of transforming practice by reviewing the ways of understanding relationships and interactions between the staff with the students and with the educational community must be recognized 42 from this perspective it is important to assume a meso micro and macrovision of intercultural education analyzing whether the political purposes and the type of institutional conditions that educational administrations impose on schools are consistent with the daily margins of action of teachers in their centers as 43 points out the school in the last decades has been accumulating an excess of expectations and missions as a consequence of having delegated everything that the family or society could not do or was concerned about this takes the risk of making the school responsible for what it cannot achieve in isolation and on its own in this sense it is necessary to strengthen the conception of educational contexts as spaces for dialogue beyond the physical barriers of schools 44 where critical reflection on dilemmas and paradoxes can be enriched so that inclusion can take root in praxis 45 it must be assumed that in order to achieve a true culture of diversity the traditional view of cultures and the compensatory curricular approach for minorities must be overcome 254446 at the same time intercultural education must be considered beyond specific ethnic markers from which a process of homogenization of cultural groups is sought to be assembled starting from a cultural logic 4 the message that 47 conveyed a few years ago in a monograph focused on intercultural education culminates the theoretical framing of this systematic review today it is more necessary than ever to promote intercultural education with a pedagogical approach of inclusive nature and focused on the community and it is not only a matter of addressing the organizational didactic and curricular responses of the intercultural school but the nature meaning imprint and character of educational actions that generate peaceful and respectful coexistence equity and participation education and democratic values in academic institutions objectives based on this approach the aim of this systematic review is to examine the role of the school community in the implementation of authentic inclusive intercultural education the specific objectives are as follows to conduct an updated review of the reorganization processes that the school community have determined in order to offer an inclusive educational response to cultural diversity to analyze the current response of schools as participatory and collaborative communities in intercultural education to evaluate the current practical reality of schools as inclusive and intercultural education centers materials and methods to achieve the proposed objectives a systematic literature review was carried out applying the protocol of the updated prisma statement 48 for the identification and selection of documents this methodology aims to identify analyze and assess those studies that highlight the institutional dimension of schools as participatory and collaborative educational communities the intercultural education approach is analyzed in relation to the following dimensions 1 the construction processes of the participatory school climate 2 the organizational and pedagogical structure of inclusive schools 3 the impact of practice and experiences created in these inclusive intercultural schools to generate intercultural learning to study these facets concepts related to intercultural education cultural diversity coexistence and school climate as well as the school context were chosen as fundamental elements that make up a true educational community based on the model of collaboration and participation scopus and web of science databases were used for english language articles and dialnet for spanish ones the following descriptors from the unesco thesaurus were used to search for documents school intercultural education participation cultural diversity practice primary education secondary education and elementary education these descriptors were combined with the boolean operators and or and not several combinations were tried until the final search formula was intercultural education and the search was carried out using the topics in both english and spanish after each search the documents were selected based on the inclusion and exclusion criteria established beforehand f analysis of documents essays or theoretical reflections g studies focused on intercultural education from the inclusive cultural diversity approach in schools g studies focused on other types of specific educational support needs unrelated to intercultural school contexts and with a compensatory and noninclusive approach for the analysis and classification of the documents based on the established dimensions an analysis was applied to evaluate the degree of agreement and disagreement among the 3 judges who participated in the classification of the documents based on the inclusion and exclusion criteria that were assessed considering that some agreements could be the result of chance and that their random effect could give a greater reliability effect than the real one 49 the perreault and leigh coincidence coefficient was used to amend this result its values range from 0 to 1 and the coincidence value was i 083 which made it possible to consider the final selection of documents as adequate i r fo n 1 k • k k 1 12 if fo n ≥ 1 k i r 0 if fo n 1 k fo number of opinions on which the judges agree n total number of opinions k total number of categories procedure the exhaustive search began by using the keywords then the inclusion criteria were applied eliminating those documents that did not meet them using the mendeley bibliographic manager duplicates were located and subsequently eliminated from the initial selection after this titles and abstracts were read and the studies that met the inclusion and exclusion criteria were selected a complete reading was performed out of the chosen texts and those that did not focus on the objectives of the study after an indepth analysis of their content were excluded the objectives sample methodology main results and conclusions were analyzed for each article from the sample of selected documents the initial selection of documents was as follows a total of 3755 results were obtained after applying the inclusion and exclusion criteria 3732 documents were eliminated the final sample of studies consisted of 21 documents the following flow chart shows the selection process and the thorough examination of the articles results characteristics of the included studies all articles published on the subject up to the time of the closing of this review were reviewed the 21 articles selected for the review were studies published mainly in english between 2018 and 2023 which ensured results on experiences developed in educational centers around the new models of promotion and work of interculturality in schools the studies were conducted mainly in spain and chile although they were also carried out in countries such as mexico brazil colombia russia italy austria denmark slovenia poland and the united kingdom it is noteworthy that 11 out of the 21 studies were conducted exclusively in spain four studies used a purely quantitative methodology and the other fifteen used qualitative methodology two studies were mixed some evaluation tools were used in the studies including questionnaires observation interviews focus groups and documentary analysis in 471 the sample was made up of teachers management teams or social professionals in 324 the sample was made up of students in 147 of family members and in 29 there were programs designed for the intervention of children with cultural diversity all the information can be seen in table 2 which also lists the authorship year of publication purpose sample country methodology with the evaluation tool and main results results characteristics of the included studies all articles published on the subject up to the time of the closing of this review were reviewed the 21 articles selected for the review were studies published mainly in english between 2018 and 2023 which ensured results on experiences developed in educational centers around the new models of promotion and work of interculturality in schools the studies were conducted mainly in spain and chile although they were also carried out in countries such as mexico brazil colombia russia italy austria denmark slovenia poland and the united kingdom it is noteworthy that 11 out of the 21 studies were conducted exclusively in spain four studies used a purely quantitative methodology and the other fifteen used qualitative methodology two studies were mixed some evaluation tools were used in the studies including questionnaires observation interviews focus groups and documentary analysis in 471 the sample was made up of teachers management teams or social professionals in 324 the sample was made up of students in 147 of family members and in 29 there were programs designed for the intervention of children with cultural diversity all the information can be seen in table 2 which also lists the authorship year of publication purpose sample country methodology with the evaluation tool and main results to analyze the challenges of school leaders when including migrant students in a chilean school to identify school leadership practice that favor the inclusion of migrant students to understand school leaders perceptions about the inclusion of migrant students and their strategies to promote it to identify barriers and challenges in the process of inclusion of migrant students and how school leaders can address them qualitative methodology a total of three members of the management team three teachers with migrant students and three inspectors three teachers of the school integration program and six parents of foreign origin semistructured interviews and a focused discussion group three strategies were identified for school leaders to foster the inclusion of migrant students in a chilean school and establish an inclusive school climate they provide emotional and social support and adapt pedagogical practice to meet the needs of migrant students chile león et al 51 to know the management tasks that promote inclusion quantitative methodology a total of 243 families and 154 teaching teams from 17 public and subsidized primary and secondary schools questionnaire leading inclusive education the management teams of schools in socioeconomically disadvantaged areas carried out fewer inclusive actions than those located in more favored areas spain jiménezvargas 52 analyze how schools manage the tensions between an inclusive model and an advanced neoliberal model aiming to identify effective strategies to promote inclusion and educational equity to determine teachers beliefs about cultural diversity and how they influence planning and teaching practice qualitative methodology a total of 45 elementary school teachers interview there is a discrepancy between the theories and normative documents of intercultural education and the beliefs and practice of teachers there are biases in the teachers statements which led to a moralizing discourse and the repetition of practice without reflecting on their appropriateness to the specific context italy garretabochaca et al 55 to analyze the degree of recognition of cultural diversity in the schools documentation the actions carried out in relation to cultural diversity and the practical development of intercultural educational practice quantitative methodology a total of 1730 representatives of the management teams of primary education schools questionnaire the results indicate that there is still a long way to go in intercultural education schools with a lower presence of students of foreign origin tend to perceive this issue as less of a priority and act less in this direction compared with other schools the misconception persists that it should only be addressed in culturally diverse schools spain antolinez domínguez and jorge barbuzano 56 to analyze the models of cultural diversity management through two case studies carried out in spain and mexico during the rise of intercultural education qualitative methodology two schools one in andalusia and the other in oaxaca key players in the centers 55 interviews in spain and 47 in mexico case studies school and community ethnographies it highlights the importance of identifying the aspects that can function as analytical facets for intercultural education from the paradigm of diversity the paradigms of inequality and difference are those that underpin educational policies based on culturalism which has a double logic first diversity is reduced to cultural criteria which can confuse diversity with inequality second cultural homogenization occurs within groups leading to a distinction between them and us spain and mexico dežan and sedmak 57 to analyze the influence of the school environment on the wellbeing of adolescent migrants focusing on the pedagogical practice and interpersonal relationships established between them their peers and teachers how these factors may affect their academic social and emotional adaptation and development in the school environment analyze the process of implementation of activities and reflect on the notion of interculturality in education from a broad perspective related to global citizenship and education for development qualitative methodology two primary education centers with few migrants in the basque country a total of 16 teachers focused discussion group and teachers logbooks three perceptions of interculturality were distinguished generalist focused on cultural aspects and social justice approach the intercultural logic is based on assumptions such as equality and justice which cannot be imposed but must be adopted at a personal level spain molina díaz and sales 63 to know the process of building the schools educational community and the factors involved in this process qualitative methodology interview of the principal two teachers two parents two students and one member of the city council focused discussion group four parents four teachers and three students interviews focused discussion group and participant observation the results remark the importance of highlighting the collective identity of the community at the beginning of the construction process and how affiliation to a group is not enough for people to identify with it the complexity of the collective identitybuilding process in the community is highlighted the importance of searching for identity symbols and motivating community members on an ongoing basis is pointed out dichotomous discourse that influences the evolution of collective identity spain chile torrelles montanuy 65 to analyze the predominant approaches and actions in the practical development of intercultural education in primary education in spanish schools considering the ownership and the percentage of students of foreign origin in each of them mixed methodology a total of 1730 primary school students 19 interviews with teachers from five schools questionnaire and interview the results show that the presence of foreign students is the most influential variable in the implementation of intercultural education in schools although there is a discursive recognition of the value of intercultural education no actions with an intercultural perspective are identified in its practical application in most schools democratic participation in the community is essential and is related to coresponsibility and shared sovereignty the relationship between democratic participation collaborative culture and distributed leadership in the inclusive educational community is highlighted and the importance of learning to participate is emphasized spain gromova et al 66 to identify the educational practice used by elementary school teachers to provide linguistic and academic support to immigrant children and to promote a welcoming classroom environment that favors their psychological adjustment qualitative methodology a total of 20 elementary school teachers who have experience with immigrant students interview teachers do not use special methods for teaching russian as a foreign language and recognize the need for training in teaching methods for immigrant students there is a need for teacher training programs that include teaching multilingual and culturally diverse students in the classroom to describe the development of the learning and service project as a curricular practice linked to the territory to analyze the strategies of curriculum negotiation and student participation in this educational practice qualitative methodology students in sixth grade of primary education two teachers the families involved in the aps the schools management team and the education councilor of the city council participant observation interviews focused discussion groups audiovisual records documentary analysis and field diary the aps curricular practice carried out among all sectors of the educational community through cooperative dynamics and participatory social diagnoses such as social mapping cooperative learning and class assemblies has allowed students to reach their maximum learning potential and achieve true democratic participation the educational experience has enabled all participants to become critically and actively aware of their reality and has led to a transformative and emancipatory education the leadership exercised by the teachers is within the parameters of distributed leadership central to the experiences of democratic schools and social justice models spain guzmán vargas et al to identify a pedagogical strategy that would allow the interaction of the wounaan and mestizo cultures present in the classrooms of a school in bogota qualitative methodology a total of 27 students of the compartir recuerdo ied school action research the project sharing our worlds construction of a mural through collaborative work sharing experiences languages cultural diversity and ways of life with empathy solidarity and respect for diversity is presented intercultural processes have been achieved in students parents and teachers which highlights the importance of pedagogical strategies that promote the formation of individuals who transform formative dynamics based on cultural diversity it is necessary to reconstruct the meaning of inclusive education in order to take into account cultural exchanges in the classroom and allow the general population to achieve human dignity and quality of life to describe and understand how intervention in cooperative learning and the use of cell phones in kindergarten and primary school classrooms favors school coexistence in a context of socioeconomic vulnerability and cultural diversity qualitative methodology a total of 52 students from two kindergarten classrooms and their respective tutors and 55 students from two primary school classrooms and their respective tutors participant case study semistructured interviews and focused discussion group the results point to a reduction in disruptive behaviors academic disaffection and exclusion which is mainly attributed to the combination of some cooperative elements that are favored by the cell phone the educational use of cell phones with a cooperative methodology improves school coexistence brazil melacontreras et al to encourage dialogue and critical reflection among teachers and students on the respect and appreciation of cultural and ethnic diversity through cinematography qualitative methodology five public schools 11 teachers and 145 seventh grade students in visual arts and history geography and social sciences documentary and narrative analysis of film language the cineduk program generated in the students the acquisition of adequate competencies to interpret and signify the diversity of the world it advocates cinematographic praxis to enrich teaching practice and learning through the curricular and cultural content of students the development of cinematography as a didactic strategy promotes nondiscriminatory and dialogic teaching based on the dimensions established for the analysis of the documents figure 2 shows the distribution of studies by dimensionsfields as can be seen most of the studies focused on organizational aspects and the pedagogical approach while the aspects centered on the processes of building a participatorycollaborative school climate were the least frequent studies based on the dimensions established for the analysis of the documents figure 2 shows the distribution of studies by dimensionsfields as can be seen most of the studies focused on organizational aspects and the pedagogical approach while the aspects centered on the processes of building a participatorycollaborative school climate were the least frequent studies discussion to facilitate the reading and discussion of the results we display the analysis arranged according to the dimensions that made it possible to identify the main lines of work developed by the schools in the framework of intercultural education regarding the processes of organization and management of the educational response and pedagogical approaches it should be noted that several studies highlight the importance of school leadership and the adaptation of pedagogical practice in promoting the inclusion of migrant students and the implementation of an alternative intercultural education model focused on the needs of migrant groups 5064 it has been observed that management teams in socioeconomically disadvantaged areas have more difficulty carrying out inclusive actions 51 suggesting the need for support and improvement plans that are more ecological and sensitive to the nature of the community to which it intends to respond studies such as 52 highlight the role of teachers in educational inclusion and the importance of training models focused on fundamental aspects for the improvement of attitudes and respect for cultural diversity the coexistence of different models for the promotion of respect for cultural diversity generated resistance practice that strained the management of a model truly adequate to the needs of the context in this sense the adaptation of pedagogical practice is essential to meet the needs of migrant students 50 the presence of foreign students is a key factor in the implementation of intercultural education in schools 65 but it is also essential to overcome the misnamed folklorization that has led to the identification of different cultures by reference to their traditions gastronomy dances etc 65 the construction of a collective identity in the educational community is a dynamic and complex process in which all members of the community must participate 63 the existence of a dichotomous discourse in intercultural education can lead to cultural homogenization within groups and a distinction between them and us 56 as 54 points out there is a discrepancy between the theories and normative documents of intercultural education and the beliefs and practice of teachers which can generate contradictions and make it difficult to effectively implement intercultural education taken together these findings suggest that it is crucial for schools to adopt an inclusive pedagogical approach tailored to the needs of migrant students and to promote cultural diversity supported by committed school leadership and adequate teacher training in intercultural education 505264 it is essential that the educational administration provides support and specific improvement plans to schools in socioeconomically disadvantaged areas to facilitate the implementation of inclusive actions 51 intercultural education should be 57 24 19 00 10 20 30 40 50 60 organizational structure and pedagogical approach the impact of the practices and experiences created in the schools the processes of building a participatorycollaborative school climate discussion to facilitate the reading and discussion of the results we display the analysis arranged according to the dimensions that made it possible to identify the main lines of work developed by the schools in the framework of intercultural education regarding the processes of organization and management of the educational response and pedagogical approaches it should be noted that several studies highlight the importance of school leadership and the adaptation of pedagogical practice in promoting the inclusion of migrant students and the implementation of an alternative intercultural education model focused on the needs of migrant groups 5064 it has been observed that management teams in socioeconomically disadvantaged areas have more difficulty carrying out inclusive actions 51 suggesting the need for support and improvement plans that are more ecological and sensitive to the nature of the community to which it intends to respond studies such as 52 highlight the role of teachers in educational inclusion and the importance of training models focused on fundamental aspects for the improvement of attitudes and respect for cultural diversity the coexistence of different models for the promotion of respect for cultural diversity generated resistance practice that strained the management of a model truly adequate to the needs of the context in this sense the adaptation of pedagogical practice is essential to meet the needs of migrant students 50 the presence of foreign students is a key factor in the implementation of intercultural education in schools 65 but it is also essential to overcome the misnamed folklorization that has led to the identification of different cultures by reference to their traditions gastronomy dances etc 65 the construction of a collective identity in the educational community is a dynamic and complex process in which all members of the community must participate 63 the existence of a dichotomous discourse in intercultural education can lead to cultural homogenization within groups and a distinction between them and us 56 as 54 points out there is a discrepancy between the theories and normative documents of intercultural education and the beliefs and practice of teachers which can generate contradictions and make it difficult to effectively implement intercultural education taken together these findings suggest that it is crucial for schools to adopt an inclusive pedagogical approach tailored to the needs of migrant students and to promote cultural diversity supported by committed school leadership and adequate teacher training in intercultural education 505264 it is essential that the educational administration provides support and specific improvement plans to schools in socioeconomically disadvantaged areas to facilitate the implementation of inclusive actions 51 intercultural education should be extended to the entire student body and educational community fostering the construction of a collective identity that values and celebrates diversity 6365 it is necessary to promote teacher training in intercultural competencies and to encourage critical reflection on own beliefs and practice in relation to cultural diversity 56 concerning the situation of schools in relation to creating participatory and collaborative communities with a climate favorable to intercultural education the selected studies highlight the importance of building a participatory and collaborative school climate to promote the wellbeing and inclusion of migrant students 57 intercultural education and successful interpersonal relationships between teachers and students are fundamental to achieving this goal 58 likewise it is necessary to address the specific difficulties faced by migrant students such as migratory experience gender role conflicts and belonging to segregated groups 59 overcoming these challenges requires a caring school culture and teacher training in intercultural and emotional competencies as well as in the collaborative relationship with migrant families 59 promoting intercultural sensitivity among native pupils and paying attention to the academic selfconcept and life satisfaction of immigrant students are key elements to improve school coexistence and the educational inclusion of this group 60 the strategies identified by the different studies analyzed include fundamentally teacher training in interculturality the development of intervention programs to improve communication and emotional selfconcept and the participation of families and social entities to promote respect and trust among students 60 in this sense the affective dimension emerges as a fundamental aspect of educational research emphasizing the importance of understanding and intervening in education at the local level by recognizing intercultural educational regions and their particularities 58 establishing horizontal relationships in the process can expand the possibilities of understanding the cultural meanings and senses that guide peoples actions 58 where the practical and experiential reality developed from schools on intercultural education is concerned the selected studies show the impact of the practice and experiences created in schools to generate intercultural learning for example ref 66 examines the teaching methods used in russia to teach russian to immigrant children and highlights the need for training in teaching methods for immigrant students the findings suggest that teacher training programs are needed that include teaching multilingual and culturally diverse students in todays classrooms 66 according to 67 educational practice allows students to reach their full learning potential and achieve true democratic participation these educational experiences promote a transformative and emancipatory education and the leadership exercised by teachers is recognized as essential to the experiences of democratic schools and social justice models 67 where 68 is concerned there is an emphasis on the importance of pedagogical strategies that promote the development of transforming individuals of formative education dynamics based on cultural diversity pedagogical proposals should be based on relational functional and critical interculturality to generate spaces of exchange considering the knowledge of each student 68 as examples of practical strategies ref 69 indicates that the educational use of mobile phones with a cooperative methodology is a good example of a useful strategy to improve school cohabitation and reduce disruptive behaviors academic disaffection and exclusion 27 on the other hand refs 7071 are committed to the use of cinematography as a didactic strategy to promote nondiscriminatory and dialogic teaching by using film language in audiovisual creations on cultural diversity limitations and future work one of the main limitations found in this study focuses on the nature objectives and scope of the interventions around the working model in intercultural education the evidence points to the need to consider new organizational models for managing and approaching pedagogical styles focused on the construction of an intercultural school climate isolated sporadic interventions are disconnected from the organizational and pedagogical development of the centers without a global and integrating vision of intercultural education within the curricular design of them these are highly frequent and ineffective as they only cover areas of the curriculum and are not integrated into the culture of intercultural inclusion the reality of the intercultural fact of the centers is hardly visible few experiences are shared and the real scope of the actions carried out in the schools is unknown the specific and particular initiatives that are being proposed could be redirected toward the construction of innovations at the center or institutional level and could be triggered for more global actions that mobilize the entire educational community in this way the deployment of inclusive intercultural education could result in repercussions of greater scope reach breadth and significance it is recommended that future studies consider the experiences of centers the pedagogical principles of which contemplate the educational response to intercultural reality field studies could improve the analysis quality and scope of the experiences that have been collected in the studies presented in this manuscript these studies would provide detailed information on how this practice is being applied in schools and how it is perceived by students teachers and families therefore the knowledge of this practice could be deepened and provide more precise and effective recommendations for educational leaders who wish to implement strategies to foster a culture of inclusion and diversity in their institutions conclusions this study dealt with three key dimensions in the search for inclusive and intercultural education in diverse school environments through an updated systematic literature review management reorganization processes and pedagogical approaches participatory and collaborative school climate construction as well as the impact of practice and experiences created in schools to generate intercultural learning were assessed the study provides a comprehensive view of the advances and challenges in inclusive and intercultural education in diverse school sceneries although significant progress has been made in implementing inclusive practice and building participatory and collaborative school climates there are still areas that require greater attention and development one of these areas is the ongoing training of teachers in intercultural competencies and socioemotional skills the inclusion of cultural diversity into the curriculum and the adoption of inclusive pedagogical approaches not only enhances the educational experience of students but also promotes fairness and social justice in the educational system in addition it is essential to strengthen the relationship between schools and families to support the process of integration and adaptation of migrant students and their families to the school environment it is important to continue researching and evaluating the impact of educational practice and experiences on the generation of intercultural learning identifying and promoting effective pedagogical strategies and innovations in teaching and learning can contribute to a more inclusive and fair education in addition it is essential to promote the participation and collaboration of all actors involved in education including students parents teachers administrators and educational leaders as well as political authorities and civil society organizations in summary this study provides an updated and comprehensive overview of the situation of inclusive and intercultural education in diverse school environments linking the results obtained in the three dimensions with the objectives the findings can help future research and practice in this field as well as inform educational policies and strategies to address cultural diversity in schools through an interdisciplinary and collaborative approach it is possible to move towards a more inclusive equitybased and socially fair educational system that values and celebrates cultural diversity as a stimulating resource for all students data availability statement information and queries on the data used can be obtained from this article

in todays society highquality educational contexts must include intercultural education and educational inclusion as main elements of school culture equity social justice and equal opportunities for everybody require the construction of flexible processes relationships and organizational structures open to diversity this paper presents an updated review of studies focusing on models of educational responses adapted to cultural diversity it analyzes the response of schools as collaborative communities in intercultural education and their reality as inclusive and intercultural communities an exhaustive search of documents was carried out consulting the web of science wos scopus and dialnet databases after analyzing and applying inclusion and exclusion criteria 21 documents were identified that showed the structural cultural and relational transformation of educational centers and the improvement of their organizational and public response and adaptation to current needs the challenge of building intercultural educational contexts is a concern for schools and the educational agents who coexist in them

introduction noncommunicable diseases are estimated to be responsible for twothirds of global mortality 1 cardiovascular diseases are the most prevalent ncd both globally and in south africa 2 3 ncds remain vastly undersupported currently less than 01 of south africas national health budget is spent on ncds 4 access to care is a vital element of universal health coverage and a key challenge for south africa economic geographical and racial inequalities together create vast disparities 5 6 7 the south african government is now in its second phase of implementing national health insurance 8 this second phase has come with an emphasis on strengthened and communitybased primary care a national programme reengineering primary health strengths and limitations of this study ► this is the first known investigation combining both mortality trends and barriers to access to care for people who have died of cardiovascular diseases ► in combining quantitative and qualitative analysis to develop a three delays model specific to cardiovascular disease in the agincourt population this study provides a basis for development and application to other settings to deal with care access and quality issues in the final stages of chronic illness ► using two components of verbal autopsy data provides complimentary information and a basis for refining circumstances of mortality indicators but direct comparison is limited by methodological differences in data collection ► the nonspecificity of verbal autopsy cause of death categories particularly other and unspecified cardiac diseases reduces the ability of this study to analyse trends in specific cardiovascular disease conditions ► other factors influencing equity in access to care such as migratory status and socioeconomic status cannot be included due to lack of available data within verbal autopsies open access care was initiated in 2010 with the aim of strengthening health promotion and prevention and early detection of disease 9 as a response to south africas dual burden of hivaids and ncds the national department of health introduced an integrated chronic disease management model in 2011 1 although other studies have quantitively examined gaps in careaccess using a continuum or cascade of care approach 10 11 knowledge of where barriers in access to care for cvd occur and the identity of such barriers in rural south africa as well as who is less likely to seek care is a key gap in the literature this is a crucial area for research as delays in accessing care are an important predictor of patient morbidity and mortality for cvd outcomes 12 due to a lack of civil registration data and death certification systems in many lowincome and middleincome countries existing data on trends in cvd deaths may vary in reliability 13 there is a civil registration system in south africa with marked improvements in recent years but evaluations have highlighted persisting quality issues that may which influence its reliability and validity 14 verbal autopsy is a method of ascertaining cause of death and the circumstances surrounding that death in situationssuch as deaths in the communitywhere other methods are not available or reliable vas are done by trained fieldworkers who ask a standard set of questions to carers of the deceased either physician judgement or computer algorithm is used to assign cause of death based on these data 15 which has been shown to be reliable and reproducible 16 since 2012 versions of the who va tool have included questions on circumstances surrounding deaths 17 there is also a free text section where fieldworkers record summaries about the death and its circumstances which may include information not captured on the binary responses from the rest of the va toolincluding access to care va presents a unique opportunity to understand social exclusion from access to health systems within a population as well as quantify causes of death when conducted sequentially in the same community va enables an understanding of how patterns of access to health systems change over time this research presents both substantive findings to this end and develops the va methodological approach a three delays model can be used to examine barriers in accessing care this approach categorises delays into three phases seeking reaching and receiving care 18 and draws attention to the multifactorial nature of access to care 19 it facilitates an overview of access to care for a particular context by breaking down the care pathway into a series of steps and suggests targets for health planning use of the three delays model has been used extensively for care in obstetric emergencies 18 with recent broader applications for example to sepsis 20 trauma 21 22 and timecritical conditions 23 it has not yet been applied to cvds this study aims to contribute to bridging the gap in the evidence needed to support prioritising and planning services for ncds which is especially important as south africa works towards the goal of universal health coverage 24 this study is the first known investigation combining both mortality trends and barriers to access to care for people who have died of cvd using va data this study documented trends in cvd deaths that can be described as downstream deaths cardiac conditions strokes and renal disease rather than upstream cvd risk factors it aimed to understand differences over time by condition age and sex of those dying in a rural population in south africa this study also aimed to ascertain barriers to and patterns of access to care leading up to the death using a three delays framework and examination of both com and free text components of va data 23 by combining quantitative and qualitative findings this study aimed to develop a three delays model specific to cvd in the agincourt population providing a basis for development and application of the three delays model to the final stages of chronic illness in other settings methods study design this study presents a mixedmethods analysis of va data quantitative analysis comprised of descriptive analysis of cvd mortality rates and a three delays approach to analysis of circumstances of mortality indicators and freetext narratives of the final illness free text narratives were also analysed qualitatively study setting and participants this study was done in the agincourt health and sociodemographic surveillance system site in mpumalanga province rural north east south africa the hdss covers an entire subdistrict population of 117 000 persons and has been stewarded by the mrcwits rural public health and health transitions research unit since inception 25 the population has been surveyed at least annually since 1992 with va conducted on every death in the study population occurring in each preceding year previous studies have shown recall to be good up to a year after a death 26 at the time of research va data from 1993 to 2015 was available quantitative analysis measures deidentified va data were electronically stored and three elements extracted cause of death derived using interva5 27 interva5 is the most recent probabilistic modelling approach developed to assign cause of death using responses to va interview questions detailed explanation of how cause of death is assigned is provided by byass et al 28 two authors reviewed va cause of death categories to select deaths related to cvds included categories were acute cardiac disease stroke renal failure and other and unspecified cardiac disease 29 after discussion among the authors renal failure was included in our analysis as a cvd outcome because the main causes of chronic kidney disease are cvd risk factorshypertension and diabetes these exceed other causes such as chronic glomerulonephritis or hiv 30 chronic kidney disease is especially likely to be related to cvd in older adults in this population where cvd risk factors are highly prevalent and undertreated 31 to minimise capturing noncvd causes cases of renal failure deaths in people aged under 40 years old were excluded 32 interva5 gives a likelihood of a death being due to a given cause greater than 50 was required for case inclusion each death appears once in the analysis com indicators the ten com indicators are closed questions added to the va tool in 2012 which examine social and health systems determinants of death and social exclusion from access to care 17 these indicators are based on a framework of proximate intermediate and distal determinants of health outcomes 17 an 11th indicator was included alongside the ten com indicators which asks whether the deceased was discharged while still ill while not part of the com indicators this is thought to be important to include especially for chronic conditions such as cvd as these patients may experience multiple cycles of accessing care it may suggest poor quality of care delays in access to care were examined using the com indicators including cases where death occurred between 2012 and 2015 a person was classed as having experienced a delay if they had a positive response to the relevant indicator with the exception of three where a negative response was used to capture experiencing a delay freetext descriptions of the death and its circumstances the freetext sections of each va are recorded by a trained lay field worker at the time of interview based on discussions with the respondent most often the primary caregiver this enables more nuanced details about circumstances around the time of death to be captured analysis all deaths recorded within the agincourt population were included in the dataset systematic housetohouse visiting and detailed inquiry of every household member limits the risk of missing deaths descriptive data were generated using spss v 25 33 mortality trends cvd deaths for each condition category 5year time period sex and 10year age group are described as agesextimestandardised mortality rates three delays quantitative analysis to identify inclusion of cases in the three delays analysis cases where free text and com data were not both available were first excluded free texts were examined to identify cases which were found dead at the scene or had died suddenly with therefore no opportunity to seek care these cases were also excluded the remaining cases are referred to as those able to seek care responses to com questions are described as total cases indicating they had experienced at least one delay across any of the com indicators shown as a proportion of total cases able to seek care total cases for each specific delay are then shown as a proportion of cases that had experienced at least one delay across any of the com indicators in addition delays extracted from the free text are analysed quantitatively in a similar manner for that done with the com indicators using data on the three delay coding extracted during the qualitative analysis the free text was also examined to determine the first careseeking act where this information was available qualitative analysis the free texts were analysed qualitatively to ascertain delays in access to care using a combination of deductive and inductive approaches a deductive approach enabled causes of delays to be extracted using a set of a priori codes based on the three delays framework of seeking reaching and receiving care an iterative process 23 enabled emerging codes to be incorporated until saturation was reached initial coding was conducted by jnlv with codes reviewed by jd and af this method has been previously applied to the same dataset 23 nvivo v12 software was used for the qualitative analysis 25 34 construction of a three delays model finally a three delays model specific to cvd in the agincourt population was developed through aggregating delays derived from the com and freetext analyses patient and public involvement we did not directly include public involvement in this study the database from which this study derives data is used to inform a public engagement programme at the medical research councilwits university rural public health and health transitions research unit open access results mortality trends a total of 15 305 registered deaths occurred over 1 851 449 personyears between 1993 and 2015 of these deaths 9 were attributable to cvds corresponding to a crude cvd mortality rate of 077 per 1000 personyears standardised mortality rates by sex age group and time period are displayed in table 1 the cvd mortality rate increased from 034 in 1993 to 112 in 2015 across all time periods stroke was the dominant cause of cvd deaths and suggested a linear increase responsible for 410 of all cvd deaths across all years mortality contributions of acute cardiac disease and renal failure were low across all years although 20102015 saw an increase in acute cardiac disease deaths over the entire time period the cvd mortality rate was higher in women mortality was higher in women for stroke and other and unspecified cardiac diseases mortality was higher in men for acute cardiac disease there was no significant difference for renal failure cvd mortality rate increased with age access to care between 2012 and 2015 495 cvd deaths occurred of these 41 cases did not have both free text and com information available and were excluded from analyses when considering all delays there was no significant difference in numbers experiencing any delay between sexes using the com indicators or free text no significant differences were seen in numbers experiencing a delay by age group on either com or freetext analyses significant difference was seen by condition on com with 181 acute cardiac diseases 482 stroke 469 renal failure and 378 of other and unspecified cardiac disease cases reporting any delay no equivalent significant difference was seen on the free text qualitative analysis themes identified in each delay category are summarised below with a nonexhaustive selection of quotes which have been chosen to illustrate themes each quote has been given by the field worker recording each case delays in seeking care of the cases reporting any delay almost half reported a delay in seeking care however specific reasons or explanations were rarely given and lack of careseeking was commonly expressed through phrases like nothing was done or a refusal to seek care only one of the com indicators on seeking caretraditional medicinewas explicitly mentioned in the free text traditional medicine was often sought either before or after having sought western care care was sought from a traditional healer following perceived failure of treatment given at a western facility and vice versa the doctors didnt say what was wrong treatment was given but nothing changed… he was taken to the private doctor the doctor didnt say what was wrong… he was taken to the traditional healer he went to traditional healer who gave him traditional medicine… nothing changed he then went to private doctor refusal to seek care was common among cases who did not travel to a facility however refusal appeared to be targeted towards hospitals rather than clinics she was taken to the clinic… treatment was given but nothing changed after few days she was worse she refused to go to the hospital she died at home delays in reaching care reaching care was very rarely discussed in the free text two explicit delays were mentioned which related to ambulances and dying on the way to healthcare other cases indicated a delay occurredsuch as in cases where the intention to seek care had been madebut further detail was not provided in cases where reaching care was discussed this mostly centred around ambulance transport cases which mentioned calling directly for an ambulance themselves from home frequently experienced delays an ambulance was called… it was late and when they arrive they said that she is dead in several cases there were suggestions of an intention to seek care but which were unfulfilled while the free text did not provide further insight into the reasons for this delay this suggests there may be additional delays following an intention to seek care which were not captured in the free text 2 with those who refused to seek care or initially did not seek care but later did and those who initially sought care and later refused in subsequent cycles of accessing care com circumstances of mortality open access open access she collapsed at the gate… she died after an hour before they can take her to healthcare delays in receiving care delays in receiving care were reported in the free texts of most cases this tended to focus on issues of communication between the clinician and patient or family and being discharged while still ill a repeated and persistent theme on receiving care was that the patient family or caregiver were not told by the clinician what the problem was at hospital he was admitted oxygen waterdrips and tablets was given but all the symptoms didnt change and the doctors didnt tell the family what was wrong in many cases the patient was reported to have been discharged while still ill frequently leading to reentering the three delays cycle he was discharged at the hospital after six days and he was still sick he was taken to another hospital after a day and he was admitted again… he was not getting better… he was discharged being sick referral between hospitals presented an opportunity for delays such as lack of admission at the second hospital being admitted but reporting that nothing was done andor being referred back to the first hospital without any treatment or diagnostic tests being performed this again highlights the nonlinearity of accessing care for cvds as patients reentered a process of making decisions travel and readmission while she was at hospital she was taken to another hospital… to check her chest she told them that they didnt do anything at the other hospital they didnt admit her she was sent back to the first hospital the same day other cases indicated a lack of alignment between hospitals involved in interfacility referral particularly when patients were sent to another hospital for an operation in several cases such patients were taken to the referred hospital only to not receive the operation they had travelled for the doctor said she need to be operated and referred her to another hospital for operation but she was not admitted and they said they are fully booked… she must wait until they have space many cases referenced elements of patient decision making which negatively impacted the receipt of care therefore contributing to delays in receiving care a key theme in patient decision making was self or family forced early discharge she was admitted and given treatment… the family asked doctors to discharge her but not given treatment as they promise to bring her back to hospital… she was not taken back to hospital… she died at home refusal to be admitted to hospital also emerged as a patientled delay in receiving care he was taken to the hospital he refused to be admitted… he died at home after a day of consultation from the hospital first careseeking act the first careseeking acts identified from the free text are outlined in table 3 cases were also categorised by hospital nonhospital and delayed first careseeking act a total of 391 cases were able to seek care and therefore were included in the analysis there were no significant differences in first careseeking act by sex age group or condition basetotal applicable cases delayed includes cases where initially no care was sought but later was and those who never sought care this differs from table 2 where the freetext delay at least one delay during seeking care also encompasses cases who later refused to seek care after having previously sought it open access three delays model a three delays model for cvd outcomes developed through combining qualitative analysis of the free text and the quantitative com analysis is shown in online supplemental figure a2 discussion while trends in deaths due to cvd have been the subject of previous studies 35 36 this is the first known investigation combining both mortality trends and barriers to access to care for people who have died of cvd in this lowincome rural south african population we found that cvd deaths are increasing over time with an increase in mortality rate from 034 to 112 between 1993 and 2015 most of these deaths were due to stroke and women overall suffered significantly more cvd deaths than men women experienced fewer ischaemic heart disease events than men contrasting with knowledge from other settings that women are as likely to have these conditions as men however the findings do fit with evidence from elsewhere that importance of cvd in women may be underestimated 37 and underdiagnosed 38 this difference could also be due to differences in care seeking behaviours among men and women although this analysis suggests there was no difference in reporting barriers to care in the final illness by sex to ensure validity of our findings we used two methods to examine access to care for cvd in agincourt one using the com indicators and the other free text care access was found to be generally good with most cases seeking reaching and receiving care nevertheless many cases did report experiencing multiple and reinforcing delays in seeking and receiving care both the com and free text highlighted seeking care as a key delay in accessing care although only 6 of respondents said that the deceased doubted the need for medical care when explicitly asked in the com most cases did not present to hospital or call an ambulance as their first care act suggesting that the urgent need for care was not recognised early hospitalbased care is a critical determinant of most successful interventions for cvd outcomes 39 that the first healthseeking act for people who died of acute cardiac disease was often prehospital rather than hospital is therefore troubling not seeking hospital care in the first instance can also lead to a reentry into the three delays cycle presenting opportunities for the patient to experience further delays health literacy campaigns around symptom recognition and presenting to facilities able to deal with these acute conditions could improve not only the current access to care cycle but also future iterations and have worked well in other settings 40 however this study highlights multiple supplyside factors which also drive barriers to care seeking which likely combine and converge with demandside issues the south african public health system aims to provide healthcare that is free at the point of use for all 41 despite this perceived costs were a major barrier to seeking care in most cases who experienced delays consistent reporting of prohibitive costs in agincourt has also been shown elsewhere 17 this may be due to poor information on availability of healthcare or that nonmedical direct and indirect costs are driving this barrier overall cost burdens of care have been shown to be low in agincourt but costs associated with transport and difficulty in obtaining incomerelated exemptions at hospitals limit the efficacy of stateprovided protection 42 work must be done to further delineate the reasons for high reporting of prohibitive costs and institute appropriate solutions reaching care appeared to be a fairly minimal delay although free text analysis highlighted a further delay not captured in the com indicators ambulance delay the number of cases reporting this was minimal shortages of ambulances has been a key challenge in this area but the department of health has invested in emergency medical services including increasing ambulance numbers 43 44 nevertheless given that many patients who need this service are not using it due to prior barriers at the stage of seeking care investment in ambulance services may need to be accompanied by measures to reduce these prior barriers receiving care was a common barrier in both the com and free text analyses free texts highlighted many barriers not captured by the com it is likely that the free text allows expansion on the barriers experienced in receipt of complex facilitybased care that are not possible to capture in the smaller number of com fields for this delay pointing to the complementarity of the two methods phrases like nothing was done and the doctor didnt say what was wrong were ubiquitous it could be that healthcare providers are not communicating effectively or at all with the patient andor caregiver and therefore this is an element of clinicianpatient interaction which requires intervention however it could also be an indication that the clinician was not able to determine a diagnosis potentially as a result of health system weaknesses poor quality of care is now a greater barrier to reducing mortality in lmics than insufficient access to care 45 so understanding where these issues are is vital with either interpretation these free text phrases suggest a wider issue of poor perception of care quality low expectations of care quality are prevalent in lmic settings including south africa which may reduce pressure on systems to deliver quality care 46 perceptions of care quality may also inform future careseeking behaviours as evidenced here by the frequent use of traditional healers after visiting a western facility and feeling nothing changed or nothing was done or by otherwise refusing to seek or delaying careseeking refusal of care was common and more so for hospitals than clinics it could be hypothesised that care received in hospitals is perceived as poorer than in clinics further supported by open access the number of cases who sought nonhospital care in the first instance patient experience and perceived quality of care can impact utilisation of healthcare services 47 changing perceptions of hospitals as places to receive care and be treated rather than places to die requires both improvement in the health system to enable hospitals to provide quality care 48 and positive messaging to individuals and communities negative perceptions are particularly important to remedy in chronic conditions which most cvds are where patients should have multiple opportunities to seek and receive care and are likely to accumulate experience and perceptions of care quality interpersonal skills improving drug availability and technical care have been identified as priority areas to improve perceived quality of care in the adjacent limpopo province 49 aligning with the free text analysis in this study however evidence on perceptions towards care in south africa is limited and warrants further investigation this study explores application of the linear framework of the standard three delays model to cvd outcomes however several findings have highlighted the complexity in access to care for chronic conditions delays in receiving caresuch as being discharged while still illinfluence future careseeking behaviours and many cases enter multiple cycles delays may therefore multiply and reinforce each other over the course of multiple iterations of accessing care even during the final illness as examined here a linear model is oversimplistic for application to chronic conditions which could be better represented as a cyclical model this has been raised previously in applying the three delays framework to access to care in burkina faso and indonesia 50 study limitations the nonspecificity of interva5 categories was a key limitation particularly other and unspecified cardiac diseases this reduces the ability to analyse trends in specific cvd conditions and means it cannot be determined exactly what is driving a large proportion of this cvd burden renal failure was included due cvd risk factors being major causes of chronic kidney disease especially in older adults while we have aimed to minimise the inclusion of noncvdrelated causes of renal failure we acknowledge this analysis may capture deaths due to other causes other factors influencing equity such as migratory status and socioeconomic status cannot be included due to lack of available data within vas that this study could not capture these factors limits the utility of the study for health planning from an equity perspective delays in receiving care may be underreported respondents may have had more direct experience of issues in seeking and reaching care and so be more likely to report these and people who died outside of facilities are also less likely to have experienced issues with quality of care but this does not mean the issues do not exist 17 comparing proportions of cases experiencing each delay as calculated by the com versus the free text must be given careful consideration given the differing methods of data collection but they do provide complimentary information amenable to synthesis in comparing the com and free text this study raises the question of breadth vs depth the com is an invaluable tool for gaining a broad overview of delays in accessing care and are feasible to perform at scale the free text while able to pick up delays not captured in the com is timeconsuming to analyse with challenges of scalability however it has been shown that extracted word frequency counts from free texts can be used by machine learning for automated classification 51 insight gained from the free text could inform expansion or refinement of the com to enable a greater level of detail to be captured particularly for assessing delays in receiving care the com is continually evolving 52 and this analysis provides an empirical basis for revisiting them future research the three delays model developed here presents a basis for development and application to other settings to deal with access and quality issues in the final stages of chronic illness this study also presents an opportunity to revisit and refine the com indicators it also highlights several avenues for further research first the greater burden of cvd death among women requires further investigation in order to develop strategies to tackle this inequity prominent delays in accessing care also require further examination particularly around high reporting of prohibitive costs and on perceptions of care quality conclusion this study is the first known investigation combining both mortality trends and barriers to access to care for people who have died of cardiovascular it shows the increase in deaths due to cvd between 1993 and 2015 in a rural region of south africa given cvd in south africa is now the second greatest cause of mortality after hivaids in south africa 3 there is a vital need for prevention and management strategies for these conditions as women suffer a significantly higher cvd mortality than men they should be a key focus of such strategies while care pathways appear to be generally good for cvd this study has highlighted issues around seeking care including that many cvd cases first seek care outside a hospital setting during the final illness and receiving care strategies to improve access to care are therefore needed this study highlights the complexity in accessing care for chronic conditions such as cvd many cases enter multiple cycles and may experience multiple and reinforcing delays while a three delays model provides a valuable framework the potential need for a cyclical model for examining access to care for chronic conditions should be considered competing interests none declared patient consent for publication not required ethics approval approval from the university of witwatersrand human research ethics committee to use mrcwits agincourt unit va data had been previously obtained approval to perform secondary data analysis on va data was obtained from the kings college london research ethics committee provenance and peer review not commissioned externally peer reviewed data availability statement data may be obtained from a third party and are not publicly available deidentified verbal autopsy data from medical research council wits university rural public health and health transitions research unit 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 cardiovascular diseases are the second leading cause of mortality behind hivaids in south africa this study investigates cardiovascular disease mortality trends in rural south africa over 20 years and the associated barriers to accessing care using verbal autopsy data design a mixedmethods approach was used combining descriptive analysis of mortality rates over time by condition sex and age group quantitative analysis of circumstances of mortality com indicators and free text narratives of the final illness and qualitative analysis of free texts setting this study was done using verbal autopsy data from the health and sociodemographic surveillance system site in agincourt rural south africa participants deaths attributable to cardiovascular diseases acute cardiac disease stroke renal failure and other unspecified cardiac disease from 1993 to 2015 were extracted from verbal autopsy data results between 1993 and 2015 of 15 305 registered deaths over 1 851 449 personyears of followup 1434 94 were attributable to cardiovascular disease corresponding to a crude mortality rate of 077 per 1000 personyears cardiovascular disease mortality rate increased from 034 to 112 between 1993 and 2015 stroke was the dominant cause of death responsible for 410 5881434 of all cardiovascular deaths across all years cardiovascular disease mortality rate was significantly higher in women and increased with age the main delays in access to care during the final illness were in seeking and receiving care qualitative freetext analysis highlighted delays not captured in the com principally communication between the clinician and patient or family half of cases initially sought care outside a hospital setting 509 199391 conclusions the temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions particularly for the women strategies to improve seeking and receiving care during the final illness are needed

introduction hispanics are the largest racial minority group in the united states in 2020 about 61 million people of hispanic origin were living in the country by 2060 it is projected that the hispanic population will increase to over 111 million people a significant factor in us population growth hispanics experience high prevalence of most chronic diseases for example the prevalence of diabetes among hispanic adults is 226 vs 113 in nonhispanic whites risk factors such as obesity sedentary behavior and poor healthy eating are a major concern for hispanics and significantly contribute to chronic diseases like type 2 diabetes hispanic adults and youth aged 219 years have the highest prevalence of obesity in the us hispanics are typically less likely to be aware of their conditions receive instructions from their physicians to adopt lifestyle modifications or selfmonitor their conditions if hispanics continue to experience poorer chronic disease outcomes the projected demographic change in the us population will magnify these health inequities pennsylvania is home to 1 million hispanics vibrant hispanic communities can be found in midsize cities and towns like lebanon in lebanon county and reading in berks county hispanics in both communities experience high levels of known socioeconomic factors associated with increased rates of chronic diseases in particular more than onethird of hispanics live below the poverty line over 15 points above the us average and between 136 and 252 in the target communities had limited english proficiency compared to only 85 in the us and 41 in pennsylvania several community health needs assessments conducted in the region including hispanic and nonhispanic populations prioritize chronic disease obesity sedentary behavior and inadequate nutrition as health topics requiring immediate action for example adults in lebanon reported higher percentages of inadequate fruit and vegetable consumption heart disease high blood pleasure and cholesterol than the corresponding state and national averages both communities also reported high percentages of adults with obesity and high rates for heart disease and cancer deaths the size and rapid growth of the hispanic population in these two communities coupled with their high rates of socioeconomic disparities and chronic disease offers considerable reason to focus on this populations chronic disease prevention and management established in 1999 racial and ethnic approaches to community health is the cornerstone program aimed at reducing racial and ethnic health disparities at the centers for disease control and prevention in 2018 cdc funded a new 5year cycle of grant recipients to reduce health disparities among racial and ethnic populations with high levels of chronic disease through reach recipients and their community partners plan and carry out local culturally appropriate programs to address preventable risk behaviors leading to chronic diseases in socioeconomic deprived communities since 2018 better together reach our initiative has leveraged strong community collaborations to implement locallytailored practiceand evidencebased strategies aimed at increasing physical activity opportunities healthy nutrition programming and diabetes prevention programs in lebanon and berks counties the overall objective of this report is to describe the workinprogress and lessons learned from our reachsupported initiatives in particular we describe the implementation activities and initial results of three strategies to improve physical activity three strategies to improve healthy eating and one strategy to improve communityclinical linkages for each program presented in this community case report we also summarize several activities that we carried out to incorporate the needs and preferences of our hispanic population in order to make these programs culturally appropriate we also introduce our communityacademic partnership and the conceptual model guiding our work context communityacademic partnership the better together initiative was first conceived on october 2016 when a community health advocate in lebanon found that many local organizations were offering community health and social services but operating independently with a longstanding history in prevention and community engagement penn state pro wellness partnered with these organizations to bring them together in a communityacademic partnership since then over 60 local organizations are collaborating to break down silos and share a common agenda address health disparities improve the quality of life and wellness of residents and promote healthier environments where people live work learn and play the original initiative was organized around four action themes including healthy food access physical activity mental and behavioral health and family and community engagement these themes were perfectly aligned with the goals of the overall reach program our team leveraged these existing collaborations shared interests and the expansion of penn state health into berks county to apply for the reach award lebanon and berks counties are geographically close and share similar demographics and identified community needs creating areas for cooperative integration of leading organizations and their programming within these communities currently better together reach benefits from the active involvement of many local and statewide organizations with established connections with the hispanic community convening individuals and leaders from many layers of the community helped to ensure discussions were representative and inclusive of the overall community voice conceptual model figure 2 shows our model which fully incorporates the inputs and activities of better together reach to evaluate the proposed outcomes related to physical activity nutrition and communityclinical linkages importantly we have identified short intermediate and long outcomes that align with the overall reach objectives the healthy people 2020 goals pertaining to chronic disease prevention our coalitions capacity and the needs identified from multiple chnas beyond the project period our coalition expects to achieve the following longterm outcomes increased purchasing of healthier foods and increased levels of physical activity reduced health disparities in chronic conditions and risk factors and improved health outcomes programmatic components since 2018 our better together reach partnership has implemented several locallytailored practiceand evidencebased strategies aimed at increasing physical activity opportunities healthy nutrition programming and diabetes prevention programs in lebanon and berks counties in this section we describe the workinprogress and lessons learned from our reachsupported initiatives figure better together reach communityacademic partnership physical activity city redesigning and master planning we have partnered with the city of lebanon and the lebanon valley conservancy to improve the walkability of the city one of our first initiatives was the launch of a bilingual mobile app to report issues with the citys streets and recreational areas including uploading pictures and pin locations electronic reports from residents were sent to the citys department of public works for their attention we also partnered with the community health council of lebanon to seek walkworks designation for a walking trail in downtown lebanon walkworks is a program run by the pennsylvania department of health and pennsylvania downtown center to recognize local efforts that promote safe walking routes offer social support through guided communitybased walking groups help schools develop walktoschool programs and address local policies to increase safe walking routes a 132mile route was awarded walkworks designation providing safe connection to six everyday destinations this was the first route in lebanon county with such a designation our team also conducted a survey to assess physical activity practices use of community green spaces and specific areas that residents would like to see improved the survey was developed with input from community partners including hispanics and was delivered in spanish and english to better reach our community we leveraged these survey results and partnered with the city of lebanon to help design enhance and restructure and urban alley into the liberty trail park wengert memorial park and the borne learning trail through bilingual interactive signage and trail restoration one pedestrian mile was enhanced and another mile of multiuse trail was created as part of the borne learning trail the wengert memorial park will serve as a trailhead and connector to 14 miles of the lebanon valley rail trail in the park will be a bike safety traffic garden one of its kind in pennsylvania an area for youth to learn traffic rules and practice these skills in a secure and fun environment furthermore we have worked toward installing seven automated ecocounters to monitor pedestrian traffic patterns in lebanon and reading the locations for the measurements were chosen with guidance from community stakeholders to assess the need for new or expanded crosswalks sidewalks or trails our goal is to develop new or enhance existing 11 miles of routes that connect everyday destinations and improve walkability our team also developed an interactive map for community members to identify local resources for physical activity indoor spaces where the community can exercise and other local programming including emergency food providers food assistance programs farmers markets local orchards and community gardens nature rx we partnered with berks nature a nonprofit conservation organization to implement the nature rx program to motivate adult and young individuals to spend time outdoors engaging in some sort of physical activity such as walking hiking or biking we first developed a bilingual marketing campaign to increase awareness of nature rx including examples of fun outdoors activities we also adopted goose chase a scavenger hunt mobile app available in spanish and english to encourage enrollment in nature rx and reward participants for spending time outdoors we invited those who downloaded the app to complete a brief survey to measure their levels of physical activity and engagement with outdoor spaces participants reported spending 5 days outdoors for ≥10 min and spent an average of 1 h and 56 min outdoors each week in a typical week participants reported spending around 4 days a week engaging in moderate physical activity with an average of 1 h and 41 min per week on average participants increased exercise duration by 7 min after completing the program lebanon bicycle recycle in partnership with the lebanon valley bike coalition an organization that works to educate advocate and improve physical activity through cycling we helped launching the lbr in 2021 meetings with local leaders confirmed that cycling is important in lebanon for physical activity and transportation to work and school lbr is a program that collects used bikes repairs them and returns them back to community members who need them to date over 125 bikes have been given to community members with an emphasis on youth and families further lbr has worked with volunteers to train them to repair bikes including a cohort of middleschool students who came after school to receive training over 280 hours of volunteer time have been given to the program also lbr has partnered with the migrant education program and the lebanon county christian ministries to provide bikes to their members to help with their local transportation needs for instance we developed a bilingual marketing campaign to promote this program and education to encourage physical activity through cycling including how to do it safely in the city our reach team is conducting a survey with bike recipients to learn about their levels of physical activity and social needs healthy eating farmers market nutrition program the pennsylvania department of agriculture provides those who are eligible four vouchers of six dollars each to spend from june through november on seasonal fruits and vegetables grown by pennsylvania farmers distribution and redemption rates of these fmnp vouchers are lower in lebanon when compared to neighboring counties lebanon family health services a local women infants and children office had a 367 redemption rate of vouchers in 2019 that number dropped to 256 in 2020 as a result of the pandemic the goal of our fmnp initiative is to increase voucher redemption rates among wic beneficiaries served by lfhs and senior residents to promote fmnp awareness and voucher redemption lfhs holds the latino health fair a oneday annual event that includes live demonstrations on healthy cooking and bilingual nutrition education in 2019 we conducted a brief evaluation with wic beneficiaries to survey barriers participants faced in using fmnp vouchers like transportation to vouchereligible markets variety of produce and limited locations of vouchereligible markets the survey also gauged the participants interest in additional offerings to improve voucher redemption such as healthy cooking or nutrition education to adhere to covid19 safety protocols our fmnp initiative was adapted into a grab bag program to limit physical contact between participating families and staff while offering the same quality produce in convenient packaging informed by our 2019 survey healthy recipes for cooking with seasonal fruits and vegetables were included in grab bags in both english and spanish these recipes included common hispanic dishes to further evaluate this new initiative in fall 2021 we started inviting fnmp participants to complete a brief survey figure top row sta making inventory of repaired bicycles to be distributed to youth and families through the lebanon bicycle recycle farm stand for fmnp and veggie rx participants in readings penn state health st joseph hospital and community health worker conducting screenings for diabetes prevention and management programs at a covidvaccination site in reading bottom row billboard displaying our marketing campaign for breastfeeding in lebanon bilingual breastfeeding education delivered by a community health worker at a wic o ce in lebanon and interactive map showing local resources for physical activity healthy eating and diabetes prevention programs in lebanon within 24 h of purchasing the grab bag and a second survey was sent within 7 days also in 2021 we started evaluating fmnp voucher redemption among seniors in lebanon to identify potential barriers and areas of opportunity to increase redemption rates and ultimately the consumption of fresh produce among this vulnerable group one of the indentified barriers to voucher redemption was low access to vendors who participate in fmnp in 2022 we worked with a new farmer to obtain the registration as fmnp vendor and we then partnered with the chestnut street community center in downtown lebanon to host a new farmers market cscc is the location for two hispanic churches two nonprofit organizations an overnight shelter and a new community garden this location is ideal for expanding fmnp as it is along a popular bus route and walking distance to a wic office and a local elementary school importantly this new farmers market is the only one in the city of lebanon that accepts fmnp vouchers provided to both wic and senior participants veggie rx veggie rx is a fruit and vegetable prescription program that allows clinical staff at penn state health st joseph in reading to prescribe vouchers for fresh produce to patients with chronic dietrelated health conditions the program was launched in collaboration with the united way of berks and the food trust the goal of veggie rx is to increase access to and consumption of local fresh produce among patients with diabetes clinic providers prescribe produce vouchers to supplemental nutrition assistance program eligible patients based on their patients household size that can be redeemed at local farmers markets and participating retailers during 6month followup and group education sessions with a dietitian patients fill out a nutritional assessment for daily fruit and vegetable consumption and discuss situations that may have changed their nutritional habits to improve opportunities to redeem vouchers a farm stand by a local farmer is located within the st josephs downtown campus this initiative is also assisted by one of our reachfunded bilingual community health workers a pilot study with 97 adults with type 2 diabetes hemoglobin a1c ≥ 70 and body mass index ≥ 25 kgm 2 showed a reduction in hba1c postprogram reduced hba1c was associated with higher voucher redemption rates and a change in diabetes medications there were no associations with bmi but changes in blood pressure was positively associated with veggie rx voucher redemption given the initial success of veggie rx in reading our team is expanding this initiative to lebanon in partnership with union community care a local federallyqualified health center we anticipate enrolling 30 ucc patients into the veggie rx program in the next year bilingual breastfeeding education and workplace breastfeeding policy we partnered with lfhs the local wic provider in lebanon to provide bilingual breastfeeding support to expectant or new mothers with reach funds we hired a fulltime chw and trained her in the provision of professional lactation care since 2019 our chw has provided onetoone and group education to 456 pregnant and postpartum women at the wic clinic local hospitals or by phone in both spanish and english to abide by covid19 protocols and guarantee the safety of our chw and wic recipients all counseling sessions were moved online to better support this initiative our reach program developed and disseminated a culturallyrelevant marketing campaign about breastfeeding support across local healthcare organizations and the community including media advertising in billboards and public transit partnering with the lebanon valley chamber of commerce we also conducted a survey to determine what breastfeeding policies are in place at lebanon countys businesses our team also conducted a series of focus groups with women who have returned to work while breastfeeding to learn how they are or are not supported through workplace policies we found that polices supporting breastfeeding in workplaces were not consistently implemented communityclinical linkages community health workerdelivered diabetes prevention program we partnered with the langan allied health academychw training institute to recruit and train bilingual chws for work in community and outpatientinpatient settings to date the institute has trained 11 class cohorts and over 120 chws the training provides comprehensive education in 15 areas including cultural competency health literacy patient navigation and chronic disease prevention and management our project hired three local bilingual chws to conduct diabetes screenings at community events and provide dpp classes our chws completed their training with the institute as well as a cdccertified lifestyle coach training at present our chws have provided cdcapproved dpp to 204 residents at three clinical facilities in lebanon and berks counties we have worked with lfhs to provide bilingual dpp in lebanon serving two cohorts a year 60 people have participated in this program in 2022 reach also supported the offering of dpp at union community care a federally qualified health center in lebanon we also supported the chw at family first health another federally qualified health center in lebanon to become a certified lifestyle coach in order to offer cdcapproved dpp each of these locations lfhs ucc and family first offers bilingual dpp classes including inperson and zoom options discussion better together reach has made significant progress in addressing health disparities related to chronic disease prevention in the hispanicmajority communities of lebanon and reading of note we are actively promoting existing walking and bike routes that connect everyday destinations and supporting the planning and designation of new routes which are evidencebased strategies to improve physical activity we are also expanding access to affordable and nutritious food to alleviate food insecurity among lowincome families and creating bilingual breastfeeding education programming to support wic beneficiaries in their preferred language to address critical communityclinical linkages we are expanding access and referrals to dpp offerings by training local bilingual chws to connect atrisk individuals with new and existing programs chws are trusted voices in the community who can support communityclinical initiatives for chronic diseases our initiatives are promoted throughout strong community networks with culturallyrelevant marketing campaigns a good number of our annual objectives are being met but much work lies ahead as we recover from the pandemic the pandemic impacted our coalitions ability to deliver activities as many were planned as inperson events or large community gatherings however the limitations created by the pandemic offered opportunities to innovate evidenced by our grab bag program and the virtual breastfeeding education other reach programs can employ similar approaches to support their priority populations with needed chronic diseases prevention programming during these challenging times through our established communityacademic partnership we will continue implementing locallytailored practiceand evidencebased strategies to address chronic disease disparities in lebanon and reading these strategies were also tailored to respond to the cultural preferences and needs of hispanics in the two target communities our next program evaluations will incorporate data from novel techniques including automated ecocounters to monitor pedestrian traffic patterns this approach is promising because it incorporates easytouse technology into communitylevel interventions and involves community members in making decisions about where to create new or expand trails this level of community engagement and shared decisionmaking is critical to meet our programmatic goals related to physical activity including the creation of a bicycle and safety garden and mobile bicycle repair unit as well as a park assessment initiative future program evaluation data will also be collected from new initiatives impacting nutrition and breastfeeding goals for example in collaboration with the local chamber of commerce we will champion a breastfeeding is welcome here campaign among lebanon employers after assessing existing policies and practices findings will inform the creation of resources and training to support breastfeeding practices at local worksites we will also increase the number of worksites with implemented health nutrition standards by working with local food pantries to develop and evaluate placement and behavioral design initiatives our team has always been looking for new community partners to innovate our programming for example with the lessons we have learned in the past 4 years we look forward to expanding our dpp beyond healthcare settings and directly into local employers we have partnered with the largest poultry producer in the region to offer an online version of dpp for their employers almost 90 of the employees of this company are hispanics have limited english proficiency and reside in the counties of lebanon and berks this partnership will offer expanded health services to those who need them most if this online dpp is successful it would be replicated with other employers in our catchment area also our team is continuing to refine programmatic data collection and measurements including using geographical information mapping to evaluate our activities and provide timely feedback to our community partners we will continue monitoring our coalitions capacity and updated chnas to revise our projected outcomes but always aligned with practical strategies for culturally competent evaluation although not considered in the present project there are several promising chronic disease prevention and management interventions that others working with hispanic populations could consider implementing for example employerbased walking challenge campaigns obesity reduction education at community venues and chwled physical activity programs these interventions have shown broad reach of hispanic individuals good implementation feasibility and effectiveness to improve physical activity and reduce obesity the national goal of achieving health equity cannot succeed without eliminating hispanic health disparities and engaging communities to seek and disseminate culturallyrelevant solutions together with its partners better together reach is working toward that goal and on capacity building with the aim of continuity and sustainability of this initiative postaward intervening in areas facing high chronic disease health disparities like lebanon and reading leads us to develop a communitycollaborative blueprint that can be replicated across hispanic communities in pennsylvania and the united states data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by the penn state institutional review board the patientsparticipants provided their written informed consent to participate in this study written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article 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 author disclaimer the content is solely the responsibility of the authors and does not necessarily represent the official views of cdc or nih

background hispanics in lebanon and reading pennsylvania experience high levels of socioeconomic and health disparities in risk factors for chronic disease in our communityacademic coalition better together received a racial and ethnic approaches to community health reach award to improve healthy lifestyles this report describes our workinprogress and lessons learned to date from our reachsupported initiatives in lebanon and reading methods for the past years our coalition has leveraged strong community collaborations to implement and evaluate culturallytailored practiceand evidencebased activities aimed at increasing physical activity healthy nutrition and communityclinical linkages this community case report summarizes the context where our overall program was implemented including the priority population target geographical area socioeconomic and health disparities data communityacademic coalition conceptual model and details the progress of the better together initiative in the two communities impacted results to improve physical activity we are creating new and enhancing existing trails connecting everyday destinations through city redesigning and master planning promoting outdoor physical activity increasing awareness of community resources for chronic disease prevention and supporting access to bikes for youth and families to improve nutrition we are expanding access to locallygrown fresh fruit and vegetables in community and clinical settings through the farmers market nutrition program to beneficiaries of the women infants and children wic program and the veggie rx to patients who are at risk for or have diabetes and providing bilingual breastfeeding education to enhance communityclinical linkages we are training bilingual community health workers to connect atrisk individuals with diabetes prevention programs conclusions intervening in areas facing high chronic disease health disparities leads us to develop a communitycollaborative blueprint that can be replicated across hispanic communities in pennsylvania and the united states

introduction in her dissertation the author analyzed the experience of four wives who committed homicide in response to domestic violence using the feminist radical perspective and bourdieus symbolic violence theory the authors standpoint is that women who commit homicide against their partners in response to domestic violence are victims indepth interviews of four informants support this standpoint at womens prison in bandung and the authors analysis on structure culture and process 1 the feminist radical perspective as the overall theoretical umbrella discusses patriarchal society and sexuality at the same time bourdieus symbolic violence theory with the concept of habitus space and modal composition is used to explain different forms of social domination analysis of the experiences of four women shows that they are victims of domestic violence even though they are perpetrators in the perspective of the criminal law radical feminists show that the domestic violence they experience is a result of the patriarchal society where the husband holds higher position of power within the family than his wife victimization occurs because of domination variations in dominance occur which is determined based on bourdieus theory 2 the results are domination and capital typology matrix consisting of fully dominatedfullycapital partially dominated fullycapital partiallydominated noncapital nondominated noncapital and dominated capital irrational the predominant category observed is the dominatedcapital irrational form this dominance occurs among informants who hold a space not to be dominated due to their ownership of capital however in certain situations they still experience domination this power dynamic may lead them to seek out new partners as a possible solution there are four typology models of domination and capital based on the experiences of women who have experienced victimization in radical feminist studies and criminology the punishments given to them are very diverse for example not all sentences use the law on the elimination of domestic violence no 23 of diagram 1 typology of domination and capital meanwhile when referring to the husbands role it is characterized by starting first with the perpetrator therefore it is safe to state that this type of crime is typical where the perpetrator is also the victim of the crime even though they will still receive punishment for the crime the author argues that the form of punishment will be different such as rehabilitation or social work this research aims to provide input to the proposed policy on punishment for women who commit homicide in response to domestic violence the policy should look at rehabilitation measures lenient treatment and protection programs the typology of domination and capital provides the baseline data to develop the appropriate punishment policy for them which is the novelty of this research literature review feminist criminology theory on women who kill feminist theory is developed as a new branch of science about women to provide a system of ideas about human life that depicts women as objects and subjects as actors and the knowledgeable individuals feminism refers to ideas generated primarily by women to change their selfawareness and change society feminists offer a perspective on social life from the point of view of seeing women as a disadvantaged social group for example in the context of women who commit homicide in response to domestic violence appropriate punishment is yet to be considered feminist criminology is concerned with the treatment of women in the police courts and prison systems contrary to popular stereotypes the study of womens experiences in the criminal justice system is unfavorable therefore feminist jurisprudence is looking for the truth behind the power of law formed in a positivistic way 3 in her work crime and criminology a feminist critique carol smart criticizes the lack of treatment of female perpetrators in mainstream criminology and ignores the victims experience as a victim 4 feminist criminology focuses on women as perpetrators of crime women as victims of crime and 2012 women as workers in the criminal justice system renzetti interprets feminist criminology as a paradigm of study and explanation of perpetrators of crime and victimization including institutional responses to fundamental gender issues 5 for this reason to influence the making of public policy we need scientific knowledge feminist legal theory exposes how the legal system and practices dismiss womens experiences with crime and fail to consider them during the legal proceedings that women endure for instance the sentences imposed on women who commit homicide in response to domestic violence may not receive fair treatment from the criminal justice system compared to men who commit similar offenses the objectives of feminist legal theory involve comprehending womens experiences investigating whether laws and legal establishments provide equal treatment and identifying potential reforms according to this theory the law sees and treats women the way men see and treat women substantively the perspective of state policy in formulating experience is the same as the way men formulate experience 6 the feminist legal theory also seeks to analyze and improve traditional legal theory and practice it focuses on how laws are structured to deny womens experiences and needs in addition feminist jurisprudence opposes and reflects the demand for women regardless of race class age ability to be recognized as an equal group by a social contract supported by existing laws and legal systems 7 this article examined the policy of punishing women who commit homicide as a response to domestic violence in indonesia however this does not guarantee that all women in different social conditions are powerless to challenge the law patriarchy the legal context in politics in defending their cases patriarchy and sexuality in radical feminism to understand husbands domination over wife for radical feminism patriarchy and sexuality are the two main concepts in understanding male domination over women the term patriarchy was initially used by max weber to describe a particular sociopolitical system in which a father due to his position in the household can dominate members of his extended family network and control the economical production of the kinship unit meanwhile one of the first radical feminists kate millet argued that patriarchy was brought by the idea of control and culture by men not limited to the arena of kinship but all of human life such as economics politics religion and sexuality 8 meanwhile in other radical feminist writings they proposed three universal types biological maternal care marriagebased families and heterosexuals shulamith firestones argument for example said that patriarchy is based on biological factors where only women can conceive and give birth 9 while some argue that the universal phenomenon underlying patriarchy is not related to women being biological mothers but rather a social institution of the family based on certain types of marriage according to bouchier for example marriage is an institutional source of real exploitation 10 meanwhile marilyn french who researched the history of patriarchy said that the root of patriarchy is humans living in harmony with nature they see themselves as a small part of a more extensive system she stated that early society was a matricentric society the roles that were passed on involved feminine traits such as bonding sharing and harmonizing with nature 11 in its development which is characterized by an increase in population the food supply becomes limited as a result humans slowly began to distance themselves from nature humans want to control nature but in turn it causes them to be alienated from nature this alienation then encourages the traits of divorce hostility fear and hatred these negative feelings encourage men desire to control nature and women as women are often viewed as a part of nature because of their reproductive function 12 the use of power by men over women is found in the publicstructural and ideological contexts in work education the media and beyond besides patriarchy is also significant at the personal level in the private world of intimate relationships between men and women as mary marynard said politics occurs 2013 within families and between individuals when one person seeks to control or dominate another it is in the personal and personal context that women are especially vulnerable to male power 13 as sylvia walby points out from this point of view the slogan the personal is political applies the point is that because male domination exists not only in the public arena but also in the very private arena of life women struggle to abolish subordination not only outside the house but starting inside the house for instance the question of who is responsible for performing household tasks or who has the right to interrupt others during casual conversations is regarded as a component of the system of male dominance 14 feminists have taken over some ideas about sexuality and patriarchy from other schools but criticisms of the use of these concepts and the fundamentals of radical feminist thought have been raised first this view emphasizes the universality of womens conditions regardless of the context of time and place thus various things are not considered such as the differences among women themselves which give a different context to the condition of women second the fixation on the context of sexuality does not allow people to see other factors that affect womens lives such as the development of capitalism or the dynamics of political economy or the influence of all of them on womens work third analytically they do not explain why men need to dominate women generally the explanations given tend to refer to male biological drives 12 methodology this research on punishment policy for women who commit homicide in response to domestic violence was feminist research the british sociologist liz stanley said that feminist research is research done by women and oriented to defending the interests of oppressed women by male domination 15 the partiality of the authors standpoint was firmly on the fact that women who commit homicide in response to domestic violence are victims and therefore imprisonment is not appropriate for them this research used a mixed approach of qualitative and quantitative methods by adopting a qualitative methodology the author investigated the experiences of women this approach permitted an emotional connection as it did not require the author to adopt a neutral stance as was typical in positivist thinking to attain the objective truth however on the contrary the authors personality was brought to the surface to attract information the quantitative approach in this research was used in the early stages by conducting two surveys of respondents the first to students and lecturers of criminal law at a state universities and then the second survey was conducted to members of mahupiki apvi and aswgi as mentioned earlier this was followup research of the authors dissertation which proved that women who committed homicide in response to domestic violence were victims therefore imprisonment was not appropriate and a particular policy was needed in the positive law women who commit homicide regardless of the reason are considered guilty however from a radical feminist perspective women who commit homicide in response to domestic violence are viewed as victims and require alternative sentencing then to achieve the research objective which is to provide input for the proposed legal policy related to the punishment of women who commit homicide in response to domestic violence the author also collected secondary data using the online desk review method with this method the author conducted a literature study on textbooks journals or institutional reports that the author considered relevant the data obtained were punishment policies for a similar topic in various countries and used as a comparison the following is an illustration of data sources and research methods 2014 findings why women commit homicide in response to domestic violence unstructured interview issue 1 a woman commits homicide in response to domestic violence is not a crime informants opinions on the above issue were grouped into two categories of opinions as follows 1 a woman who commits homicide against a man in response to domestic violence shall receive no punishment why is this case the majority of the informants who hold this view stated that killing was the most effective means of avoiding victimization within the family by murdering their husbands or partners they believe they can escape the violence inflicted upon them 2 women who commit homicide in response to domestic violence indicate that they are no longer strong enough to accommodate their suffering from violent treatment obtained from their husbands or partners publics perception of homicide by women in response to domestic violence survey upn veteran faculty of law students and unstructured interview several issues to describe how society perceives homicide by women in response to domestic violence are 2 a woman who commit homicide against a man who abuses her is seen as a crime 3 many people argue that a woman who commit homicide against a man in response to domestic violence does not deserve punishment 4 women who commit homicide in response to domestic violence should not be solely held responsible for acting in selfdefense issue 2 a woman who commits homicide against a man who abuses her is seen as a crime 344 of the respondents agreed with the statement meanwhile only 293 disagreed and the rest were hesitant the following are the results of the authors interview with one of the informants the statement implies that murder is a criminal act regardless of who kills and the reasons for killing therefore a woman who commits homicide against a man who abuses her is seen as a crime issue 3 many people argue that a woman who commits homicide against a man in response to domestic violence does not deserve punishment there were 39 of respondents agreed with the statement meanwhile 488 disagreed and the rest were hesitant the following are the results of the authors interview with one of the informants the statement implies that women who commit homicide will be free of all charges and i cannot fully agree with that after all a persons life was taken away and the act of killing is morally wrong regardless of its reason however punishment should be appropriate taking into account the reasons and context therefore the statement shall be changed to a woman who commits homicide against a man in response to domestic violence does not deserve maximum punishment in other words the criminal justice system shall consider the sociopsychological aspects when giving sentences to women who commit homicide in response to domestic violence issue 4 women who commit homicide in response to domestic violence cannot be solely blamed as they are acting in selfdefense 854 of respondents agreed with the statement meanwhile 98 disagreed and the rest were hesitant the following are the results of the authors interview with one of the informants i tend to agree with the statement that she cannot be solely blamed there is also a plea mechanism to understand how she became a victim domestic violence does not happen once but throughout the marriage when this violence continued some women finally fought back but some women did nothing about it therefore we shall explore the selfdefense plea because we understand the social and psychological context while in some cases extreme emotions may cause someone to unintentionally cause harm while defending themselves leading to murder rehabilitation measures for women who commit homicide in response to domestic violence survey upn veteran faculty of law students and unstructured interview an issue raised in this topic is whether rehabilitation measures are necessary for women who commit homicide in response to domestic violence the given statement to the respondents is 5 rehabilitation measures are a must for women who commit homicide due to domestic violence to recover from past trauma it turns out that all respondents agreed with the statement issue 5 rehabilitation measures are a must for women who commit homicide due to domestic violence to rcover from past trauma as mentioned earlier all respondents agreed with the statement and one of the informants said firstly we have to see that she is a victim which means protection and rehabilitation measures shall be in place because her act of murder is not premeditated in this context the victim usually has a psychological trauma conflicting over being a victim yet she committed a murder often domestic violence has a layered psychological impact on the victims 2017 the need for special treatment and protection for women who commit homicide in response to domestic violence survey upn veteran faculty of law students and unstructured interview several issues raised in this research were to describe the need for special treatment and protection for women who commit homicide in response to domestic violence these issues are 6 judges presiding over cases involving women who commit homicide in response to domestic violence are required to include expert testimony and consider it during the proceedings 1 judges who decide cases in court against women who kill in response to domestic violence must adhere to the protection principle for domestic violence victims 2 the state shall provide more protection and attention to women victims of domestic violence 3 the positive legal system should prioritize the protection of women victims of domestic violence 4 there is a high tendency to believe that women who commit homicide in response to domestic violence shall be considered victims and do not deserve punishment can this be accepted and realized in our criminal justice system 5 the state should pay more attention and protect women victims of domestic violence 6 judges decide cases in court against women who commit homicide in response to domestic violence 7 should you agree that women who commit homicide in response to domestic violence must be given special legal treatment what are the underlying reasons issue 6 judges presiding over cases involving women who commit homicide in response to domestic violence are required to include expert testimony and consider it during the proceedings of the respondents 978 agreed with this statement an interview with one of the informants oh yes having a witness expert present at a trial is very important particularly expert witnesses who have experience accompanying women victims of domestic violence issue 7 judges presiding over cases in court against women who commit homicide in response to domestic violence must adhere to the protection principle for domestic violence victims of the respondents 854 agreed 98 disagreed and the remaining were hesitant the following is the result of the authors interview with one of the research informants yes it is important to consider the victims perspective objectively therefore the victim must receive protection and the murder case should be intertwined with her status as a victim this principle involves trusting the victims statement as a primary factor and subsequently considering other evidence expert witness testimonies and imposing punishment issue 8 the state shall provide more protection and attention to women victims of domestic violence 2018 of the respondents 854 agreed 98 disagreed and the remaining were hesitant one of the informants said yes i think this issue has persisted for a considerable period of time i understand that indonesia has a law on the elimination of domestic violence in place however how does the implementation or practice of the law in reality although in each region we have an integrated service center for women and children empowerment or center for the protection of women and children it remains unclear whether the public facilities and services are sufficient when implementing the protection program we can all agree that victims will need paralegal assistance a psychologist maybe even a doctor if they experience physical abuse now the question is what is the perspective of law enforcement officers on the many domestic violence issues when the police and judges see women as victims although in this context the state is obligated to make an effort to achieve these goals it is clear that many things need improvement issue 9 the positive legal system must prioritize the protection of women victims of domestic violence of the respondents 854 agreed 98 disagreed and the remaining were hesitant the following is the result of the authors interview with one of the research informants hmyes it is still important because this positive law should have an orientation towards protection in my opinion the law is actually a reflection of social reality therefore all aspects shall be considered including the reason behinds the crime but unfortunately i do not know how to change the way of this positive legal system in the faculty there is a sociolegal approach maybe that is how the legal system includes it yes it means that there must be such kind of training issue 10 there is a high tendency to believe that women who commit homicide in response to domestic violence shall be considered as victims and do not deserve punishment can this be accepted and realized in our criminal justice system of the respondents 854 agreed 98 disagreed and the remaining were hesitant one of the informants said it would be difficult in our judicial system it may prove challenging within our current legal framework to account for cases where murder is committed in response to domestic abuse as the criminal code has yet to be amended the ongoing discourse prioritizes the abolition of capital punishment even after this is achieved addressing this issue remains a difficult task i do not think they will not be completely free issue 11 the state should pay more attention and protection on women victims of domestic violence of the respondents 854 agreed 98 disagreed and the remaining were hesitant one of the informants said yes but here is the relation with women who become victims so what is clear is that first legal assistance is needed then psychological assistance is also part of protection moreover perhaps shelter should also be provided for example protection from the security side it could also be from the husbands family which is also from a security perspective that is what the state must do including protection from the media 2019 issue 12 judges decide cases in court against women who commit homicide in response to domestic violence of the respondents 854 agreed 98 disagreed and the remaining were hesitant in addition many informants claimed that they had never seen an expert witness present at the trial issue 13 should you agree that women who comit homicide in response to domestic violence must be given special legal treatment what are the underlying reasons 1 some of the reasons for some of the informants are as follows the position of womens status is indeed also subordinate in our society so that women always experience discrimination and marginalization 2 sociological reasons are also important because understanding the context of why doing so needs to be considered premarital induction as prevention of domestic violence survey upn veteran faculty of law students and unstructured interview premarital induction as one of prevention measures to prevent domestic violence issue 14 the government should require all state marriage institutions to provide mandatory premarital counseling sessions to the prospective bride and groom the sessions should explain the potential risks of domestic violence its impact and the procedures for reporting complaints of the respondents 976 agreed that the kua conducts premarital induction and explains the possibility of domestic violence the following is the result of the authors interview with one of the research informants yes i think this is important prospective marriage couples must have counselling session about domestic violance in fact according to the law domestic violence can be criminalized right if we think about the most appropriate service provider to place complaints perhaps kua would be best hence this issue is important mainly because the law on eliminating domestic violence already exists punishment policies for women who commit homicide in response to domestic violence in various countries in many countries cases of homicide committed by women against their partners in response to domestic violence are mainly associated with battered women syndrome also known as the syndrome of women victims of violence or domestic violence syndrome initially bws was a psychological term to describe a subcategory of posttraumatic stress disorder where victims of domestic violence experienced significant trauma and believed themselves to be in danger even when they were safe over the years the definition has evolved and entered the legal realm where bws is usually seen as an extension of selfdefense for homicide as the perpetrators death usually occurs when there is no imminent danger such as when the perpetrator is asleep in this scenario the victim chooses the only way to be sure of her safety from the tormentor which is to murder him 16 research conducted by penal reform international in 2016 17 showed a global awareness of the issue of bws and a slow reaction to it however legislative and judicial attitudes towards women who retaliate or commit criminal acts against their abusers in response to violence have varying degrees of leniency in the countries that were the focus of pri research there was no specific legislative basis for a history of harassmentviolence against 2020 women which was considered a mitigating factor therefore requests for lenient treatment were then brought into the existing criminal law framework usually violators try to cover up their plea to get lenient treatment in the existing defense attempts by victims of abuse to rely on selfdefense temporary insanity and provocation have had different results in various countries however the pri report also revealed that the existing defenses have proven to be unable to adapt to women with bws conditions in many countries and its reaction is prolonged in a few countries studied notably in several australian states the pri found legislative amendments to the criminal code to facilitate more lenient treatment of female offenders due to the violence they experienced these amendments take a variety of forms from the introduction of new defenses specifically available to victims of domestic violence to amendments to existing defenses so that they are better adapted to address victims of domestic violence while some legal systems have been willing to adapt existing laws or even create new laws to deal with victims of domestic violence other systems seem reluctant to expand beyond traditionally defined parameters their adapted legal system sympathizes with the view that the killing reaction may result from longstanding and accumulated domestic violence the pri report reveals that in certain countries a record of domestic violence might diminish culpability or reduce penalties hong kong india japan and spain lack explicit sentencing rules or protocols in contrast to australia brazil mexico poland and the united states according to the pri these countries have significant latitude in imposing sentences even if formal sentencing guidelines do not exist • in poland courts have used their discretion to consider general factors in sentencing such as the history of domestic violence it led to the application of a reduced sentence or a reprieve • in mexico courts may consider various factors when determining guilt including the family relationship with the offense victim and other relevant circumstances • in the united states judges have broad discretion under the federal sentencing guidelines and state act allowing various mitigating factors to be considered in practice it allows a history of past domestic violence to be used as a mitigating factor in some cases • in brazil the rules on punishment can be applied broadly allowing factors such as a history of domestic violence to be considered • in australia sentencing guidelines and policies do not expressly allow the history of domestic violence to be considered however courts in all states usually rely on the courts power to consider all relevant factors in awarding sentences taking into account the relevant case law • in spain if there are mitigating circumstances the court will impose a sentence that corresponds to the lower end of the penalty scale appropriate for the crime unless one or two aggravating factors are also present • in japan a wide range of legal penalties are available for each crime allowing judges and jurors considerable flexibility in determining the sentence to be imposed in each case therefore this will allow a history of past domestic violence to be considered in sentencing • in india courts have recognized continuous provocation as a defense for murder the acknowledgment has allowed a reduced sentence to be applied in the context of a history of domestic violence in some cases specific statutory reduced sentences may be applied if past history of domestic violence is considered a mitigating factor under one of the broader sentencing principles available under jurisdictional law 2021 • in brazil if a crime is committed because of social or moral values or excessive emotion sentencing guidelines allow the sentence to be reduced by between onesixth and onethird as mentioned above the history of domestic violence has been taken into account to determine that womens violations were indeed committed because of relevant social or moral values • in australia there are no laws or guidelines that expressly define the weight that should be given to a history of past abuse however particular examples have been identified to demonstrate the weight given to a history of domestic violence in sentencing current policy in indonesia based on the research findings women who commit homicide in response to domestic violence are sentenced using the criminal code or the law on the elimination of domestic violence no 23 of 2004 judges tend to use the kuhp which is gender neutral moreover victims undergoing police examinations sometimes experience multiple victimization in cases of domestic violence this occurs due to inquiries being made about sensitive subjects and exerting pressure on the victim who may be emotionally unstable 1 suggested policy and intervention programs according to babcock and steiner several studies have shown that detention alone will not help rehabilitate offenders from sacrificing their partners 18 meanwhile bennett et al stated that programming in prisons that extends to the community after a period of detention is vital for the success of the rehabilitation of perpetrators 19 covington and bloom 20 suggested that intervention programs for cases of domestic violence should be genderspecific since women who commit domestic violence and then commit homicide have different motivations than men identifying and addressing the particular risks and needs of both genders is crucial to effective intervention they also suggested that intervention programs for domestic violence cases for women could include therapy related to why she committed the crime another program could also include an education program related to victim trauma because many women are victims of domestic violence many women who were previously victims of domestic violence also had experienced sexual harassment from their partners when she is sexually abused by her partner trauma informed therapy specific to sexual abuse is needed studies show that women are usually victims of domestic violence but women can also be perpetrators of domestic violence when providing a program for women who commit homicide in response to domestic violence it is crucial to address the underlying issues related to why she made efforts to solve her problem of victimization by committing domestic homicide as an option the duluth model 21 suggests that programming for men should be different from programming for women because it must identify some genderspecific differences for example male domestic violence programs may include education about power and control parenting classes and dealing with substance or drug abuse the role of men in domestic violence has been described as one rooted in the manipulation and power and control of others therefore programming for men should address their inherent desires for power and control by providing specialized work opportunities meanwhile for women who murder to avoid victimization in the household the next step is to focus more on problemsolving options such as filing a complaint with the police seeking protection from neighbors and other parties several policies and procedural implications can help protect victims of domestic violence and provide the necessary programs for perpetrators in prison among others a consistent and cohesive program of legal guidance and awarenessraising interventions in prisons and the community alternatively an intervention program for guidance and legal awareness to perpetrators in the community can help them mentally through these intervention programs they can opt not to choose violence to avoid the possibility of further victimization within their family 2022 bennett stoops call and flett 19 have examined the effect of completing an intervention program of guidance and legal awareness on perpetrators of domestic violence and the rate of rearrest they determined that the average length of time between initial participation in the intervention program and recidivism was 24 years regarding rearrests 143 percent of program completers and 347 percent of noncompleters were rearrested for acts of violence to avoid victimization of domestic violence completing the intervention program reduces recidivism rates related to the selection of violence in order to avoid further domestic violence victimization the findings from the research above show that behavior can be learned for example suppose violent behavior carried out by women to avoid domestic violence victimization has previously been believed to be a robust effort through previous social learning in that case it teaches them how to think about other options to prevent violence victimization through intervention programs and rehabilitation although this necessary procedure may encounter obstacles it should be approached with optimism perpetrators need to be motivated to change not forced to change motivation is the key for prisoners to complete the program successfully and lack of motivation is often cited as a reason for failure to comply and reoffending the suggestion for this is to allow inmates to decide if they want to get involved in the programs prisoners motivation originates from the belief that they can effect positive change and that their future behavior hinges on their own actions and successful completion of the current program 22 when providing programs for men and women in prison settings it is crucial to provide genderspecific programs to address their unique risks and needs for instance as mentioned earlier a larger percentage of men have a record of domestic violencerelated offenses compared to women it is explained by the theoretical paradigm which states that a man is dominant and aggressive in innate behavior the duluth model a popular domestic violence program explicitly provides programming for men while purposely addressing the patterns men used to control and dominate their intimate partners the model also addresses the significant issue of societal acceptance of men using power and control to gain obedience from women to address the specific needs of female offenders in the context of avoiding victimization covington and bloom 20 stated that the three most critical problems in womens lives are substance abuse trauma and mental health therefore womens programming should include rehabilitation for substance abuse opportunities to improve their current mental health improve relationships with children and families and cope with significant trauma when female murderers in the context of family violence are released from prison it is very important that there are parties in the community who help protect them from being perpetrators in responding to domestic violence if they are to rebuild their family life perpetrators must also be protected from feelings of revenge from the family of the husband or partner she murdered often the family of the victim may seek revenge against the female perpetrator by attempting to contact them after their release and possibly using violence the ohio center for the prevention of family violence 23 states that it is vital to have a security plan for female offenders whether or not they decide to remain in the relationship with the victims family in addition the information and resources provided in the safety plan can be helpful in the future when the female offender finally decides to leave her victims family the center also recommends three strategies when dealing with female offenders providing protection if they stay offering support if they choose to leave or ensuring their safety if needed first protection strategies seek to prevent or respond to physical violence experienced by female offenders these strategies may include leaving the victims family intervening in a third party defending oneself or temporarily leaving the relationship second defensive strategies address the problems and risks that the female offender experiences as long as she remains in the relationship the strategy includes • joining a support group for victims of domestic violence 2023 • maintaining a victim support system by staying close to family and friends and • always trying to reconcile with the families of victims of domestic violence to avoid more severe treatment of violence the final strategy is the leaving strategy which addresses to the risks that female murderers may face when deciding to leave the relationship another way to help female perpetrators of murder is through thorough safety planning with the families of highrisk victims there is a safety plan in place when they are released into the community before the female murderer is released from prison the victims community must develop a plan to implement specific safety measures to protect themselves with a security plan in place victims of domestic violence can have a plan for the worstcase scenario 23 resources are limited particularly for women who commit murder to ensure their success upon release it is important to focus on planning for their safety and release therefore prison personnel and members of the public who are willing to participate need to unite it will be challenging when there is a lack of community or staff resources and advocacy programs for women who commit murder in addition to providing resources for women who commit murder in the context of domestic violence resources should be offered to prisoners upon their return to society some suggestions include community programs to continue to address core issues of domestic violence therapy and programs to help teach bettercoping skills and resources to help inmates find housing education and jobs although these resources are necessary for successful reintegration into society many prisoners are not linked with the right resources or there are not enough resources available to prisoners on release training should be provided to professionals in healthcare and the criminal justice system to fully comprehend the extent of domestic violence services and safety planning can then be provided to the female murderer so that she has the resources she needs if she decides to leave her abusive partners family according to kalra tanna and garciamoreno 24 healthcare providers are the first point of contact for many victims of intimate partner violence healthcare providers may be the only people the female murderers feel comfortable talking to about the abuse they experience at home by identifying and providing care for women victims of domestic violence healthcare providers can assist in reducing the violence experienced by them healthcare providers can also play an important role in gathering evidence for legal action against perpetrators the human resource and its implication provide inputs for making better policies 25 implementation of performance accountability system for government institution provides inputs for making better regulation on implementation of performance accountability system for public officials and practitioners 26 the performance accountability system for government agency provides inputs for making better regulation on performance accountability system for government institution policy 27 transformational leadership technology adoption public service have a significant positive effect on job competency 28 the leadership and service are useful for improving policy and practice and providing information to stakeholders 29 the user satisfaction has a positive and significant effect on organizational performance 30 public private partnership policy and practice provide information to stakeholders related 31 the role of workplace spirituality mediates effects of information technology on innovative work behavior and mediates effects of transformational leadership on innovative work behavior 32 the collaboration must involve related institutions and should aim to improve regulations on disaster management 33 managing conflict strategy and its implementation are needed for providing information to stakeholders to provides inputs for making better regulation and policy 34 improving policy are needed for providing information and producing a clear input for public officials in making better regulations 35 the community empowerment 2024 positively affects production capacity and social capital 36 the collaborative governance in digital infrastructure development and its implementation are needed for providing information to stakeholders 37 it is necessary to formulate and implement a policy as inputs for making a better regulation in managing the implementation of the policy 38 the content of policy and context of implementation are positively affected by the program the collaborative governance positively affects the program 39 the social leadership and social capital positively affect community empowerment and social capital fully mediates the relationship between social leadership on the community empowerment 40 it is essential to implement community empowerment to provide stakeholders with information and inputs for making better regulations and policies 41 44 conclusion and suggestions for future research in indonesia based on the research findings two policies are used for sentencing the penal code and the law on the elimination of domestic violence no 23 of 2004 however most judges tend to use the penal code which is gender neutral in addition victims undergoing police examinations sometimes experience multiple victimization in cases of domestic violence this occurs due to inquiries being made about sensitive subjects and exerting pressure on the victim who may be emotionally unstable against the backdrop the author concludes that a specific policy is needed in indonesia to regulate alternative intervention programs for women who murder their partners in response to domestic violence the intervention programs shall include social work penalty and rehabilitation measures as well as implementation procedures success indicator measurement and evaluation criteria to see the implications of the policy on the rehabilitation measures the policy can adopt the duluth model where women who commit homicide in response to domestic violence can receive treatment for substance abuse trauma and mental health which ultimately increase opportunities to improve their current mental health improve relationships with children and families and cope with significant trauma having a specific policy will help protect victims of domestic violence and provide the necessary programs for perpetrators in prison among others a consistent and cohesive program of legal guidance and awareness raising interventions in prisons and the community alternatively an intervention program for guidance and legal awareness to perpetrators in the community can help them mentally through these intervention programs they can opt not to choose violence to avoid the possibility of further victimization within their family this research suggests that further research is needed to better understand the criminal history of domestic violence among prisoners including women who commit homicide in response to domestic violence in addition since this research only analyzed a selected sample of individuals encountered in several correctional institutions future research shall include a larger population sample future research should also include additional demographic and social factors to examine the prevalence of domestic violence by race age socioeconomic status and sexual orientation these demographics will make it possible to specifically focus on each populations specific risks and needs through specialized programming in addition future research should analyze the prevalence of domestic violence by sex to see if there are significant differences between men and women but further research could complement a comprehensive examination of gender differences and look at the relationship between prisoners and their victims which will provide insight into who is the victim of a crime related to domestic violence these further assessments are critical because someone who abuses their intimate partner will require a different program from someone who abuses their young child also future research can specifically look at the population of women who had domestic violencerelated offenses and analyze the situation as to why these women were indicted and or punished for domestic violence for complaint analysis could offer insight into whether the

the findings from the dissertation showed that in a normative manner a wife who committed homicide against her husband was guilty and violated the criminal law regardless of the motive behinds it using feminist research and qualitative approach the author argued that women wives who killed their partners in response to domestic violence were also victims therefore imprisonment was not appropriate for them this article discussed the publics perception on women committing homicide in response to domestic violence by exploring the reasons why women engaged in such acts rehabilitation measures lenient treatment and protection programs for women who committed homicide in reaction to domestic violence based on these discussions the author concluded that a specific policy was necessary in indonesia to regulate alternative intervention programs for women wives who commit homicide to their partners in reaction to domestic violence the intervention programs shall include social work penalty and rehabilitation measures as well as implementation procedures success indicator measurement and evaluation criteria to see the implications of the policy

introduction background eating disorders such as anorexia and bulimia are complex mental disorders defined by extreme obsessions with body weight or shape and unusual eating behaviors 1 these diseases have the highest mortality rate of any mental illness 2 intractable comorbidities 3 and worldwide prevalence 4 having become a major public health concern although a variety of treatment options have emerged over recent years 5 populations affected by eds are often hard to reach through traditional health care services this is mainly because of fear of stigma or a feeling of shame many sufferers conceal their ed symptoms and never seek professional treatment or support 67 to keep struggles with illnesses private people often seek healthrelated information and support through online peertopeer communities particularly via social media sites such as twitter and facebook participation in online communities is common in ed populations 8 and has been suggested as a screening factor for eds 3 this provides an opportunity for health care professionals to deliver health support to these hardtoreach populations through online communities 9 10 11 12 13 moreover as online communities present a relatively anonymous environment for individuals to naturally selfdisclose and socialize 14 usergenerated data online provide a large amount of records about individuals concerns thoughts emotions and social interactions 15 16 17 which can complement traditional data sources in understanding risk factors of eds hence growing research has focused on characterizing individuals behavioral patterns in online communities 15 16 17 18 19 so as to better understand eds and promote populationlevel wellbeing one notable characteristic of online ed communities is their participants have widely different stances on eds 82021 some communities encourage members to discuss their struggles with eds share treatment options and offer support toward recovery from eds so called prorecovery communities 20 21 22 there are also many antirecovery or proed communities in which members often deny an ed to be a disorder and instead promote eds as a healthy lifestyle choice 823 these proed communities can negatively affect health and quality of life among people with and without eds through reinforcing an individuals identity around eds 24 promoting thin ideals 25 and disseminating harmful practices for weight loss 8 recent studies have shown that individuals language use online strongly indicates their proed or prorecovery stances 151720 as well as emotions of depression helplessness and anxiety that reflect their mental disorders 16 other studies have also examined interactions between proed and prorecovery communities on flickr 21 anorexiarelated misinformation 18 sentiments in comments on edrelated videos on youtube 26 characteristics of removed proed content 27 and lexical variation of proed tags on instagram 1928 yet prior studies have largely focused on examining how people engage in and maintain an online ed community whereas little is known about how people drop out of such a community as a dynamic process people who join and actively engage in a community at earlier stages can have less participation and leave the community at later stages understanding the attrition processes of online communities can enhance our knowledge of the dynamics in these communities studying the attrition process of an online community can also have practical implications for disease prevention and health interventions given the ease of accessibility of social media for many individuals increasing attention has focused on using online communities to deliver health interventions 9 10 11 12 13 2930 one of the most popular approaches is to deliver health lessons and behaviorchanging instructions via online communities 9 10 11 12 13 29 although pilot studies based on small samples have demonstrated the effectiveness of these approaches in reducing body dissatisfaction and disordered eating 1213 evidence from interventions for a variety of health behaviors suggests that attrition is one of the most common challenges in online interventions 1029 this is known as the law of attrition of online interventions 31 a recent study has shown a high attrition rate in an online intervention for eds 32 though this intervention is delivered via a purposely designed website rather than a general social media site thus an important goal in conducting successful interventions via online communities is to improve members retention as members who remain longer are more likely to receive these interventions and have more opportunities to promote a target behavior change to achieve this goal a critical first step is to understand what factors influence members retention in an online community previous studies have shown that peoples decisions of retention or dropout in online communities are associated with a variety of factors 3334 including personality traits 3536 interests 37 recognition in a community 38 39 40 41 and support from others 4243 however such an association is not adequate to conclude the presence of a causal relationship 4445 between an individuals attributes and her or his online participation this is because an association can arise from noncausal relationships for example most previous studies focus on the use of selfreported surveys and rely on participants reports of their own personality concerns and behaviors 353946 this can introduce considerable retrospective bias and measurement errors leading to a coincidental association between 2 unrelated variables particularly in small samples even if variables are measured rather than selfreported 4347 participation in an online community is inherently selfselected and members can drop out for many different reasons thus unobservable factors may affect both a main predictor and participation outcomes causing a spurious association moreover in some cases reverse causality can lead to an association for example previous studies suggest that feelings of social isolation are linked to frequent social media use 3548 whereas recent studies indicate that social media use is linked to increased feelings of social isolation 49 technically speaking the issues of measurement errors confounding variables and reverse causality can cause endogeneity which refers to an explanatory variable of interest being correlated with the error term in a regression model 44 in these cases traditional methods such as ordinary least squares give biased and inconsistent estimates of the effect of interest it is therefore not surprising that mixed results exist in previous studies for example a positive association between individuals expertise and online participation was found in a study by tausczik and pennebaker 46 whereas a negative association was found in another study by cook et al 38 objectives this study aimed to estimate determinants of dropout in an online ed community while addressing the endogeneity issues by using an instrumental variable approach 44 specifically we analyzed tweeting activities for a large set of individuals who selfidentified with eds on twitter for over 15 years and identified the presence of dropout if a user ceased to post tweets in the observation period we explored determinants of a users dropout based on the incentive theory 3450 which argues that peoples engagement in an activity can be driven by intrinsic motivation which refers to doing something because it is interesting or enjoyable and extrinsic motivation which refers to doing something because it earns an external reward we focused on intrinsic motivation captured by personal emotions and extrinsic motivation captured by sociometric status in an online peertopeer community rather than using selfreports 353946 we measured users emotions based on their emotional expressions in tweets using sentiment analysis techniques 51 and quantified users sociometric statuses by network centrality 52 in the social network of an ed community on twitter on the basis of these measured variables iv estimators both for the decision to drop out and for the time to drop out were implemented to achieve consistent estimates of the effects of personal emotions and network centrality on dropout in an online ed community to better understand the estimation results we further examined heterogeneity in tweeting interests of users with differing levels of characteristics and dropout outcomes to our knowledge this study is the first to systematically characterize the determinants of dropout behaviors in online ed communities a total of 3 research questions were examined what are the general characteristics of the attrition process in an online ed community how do intrinsic and extrinsic factors affect the decision of an individual to drop out of the community and how do these factors affect the duration of time until the occurrence of dropout methods data collection our data are collected from twitter a microblogging platform that allows millions of users to selfdisclose and socialize as many social media platforms such as facebook and instagram have taken moderation actions to counteract proed content and user accounts 28 twitter has not yet enforced actions to limit such content 53 this makes twitter a unique platform to study the attrition process naturally happening in an online ed community and allows us to examine individuals behaviors in a nonreactive way our study protocol was approved by the ethics committee at the university of southampton all data used in our study are public information on twitter and available through the twitter application programming interfaces no personally identifiable information was used in this study our data collection process included 3 phases 1 first we collected a set of individuals who selfidentified with eds on twitter using a snowball sampling approach specifically we tracked the public tweet stream using eating disorder anorexia bulimia and ednos from january 8 to 15 2016 this resulted in 1169 tweets that mentioned eds from the authors of these tweets we identified 33 users who selfreported both edrelated keywords and personal bioinformation in their profile descriptions starting from these seed users we expanded the user set using snowball sampling through their social networks of followees and followers at each sampling stage we filtered out nonenglish speaking accounts and finally obtained 3380 unique ed users who selfreported edrelated keywords and bioinformation in their profile descriptions note that our focus in this work is studying individuals who are affected by eds rather than those who are related to eds the inclusion of bioinformation in user sampling allowed us to filter out edrelated therapists institutes or organizations as these users often displayed edrelated keywords but did not show bioinformation in their twitter profile descriptions details about the data collection of ed users can be found in our previous study 54 2 then we collected all friends of each ed user leading to a large social network consisting of 208063 users for each user we retrieved up to 3200 of their most recent tweets and obtained 241243043 tweets in total the data collection process finished on february 11 2016 3 finally we opened a followup observation period for all users on august 17 2017 to obtain measurements on users activities online in the second observation we only collected users profile information which includes users last posted statuses to verify the quality of our collected sample 2 members of the research team classified a random sample of 1000 users on whether they were likely to be a true ed user based on their posted tweets images and friends profiles users were classified as disordered if they frequently and intensively posted their body weights details of their dietary regimen struggles with eating pictures of themselves and selfreports of being disordered or in recovery in tweets and followed edrelated friends the process revealed a 952 match between the identified ed individuals in the data collection stage and those classified as ed during inspection although it is impossible to diagnose individuals disorders based on their online behaviors this inspection provides a strong indication that the collected users are likely to be affected by eds rather than those who merely talk about eds online see 54 for details of data validation estimation framework there are 2 different models specified to estimate the effects of emotions and network centrality on dropout first we specified a linear probability model on the whole sample to estimate the effects of individuals characteristics observed in the first observation period on the probability of dropping out in the second observation period finally we estimated survival models to explore the effects of individuals characteristics observed in the first observation on the time to dropout in the second observation however similar to all social media studies only a limited number of individuals characteristics are available for our estimations and these are mostly observed through usergenerated data online this leads to confounding variable bias as unobservable factors can be correlated with both the main explanatory variables and dropout outcomes for example undergoing hospital treatment can simultaneously affect a persons emotional state and the use of social media furthermore previous studies have shown that social media use is associated with increased depression 55 social anxiety 49 and body dissatisfaction 5657 implying an effect of online participation on individuals emotions both confounding variables and reverse causality result in biased estimates of the effects of emotions and network centrality on dropout this problem can be addressed by using a randomized controlled trial in which emotions or network centralities are randomly assigned to users by researchers 58 such a trial however is not feasible because of ethical and practical limitations 59 here we utilized an alternative approach for estimating the effects of interest that is based on iv regression an econometric technique to infer causal relations from observational data 44 this technique has been applied to a variety of contexts from identifying the causal effect of education on earning 60 the effect of a health treatment 61 to estimating social contagion effects on both online 59 and offline behaviors 62 formally consider a model ybeta1 x1 beta2 x2 u where x1 is endogenous x2 is exogenous u is a random error term and betas are effects to be estimated iv methodology uses an instrument z is not equal to 0 and iii uncorrelated with u ie cov0 conditional on the other covariates such as x2 and runs a first stage reducedform regression x1 b1 z b2 x2 v where v is a random error and b s are coefficients the causal effect of x1 on y is then given in a second stage regression ybeta1 x3 beta2 x2 u where x3 is the predicted value of x1 from the first stage see 44 for more details measures a number of variables are needed for estimations all independent variables and ivs are measured in the first observation period whereas dependent variables are measured in the second observation period dropout outcomes as dependent variables following previous studies 4243 we identified the presence of dropout if a user ceased to post tweets specifically in the linear probability models we encoded the dropout status of a user as 0 if the user had updated posts in our second observation and 1 otherwise in the survival models each user has a 2variable outcome a censoring variable denoting whether the event of dropout occurs and a variable of survival time denoting the duration of time until the occurrence of dropout we censored the occurrence of a dropout event in 2 ways first users are said to drop out if they have not posted tweets for more than a fixed threshold interval π before our second observation as people use social media platforms with different activity levels our second censoring method further accounts for personalized posting activities of individuals in this method users are said to drop out if they have not posted tweets for more than a variate threshold interval λπ ii before our second observation where π is a fixed threshold ii is the average posting interval of individual i in our first observation period and λ is a tunable parameter to control the effects of individual activities we tuned the parameters by maximizing the agreement between the estimated dropout states based on users activities in our first observation and the observed states in our second observation see multimedia appendix 1 for details for users who were censored as droppedout we set their survival times as the durations from our first observation to their last postings in our second observation for those who were censored as nondroppedout we set their survival times as the whole time period between our 2 observations emotions and network centrality as main explanatory variables individuals emotions were measured through their language used in tweets there is a variety of sentiment analysis algorithms to measure emotional expressions in texts 5163 in this study we used sentistrength 51 as it has been used to measure the emotional content in online ed communities and has shown good interrater reliability 26 and it is designed for short informal texts with abbreviations and slang and is thus suitable to process tweets 51 after removing mention marks hashtags and urls each tweet was assigned a scaled value ranging from 4 to 4 by sentistrength where negative and positive scores indicate the strength of negative and positive emotions respectively and 0 denotes neutral emotions we quantified a users emotional state by the average score of all tweets posted by the user all retweets were excluded as retweets reflect the emotions of their original authors more than those of their retweeters to obtain robust results from the language processing algorithms we only considered users who had more than 10 tweets and posted more than 50 words network centrality measures the importance of a person in a social network people wellrecognized by their peers often have high centralities in a group 52 to measure a users centrality in the ed community we built a whofollowswhom network among ed users and their friends where a directed edge runs from node a representing user a to node b representing user b if a follows b on twitter although there are various measures of network centrality we focused on coreness centrality 64 as it has been shown to outperform other measures such as degree and betweenness centrality 52 in detecting influential nodes in complex networks 65 and cascades of users leaving an online community 6667 we measured the sociometric status of a user in the ed community by the incoreness centrality 68 of a node in the generated network using the package igraph version 070 69 aggregated emotions and network centrality of friends as instrumental variables as ivs for a users attributes we used average emotions and network centrality over all followees of the user namely people who are followed by the user the choice of these ivs is based on the following considerations first we considered the relevance assumption of our instruments requiring that the characteristics of followees be correlated to the users characteristics namely cov is not equal to 0 we expected the followees updates to act as information sources for a user and followees behaviors as well as emotions manifested in their tweets can influence the user previous work 54 has shown the presence of homophily among ed users on twitter suggesting that users who share similar emotional and network attributes tend to follow one another furthermore the empirical existence and strength of the relevance property are tested in a firststage regression and presented along with the structural estimates of the models finally we examined the exogeneity requirement 0 where followees emotions and centrality must not have a direct effect on the dropout decision of the user other than through their effect on the users emotions although we have taken such assumptions to be reasonable we identified a pathway through which direct links could arise followees attributes could affect a users dropout through their effects on followees own dropouts for example followees emotional states may affect their own dropouts and a feeling of loneliness because of friends leaving may then drive the target user to drop out to control for this channel we measured the proportion and durations of followees that remained active in our second observation furthermore we changed the definition of followees to those who are followed by a user but do not follow the user back in this setting the reverse causality of a users dropout on followees attributes was nullified which strengthened the exogeneity assumption on ivs and controls estimation covariates our estimates control for several covariates that may affect users tweeting activities as listed in table 1 first we measured users social capital on twitter to capture the fact that people with different levels of popularity may have different tendencies to share content online 70 note that although the numbers of followees and followers can be regarded as the inand outdegree centralities of a user in the whole social network on twitter we were interested in the local network centrality in the edspecific communities second as previous studies show an association between social media use and depression 55 we measured historical activity levels of users to capture effects that previous engagement may relate to both users emotions and their future engagement we also measured users activity frequencies to capture their patterns of twitter usage third the covariates on observational bias were used to control for effects caused by incomplete observations for example a limited number of tweets were retrieved and used to measure emotions for a user all variables on social capital activity level and observational bias were measured from users profile information and tweets collected in our first observation finally as discussed above we included the proportion and average durations of followees that were active in our second observation to capture the channel that followees emotions affect a users dropout through their effects on followees own dropouts model estimations instrumental variables estimation in linear regression model we use standard 2stage least squares estimators for linear probability models in the first stage we ran an auxiliary regression and predicted the endogenous variables based on ivs and exogenous covariates in the second stage regression we substituted the endogenous variables of interest with their predicted values from the first stage estimation was conducted through the package of applied econometrics with r 71 and robust standard errors were computed instrumental variables estimation in survival model we used a kaplanmeier estimator 72 to estimate the survival function from data aalens additive hazards model 73 was used to estimate the effects of users attributes on the time to dropout compared with the proportional hazards models in which the ratios of hazard functions for different strata were assumed to be constant over time 74 the additive model was more flexible and applied under less restrictive assumptions to compute an iv estimator in an additive hazards model we used a control function based approach which was proposed by tchetgen et al 61 the timereg package 75 was used for the implementation of the estimation algorithm standard errors were obtained through nonparametric bootstrap results descriptive statistics we obtained 2906 users who posted more than 10 tweets and 50 words in our data where 8461 of users had no posting activities during our 2 observation periods among the 357 users who selfreported gender information in their twitter profile descriptions 840 of them were female the mean age was 173 years among ed users who selfreported age on the basis of the timestamps of account creation and last posting we used the kaplanmeier estimator to estimate the lifetime of a user on twitter namely the duration from account creation to the last posting the estimated median lifetime of these users on twitter was 6 months that is one half of the entire cohort drops out at 6 months after creating an account figure 1 visualizes the social network between dropouts and nondropouts among ed users laid out by the fruchtermanreingold algorithm 76 we noted that users with the same dropout states tended to cluster together computing newmans homophily coefficient r 77 of this network by users dropout states we found r009 suggesting that users with the same dropout states tended to befriend one another see multimedia appendix 1 for details of data statistics estimation results of linear probability models table 2 shows estimated results in the linear models with 2 different iv specifications in the first specification we used all followees of a user to create ivs for the users attributes the results are given in columns 2 to 3 in which both ols and iv estimators show that positive emotions are associated with a higher probability of dropout with largely comparable coefficients for covariates compared with the ols estimator the iv estimator of the effect of emotions on dropout was remarkably stronger the wuhausman test further showed a significant difference between the ols and iv estimators suggesting the presence of endogeneity these results indicated that ignoring endogeneity in the ols estimation leads to an underestimation of the effect of interest moreover the f statistics in the first stage regressions showed that the relevance of ivs exceeds the conventional standard of f10 78 indicating the validity of our ivs columns 4 to 5 show results of the second iv specification in which only single way followees are used to create ivs users who have no single way followees are excluded as instruments for these users attributes were not available thus the number of observations decreased as compared with that in the first iv specification moreover as data on a smaller number of friends were used in the second iv specification the relevance of iv became weaker but still passed the conventional test in the first stage regression despite such changes the 2 specifications produced largely similar results computing wald tests of equality of coefficients between the 2 iv models we found that the estimated effects of emotions on dropout were statistically the same across different iv specifications potentially suggesting robustness of the results note that network centrality was excluded from the linear models this is because many users had dropped out long before our first observation and the social networks of such users might largely change from the dates of their dropouts to our first observation for example a user might be followed by new followers when these followers were unaware of the dropout of this user in these cases network centralities in the future are used to explain dropouts in the past which can produce misleading results in the linear models in fact including network centrality in the above linear models produces statistically insignificant effect of centrality on the dropout decision confirming our argument that network centrality is irrelevant to the binary decision to drop out or not estimation results of survival models in the survival models we only considered users who were active past our first observation period so as to examine the effect of network centralities in our first observation on users activities in the second observation period table 3 shows mean coefficients of emotions and network centrality in the survival models all models are estimated controlling for the full list of covariates but are omitted from the tables because of space concerns the complete results are available from the authors following 61 the effects of all covariates are assumed to be time dependent in estimations both the standard and iv models on the identical interval censored data show that positive emotions lead to a shorter survival time and a core position in social networks is associated with a longer survival time estimations on the personalized interval censored data and using different iv specifications gave similar results the strong relevance of ivs in the first stage regressions confirms the validity of ivs across different models a comparison of results between the linear and survival models further shows that these models have consistent estimators for the effect of emotions on dropout namely positive emotions increase the likelihood to drop out identical interval censoring 0061 0018 0043 0018 emotions 0001 0001 0001 0001 centrality personalized interval censoring 0056 0015 0038 0016 emotions 0001 0001 0001 0001 centrality a fstatistic tests the joint significance of the 2 instruments from a firststage regression of a users emotions on followees emotions and followees centralities plus the rest of the covariates where f6611 when all followees are used to build instruments and f3499 when only single way followees are used b fstatistic tests the joint significance of the 2 excluded instruments from a firststage regression of a users centrality on followees emotions and followeescentralities plus the rest of the covariates where f2785 when all followees are used to build instruments and f1262 when only single way followees are used c the numbers of samples that are used in estimations d cis for coefficients are obtained from 1000 bootstrap replicates a coefficient is significant at p 05 if 0 is not in 95 cis e ivs stands for instrumental variables underlying connection between emotions and dropout to better understand the relationships between emotions and dropout we examined posting interests among users with different dropout statuses and emotional states based on hashtags used in users tweets we found nondropouts were interested in advocating a thin ideal and promoting a proed identity in contrast dropouts engage in discussing their health problems and offering emotional support for others which implies a tendency of these users to recover from disorders 20 21 22 similarly we split all ed users into 3 equalsize sets based on their emotional scores and examined hashtags used by each set of users we found that users with negative emotions often engage in promoting thin ideals showing largely overlapping interests with the nondropouts in contrast users with neutral and positive emotions were more interested in discussing their health problems opposing proed promotions and encouraging healthier body image and behaviors showing similar interests with the dropouts see multimedia appendix 1 for more detailed lists of hashtags measuring the spearman rank correlation ρ between pairwise lists of hashtags posted by users with a given state we found a positive correlation between negative users and nondropouts in hashtag usage indicating similar posting interests among these users a similar pattern occurred between positive users and dropouts in contrast users with other pairs of states showed a negative correlation or noncorrelation in hashtag usage indicating their discrepancies in posting interests note that all tags in 2 lists di and dj are considered in computing the correlation ρ tags in each list are ranked by tfidf scores 79 and the tfidf score of tag t in list di is 0 if di does not contain t these results revealed a possible underlying connection between positive emotions and dropout compared with users with positive emotions those with negative emotions had more similar interests to active members in the ed community finding similarities with other members in a community can enhance a sense of belonging to the community and positively increase intention to engage in community activities 3337 therefore it is not surprising that negative users are less likely to drop out than positive users in our estimations discussion principal findings this study provided the first estimates of the effects of personal emotions and interpersonal social networks on dropout in online ed communities this study has several strengths first we based our analysis on the incentive theory to explore determinants of users online behaviors allowing us to study users behaviors in a more systematic way than most previous studies that often focus on a single type of determinant second we used automated sentiment analysis techniques to measure users emotions and network analysis methods to quantify users sociometric statuses in an online community leading to higher efficiency than traditional research methods such as surveys 3537394148 finally we applied an iv approach to both linear probability and survival models which enabled us to achieve a more consistent estimate of human behavior in online settings than traditional methods used in previous studies 394147 overall we found that positive emotions increased the likelihood of dropout in ed individuals and accelerated the dropout process on twitter in contrast a central position in the social network of ed individuals at an earlier stage was associated with prolonged participation of an individual at a later stage these findings were verified across a variety of robustness checks despite differences in methodology our findings aligned with previous studies in psychological and social media research 53335 our results suggested that ed users with negative emotions had high levels of participation on twitter this aligned with previous survey studies on social media use where people with social anxiety and shyness were found to spend more time online 354881 an explanation for this is the online disinhibition effect 82 specifically because of anonymity in online interactions people with social inhibitions might be more willing to share personal feelings and reveal themselves in online interactions than offline interactions to meet their social and intimacy needs 48 additional analyses on users posting interests revealed that users with negative emotions share similar interests with active users this allowed us to confirm the validity of our results via the social capital theory 3940 namely sharing common attributes with other members can enhance a sense of belonging and positive feeling toward a community which drives people to actively engage in the community consistent with positive associations between network centrality and active participation in other online communities 6770 we find that central users in the social network of an ed community tend to have a longerlasting participation in the community this result is expected for several reasons first users who are centrally embedded in a group have a relatively high number of social ties with other members which can lead these users to feel being socially accepted and approved as well as a strong sense of belonging to the group previous studies have consistently shown that recognition from other members and identification within an online community increase an individuals commitment to the community 34 39 40 41 finally information shared by central users is likely to spread to the majority of a community through social ties and their central positions in the community may promote other members to trust such information 70 this implies that central users have a greater potential than peripheral users in influencing members opinions emotions and behaviors in online communities 84 thus compared with peripheral users feeling influential may provide an additional incentive for central users to continue participating in line with previous studies on online ed communities 151721 we found that ed users on twitter have different stances on eds where users with negative emotions often share proed content and those with positive emotions often share prorecovery content as proed content often contains thinideal images and harmful tips for weight loss and control 82425 this result aligned with clinical evidence on ed treatment showing that more emotional distress is associated with a higher risk to learn and develop dysfunctional coping behaviors among ed sufferers 5 thus as suggested by previous studies 85 engaging in proed content may serve as a coping mechanism to deal with emotional pressures and stress of eds a possible explanation for the association between engaging in harmful online content and coping with stress is sensation seeking 86 a basic personality trait defined as the seeking of varied novel complex and intense sensations and experiences and the willingness to take risks several studies have shown that sensation seeking is prominent in adolescence and closely related to pathological internet use such as use of violent sites 87 and internet dependence 88 our study also offered new insights into online ed communities first ed users have a high dropout rate and a short lifespan between an account creation to lost posting on twitter this aligns with views of online ed communities as hidden secretive groups 30 but also indicates the dynamic characteristics of these communities second users who discuss their health problems and share prorecovery content have lower levels of posting activities than those who share proed content on twitter this can be explained as follows owing to common interests in eds prorecovery and proed groups are likely to be connected in the same social networks and content shared within a group is hence likely to be visible to the other group however exposure to content from the antagonist group can have distinct effects in proed and prorecovery groups exposure to proed content is harmful for prorecovery users and can impede their recovery process 324 whereas exposure to prorecovery content can instead stimulate harmful behaviors in proed users 21 thus prorecovery users might tend to leave such an online community to avoid a risk of further deterioration or relapse our finding may also explain why proed content is found being more pervasive than prorecovery content across social media sites 151721 for example almost 5 times in terms of unique publishers on tumblr 15 finally ed users tend to connect with others with the same dropout states on twitter this implies that whether an individual drops out from online communities depends on whether others in the individuals social networks drop out in other words dropout in online ed communities is not only a function of individual experience or individual choice but also a property of group interactions such as homophily 89 and social contagion effects 59 implications our findings are of practical relevance to the promotion of public health over social media first the decision to maintain active participation in an online community can be caused by intrinsic and extrinsic characteristics or traits of the participants such as personal emotions interests and social networks such selfselection bias can lead to the sample not being representative of the whole population and hence researchers need to consider both active and droppedout users for a wellrounded picture of online health communities this is particularly important for public health officials to make special efforts to reach these dropouts and offer more intensive support when they are trying to recover second high attrition rates are often regarded as negative outcomes in online interventions particularly in those delivered over a purposely designed website 113132 however this may or may not be the case in interventions over general social media sites depending on how targeted populations use these sites for example when an intervention is delivered in an online community in which members often shared harmful content a high attrition rate may not be a negative outcome using automated datamining techniques to track users behaviors as used in this study can provide more detailed information about peoples use of online health communities and improve our understanding of attrition in online interventions third interventions that recommend content containing positive emotions to ed users may reduce their engagement in a harmful online community this aligns with fredricksons broadenandbuild model which argues that cultivating positive emotions is useful to prevent and treat mental health problems 90 finally intervention strategies could be tailored for different individuals depending on their positions in the social network of an online community for example identifying central individuals as change agents might enhance the efficacy and costeffectiveness of an intervention because of their greater influence potential through larger numbers of social ties 91 and also their longerlasting effects through longerterm participation in the community limitations first we recognized that selfdiagnosis information on twitter might be itself selfcensored by users to align with their personality traits and perceptions of their audience on the platform people may not use tags such as eating disorder to selfreport their experience of illness and would be excluded by our collection methods also although over 208000 users and over 241000000 tweets are studied in this study a small sample of rich social media data is used to explore the attrition of ed communities on twitter thus generalization of our results to all edrelated online communities should be cautious second our measures of dropout are based on posting activity whereas some people primarily use twitter to receive outside information but rarely post their own information we have little activity data on these users and hence less understanding of the characteristics of their dropout this thus raises important issues that need further research to enhance our understanding of attrition in online health communities such as consensus and clarity about the definition of dropout third our study focused on the twitter platform without validation on other platforms however stopping using a platform can be related to the attractiveness of the platform hence future research is also in need to examine many other factors that we did not explore but can affect dropout on social media such as individual personality physical health states perceptions and purposes of using a particular social media platform fourth user accounts on a social media site are often not uniquean individual may have multiple accounts on the same site thus we cannot be certain whether individuals who stopped using an account will engage in the same or similar online communities through other accounts in other words the dropout of a user account may not necessarily imply that an individual abandons a specific identity shared within a community finally although our methodology allows us to establish a causal link from emotions to dropout behavior it offers limited insights into the pathways through which this link exactly operates and future work is needed to explore such issues in detail conclusions this study presented a systematic characterization of attrition in an ed community on twitter our analysis offered the first attempt toward the estimation of the effects of personal emotions and network centrality on dropout behaviors in individuals affected by ed on twitter our results provided new insights into the trajectories that ed communities develop online which can help public health officials to better understand individual needs in using online ed communities and provided tailored support for individuals with different needs conflicts of interest none declared multimedia appendix 1 supplementary information for estimating determinants of attrition in eating disorder communities on twitter an instrumental variables approach pdf file 700kb

the use of social media as a key health information source has increased steadily among people affected by eating disorders eds research has examined characteristics of individuals engaging in online communities whereas little is known about discontinuation of engagement and the phenomenon of participants dropping out of these communities objective this study aimed to investigate the characteristics of dropout behaviors among eating disordered individuals on twitter and to estimate the causal effects of personal emotions and social networks on dropout behaviors methods using a snowball sampling method we collected a set of individuals who selfidentified with eds in their twitter profile descriptions as well as their tweets and social networks leading to 241243043 tweets from 208063 users individuals emotions are measured from their language use in tweets using an automatic sentiment analysis tool and network centralities are measured from users following networks dropout statuses of users are observed in a followup period 15 years later from february 11 2016 to august 17 2017 linear and survival regression instrumental variables models are used to estimate the effects of emotions and network centrality on dropout behaviors the average levels of attributes among an individuals followees ie people who are followed by the individual are used as instruments for the individuals attributes results eating disordered users have relatively short periods of activity on twitter with one half of our sample dropping out at 6 months after account creation active users show more negative emotions and higher network centralities than droppedout users active users tend to connect to other active users whereas droppedout users tend to cluster together estimation results suggest that users emotions and network centralities have causal effects on their dropout behaviors on twitter more specifically users with positive emotions are more likely to drop out and have shorter lasting periods of activity online than users with negative emotions whereas central users in a social network have longer lasting participation than peripheral users findings on users tweeting interests further show that users who attempt to recover from eds are more likely to drop out than those who promote eds as a lifestyle choicepresence in online communities is strongly determined by the individuals emotions and social networks suggesting that studies analyzing and trying to draw condition and population characteristics through online health communities are likely to be biased future research needs to examine in more detail the links between individual characteristics and participation patterns if better understanding of the entire population is to be achieved at the same time such attrition dynamics need to be acknowledged and controlled when designing online interventions so as to accurately capture their intended populations

introduction in the 21st century we are facing large scale collective action problems that may have catastrophic consequences from vaccine hoarding in a global pandemic to the ongoing refugee crises around the globe it is clear that in order to solve these crises we need compassionate and coordinated action from the global community that is we need to act as one however reality tells us that we do not always adopt superordinate goals such as these particularly when our interests conflict with those who are different from us indeed as classic social psychological research has shown strong more resources than another in the current work we study two unequally resourced groups that have the option to work together to achieve a superordinate goal across three studies we explore whether diverse interventions can overcome barriers to compassionate and cooperative action across group boundaries superordinate goals help to overcome the intergroup divide muzafer sherif was one of the first to discuss the importance of superordinate goals goals where two or more groups need to cooperate to achieve a particular outcome in the robbers cave experiment sherif coordinated a summer camp with several young boys where they were separated into two groups unbeknownst to the boys the summer camp was a disguise for a larger goal to explore how individuals compete and cooperate when they are members of different groups the two groups quickly fell into conflict and cooperation could only be achieved when the experimenters introduced a superordinate goal the findings show that when people are divided into groups intergroup conflict can arise and individuals often pursue the goal of their ingroup at the expense of their outgroup counterparts since these original studies research has reinforced that an intergroup divide can be bridged when groups adopt superordinate goals however there are many sociostructural factors that prevent group members from embracing such superordinate goals one obstacle might be the magnitude of the resource gap between the groups if this is perceived to be too large group members at opposite ends of the wealth spectrum may see the groups as too different and this might affect coordinated action group resource inequality not only enhances the perceived difference between groups indeed resource inequality enhances us versus them divisions and there is evidence that inequality therefore leads to less compassionate behavior toward others failing to overcome the ingroupoutgroup divide can have negative consequences when groups need to cooperate to achieve superordinate goals we are interested in investigating potential interventions to reduce intergroup competition in this contextwith the ultimate aim of increasing compassionate action in line with a superordinate goal we focus on three possible interventions the first targets individualistic solutions and we test the power of compassion training aimed at making individual group members feel and act more compassionately our reasoning builds on past research that has shown that compassion training can foster compassionate action second interventions that change the structural context may offer an effective method to elicit compassion by altering or shifting group dynamics we reason that if relative to low economic inequality high economic inequality exacerbates the ingroupoutgroup divide and erodes prosocial behavior reducing the degree of inequality may foster greater adoption of superordinate goals third another potentially effective intervention focuses on informal leaders altering group norms that promote acting for the common good and breaking down us versus them barriers leaders that focus on achieving desired superordinate outcomes might be particularly influential when there are no established group norms and when people therefore look to others for appropriate actions on how to behave past research has demonstrated that group norms can have a significant impact on the behavior of other group members and may influence the adoption of superordinate goals the present research if we are to understand how to foster compassionate action in the face of largescale problems we need to understand what individual structural and normative factors may shift group behavior the current study aimed to gain a better understanding of effective ways of orienting individuals toward superordinate compassionate behavior when they are embedded in an unequal intergroup context in particular we assessed the efficacy of compassion meditation training lower levels of structural inequality and the introduction of a prosharing group norm by an informal leader if we are to tackle some of the pressing issues of the 21 st century such as climate change and future pandemics we need to establish which interventions are most likely to lead to collaborative action that gives priority to superordinate goals study 1 several scientific studies have demonstrated that compassion meditation practices can promote prosocial behavior and compassionate responding to date most of these have demonstrated an effect of longterm compassion meditation practice but there is less research about the effect of shortterm compassion meditation on behavior brief interventions such as 10min meditations as well as selfcompassion reframing have led to changes in selfreport levels of motivation and feelings but the researchers did not assess how behavior might be impacted past work has also shown that cueing individuals to the needs of others results in more prosocial behavior in dictator games in each of these studies however an individual is typically asked to make a compassionate decision individually yet little is known about whether compassion meditation can affect decisions made by groups and specifically group contexts where there is an unequal distribution of resources this is important to understand as many compassionate acts in the real world need to be made by groups rather than individuals and also occur in a broader ecological context here we aimed to assess the effect of a brief compassion meditation on the adoption of a superordinate goal when groups are unequal to achieve this we exposed participants to one of two 10min meditation exercises compassion meditation or a focussed imagery meditation participants were then divided into groups and asked to complete a food assembly task to make food for starving people as exposure to compassion meditations appear to enhance compassion toward others we hypothesised that all participants would behave more compassionately by working collaboratively after being exposed to a compassion meditation compared to a focussed imagery meditation method ethical clearance of the study was obtained in line with the ethical review processes of the human research ethics committee transparency and openness this study including the hypotheses and analytical approach were preregistered on the open science framework we note in the method and results sections below which measures were confirmatory and exploratory all data materials and r script has also been made available on osf see the following link for these resources b51cca6755654a76b8d1c8d77a3cfa53 1 for each study we report all data exclusions all manipulations and how the sample size was determined 1 we preregistered additional hypotheses regarding a dependent variable entitled behavior as measured by more taking of sweets however this variable falls outside our primary research concerns and we have elected not to include any information about it here however descriptions of this variable and findings have been included in supplemental materials 1 design summary our study design was inspired by an activity used with high school students in a nonscientific setting compassion itan organization that aims to invoke more compassionate action in the worldran compassion workshops with students in grade 10 in san diego usa at the conclusion of these workshops the students were assigned to groups that represented high and low income countries all countries were tasked with the same goal to produce as much food as they could using lego bricks in a specified time the countries either had an abundance or not enough lego bricks critically how they should go about achieving this goal was ambiguous the teenagers were not told whether they should compete or cooperate with the other nations the students were free to move around the room during the exercise and observe the other countries and their resources during the exercise none of the highincome countries spontaneously shared any lego bricks with the lowincome countries even when those lowincome countries asked for help this suggests that inequality may be a suppressor of behavior in line with a superordinate goal however even though these findings are noteworthy the activity was designed as a learning opportunity rather than a scientifically valid study and these findings should be interpreted with caution given the lack of experimental control in the current study we transformed the activity by compassion it into a rigorous and highly controlled experimental design participants were randomly assigned to groups that represented either a high or a low resource country and each country was presented with lego bricks whereby the high resource group had an abundance of lego bricks and the low resource group had very little participants were asked to assemble lego bricks into food items to ensure that no one will starve critically the means by which participants should achieve this goal was ambiguous we did not tell the groups to compete or cooperate the compassionate superordinate goal was to maximize the food creation to ensure no one will starve and any behavior that contributed to this goal was considered an indication of compassion to achieve this we coded for three forms of compassionate behavior initiating sharing of items resulting in a transfer of lego bricks from the high resource group to the low resource group the amount of food pieces made and the efficiency of food making we further included several selfreport measures that broadly measured competitive and cooperative attitudes toward the other group group cohesion and fears of showing and receiving compassion participants and design the sample was comprised of 283 participants and were 2136 yearsold on average based on a sample size calculation on pangea we required a minimum sample size of 152 to detect a medium effect size with 80 probability this effect size was deemed appropriate based on findings regarding competitive sentiments under situations of high inequality we aimed to achieve this sample size at a minimum and collected larger numbers until the participant pool was exhausted the data was not analyzed until data collection ceased participants were recruited from either a firstyear pool of psychology students from a large urban university or from a paidpool and were reimbursed 10 per half an hour of participation participants reported several demographic variables including their age gender level of education ethnicity total pretax income and subjective ses subjective ses refers to where one feels they fit into society relative to others in terms of job prestige education and income on a 10rung ladder on average participants reported having middle class backgrounds see supplementary materials 2 for the full demographic description of the sample used the current study employed a 2 by 2 betweensubjects design and participants were randomly assigned to a condition and resource group we were interested in the effect of these independent variables on outcomes described in greater detail below procedure before the study began the table and chairs were arranged in a way to clearly separate two groups the high resource group and the low resource group each session contained between 4 and 12 participants in the event of odd numbers the extra participant was assigned to the high resource group the table held two transparent containers with lego bricks with one container assigned to each resource group images of these containers can be provided to readers upon request from the corresponding author the high resource group container held 500 colored lego bricks and 100 noncolored bricks in contrast the low resource group container contained only 100 colored bricks and 500 noncolored lego bricks importantly the valued resource in this context was colored lego bricks whereas noncolored bricks held no value as participants entered the room they were randomly assigned to sit at the high or low resource group side of the table after consent was obtained participants were asked to listen to a 10min meditation audio track which was played aloud to the entire group each session was randomly assigned to engage with a compassion meditation track or a focussed imagery track the compassion track began with basic meditation instructions before telling participants about the definition of compassion asked them to contemplate the definition and imagine engaging in compassionate behavior our focussed imagery meditation condition served as an ideal control task as it contained basic meditative practices but did not contain any information about compassion in line with past approaches this allowed us to isolate the effect of reflecting on being compassionate from the practice of general mindfulness see supplementary materials 4 for full scripts of each meditation the experimenter then told participants they were separated into two countries nasherland and lindithia we chose fictitious countries as real countries may prime stereotypes in participants minds about behavior in that specific culture and the use of fictitious nations has been successful in past experiments participants read a basic description of their country which contained demographic information such as the local delicacy the population and the climate the experimenter then told participants the aim was to create as much food as possible within a 5min period to prevent starvation participants were told one piece of food could be created by assembling lego bricks in the following order blue green yellow red participants were then shown an image of a correctly assembled food item this image can be provided to readers upon request from the corresponding author these instructions were purposefully ambiguous we did not tell the groups to cooperate or compete as we were interested in how they would interpret the ambiguous situation as such if participants asked if they could share bricks they were told the aim is to make as much food as possible so no one will starve we pilot tested the lego brick distribution to ensure the high resource group could not finish assembling their lego bricks in the time given whereas the low resource group would always finish assembling their pieces with excess time left implicitly it was clear that the only way to maximize food creation was for the groups to work together the groups then had 5 min to assemble food and the participants were then asked to complete a questionnaire at the conclusion of the task 2 participants were then debriefed and thanked for their participation measures compassionate behavior we defined compassionate behavior as actions that would contribute to the superordinate goal of creating food for the starving people more broadly here any action that results in maximizing food creation preventing starvation was counted as compassionate behavior first we assessed whether individuals initiated sharing as well as the amount of lego bricks that were transferred from the high to low resource group per individual importantly sharing frontiers in psychology 05 frontiersinorg could be initiated by the high or low resource group table 1 demonstrates the kinds of behavior that were counted as initiating sharing per resource group and whether that instance of sharing was initiated by the high or low resource group this coding system meant that both the high and low resource group could engage in the sharing of lego bricks between the groups in addition we assessed the number of correctly assembled food pieces made per individual finally we assessed the food making efficiency of each resource group 3 fears of compassion the questionnaire contained a fears of compassion scale as past work has found people can be fearful of being compassionate to others because it could result in resource loss and be fearful of receiving compassion from others due to obligations to return the help we included these measures as exploratory additions to the study as fears of giving and receiving compassion may be a significant barrier to coordinated action participants were asked 10items that reflected fears of giving compassion and 13 items that gauged fears of receiving compassion responses per item were scored from 0 to 4 and the responses were added together for each participant to achieve a total score for fears of giving compassion the total score could range from 0 to 40 and for fears of receiving compassion the total score could range from 0 to 52 the fears of giving and fears of receiving compassion scales both yielded acceptable reliability group dynamics and cohesion in the current study the means by which the groups should achieve the goal we have reported the overall efficiency of the resource group food so no one starves was purposefully ambiguous to assess the participants interpretation of these ambiguous instructions we included three exploratory questions to ascertain whether they interpreted the task as competitive or cooperative participants were asked to what extent did you feel this task was a competition between the two countries to what extent did you feel this task was a cooperative task between the two countries and to what extent did you feel the context was one of us versus them responses were scored on a scale from 1 to 10 we further asked two exploratory questions to gauge how participants felt about the cohesiveness of their group as strong ingroup unity may act as a suppressor of coordinated action specifically participants were provided with the following statements i felt a sense of unity within my group and i felt that people in my group seemed to be on the same wavelength responses were scored on a scale from 1 to 10 and an average score of these two items was created attention checks finally participants were asked several questions probing their attention to the inequality as well as a manipulation check to assess feelings of compassion first inequality salience was measured with the following question during the activity to what extent did you notice the groups were unequal this question was scored on a scale from 1 to 10 second we included a measure to ensure the high resource group felt like they had a greater capacity to complete the task compared to the low resource group my group had enough lego bricks to complete the task responses were scored from 1 to 10 participants were also asked to what extent did listening to the audio track make you feel more compassionate and responses were recorded on a scale from 1 to 10 analytical approach in our design individual behavior was potentially impacted by the behavior of their group members for example if one group member decided to share this may have influenced other group members to share as well to adjust for this nonindependence of data all individual level measures were analyzed in linear mixed models with group as the random intercept results see supplementary materials 8 for the full results for each analysis including mean differences between conditions and resource groups an independent samples ttest showed that there was no significant difference in the sizes of groups randomly allocated to the compassion meditation and focussed imagery conditions t 132 p 0187 this variable was thus not considered further the conditions and resource groups also did not differ in terms of age and gender see supplementary materials 9 for the means and standard deviations per condition per resource group for each of the dependent variables attention checks overall participants were highly cognizant of the unequal resources between the two groups an lmm was conducted on the effect of resource group and condition on the extent to which the participants noticed the inequality there were no differences between resource groups f 050 p 0482 or conditions f 228 p 0137 in the extent to which participants noticed the inequality likewise there was no significant interaction between resource conditions and compassion manipulation conditions f 345 p 0069 we further assessed the extent to which participants felt they had enough lego bricks to complete the task an anova4 revealed a significant effect of resource group f 31362 p 0001 where the high resource group indicated more strongly than the low resource group that they had enough lego bricks to complete the task however there was no significant effect of condition f 003 p 0852 and no condition by resource group interaction f 004 p 0846 finally we assessed whether participants felt more compassionate after listening to the compassion compared to the focussed imagery meditation as a manipulation check an anova revealed participants in the compassion meditation condition felt more compassionate compared to those in the focussed imagery condition f 1829 p 0001 moreover there was no significant effect of resource group on feelings of compassion f 006 p 0805 nor was there a significant interaction between resource group and condition f 042 p 0516 compassionate behavior in total 151 of participants initiated some form of sharing a glmm was conducted to establish the effect of resource group and condition on whether an individual initiated sharing results revealed no significant effect of resource group x 2 056 p 0456 or condition x 2 029 p 0590 nor a significant interaction between the two variables x 2 069 p 0407 see supplementary materials 10 for the number of times each category of sharing behavior was observed altogether individual participants initiated the sharing of 293 lego bricks on average a glmm assessed the effect of resource group and condition on the number of lego bricks transferred when sharing was initiated for this model we used a poisson distribution and the square root link function due to the exponential nature of the dependent variable results revealed no significant effect of resource group irr 082 p 0204 or condition irr 108 p 0647 on the number of lego bricks transferred when sharing was initiated additionally there was no significant interaction observed between the two variables irr 124 p 0184 collapsed across conditions and resource groups participants assembled 935 food pieces on average the effect of condition and resource group on the number of food pieces made was assessed using an lmm more food pieces were made by the high resource group compared to the low resource group f 1836 p 0001 however there was no significant difference observed between the conditions and the number of food pieces assembled f 117 p 0284 nor was there a significant interaction between the two variables f 007 p 0789 on average the groups made approximately 693 food pieces per minute we assessed the effect of condition and resource group on the efficiency of lego brick assembly using a twoway anova the high resource group worked faster compared to the low resource group f 4183 p 0001 however there was no significant difference in work rate based on condition f 003 p 0857 nor was there a significant interaction between condition and resource group f 008 p 0773 exploratory analyses we conducted several exploratory linear mixed models examining the effect of condition and resource group on fears of compassion as well as group dynamics and cohesion as demonstrated in table 2 those in the low resource group felt their groups were more cohesive relative to those in the high resource group discussion study 1 assessed the effect of compassion meditation on working toward a shared and superordinate goal when groups the finding also suggests that while brief compassion training may increase feelings of compassion this may not translate into more compassionate behavior study 1 demonstrated that a brief standalone compassion meditation did not result in greater collaboration across boundaries of groups that are unequal it appears that this individualistic approach may not be effective when individuals are members of groups here the dynamics of the group may have a strong influence on an individuals behavior and interventions that target structural elements may instead be more effective lower inequality for example is thought to reduce us versus them dynamics between different resource groups potentially paving the way for greater coordinated action study 2 in line with classic social identity theorizing study 2 examined whether the structural context shapes group behavior we proposed that structural factors as opposed to individual factors may be a more important determinate of whether groups adopt superordinate goals previous research has shown that intergroup competition is lower when individuals or groups have more equal resources than when inequality of resources is high and cooperation declines when inequality in resources is highly visible following from this research we explored whether lower inequality would result in more behavior that is in line with a superordinate goal to examine this we placed participants in two groups where the difference in group resources was either moderately or extremely unequal 5 since lower inequality reduces competition we expected that participants in groups that experienced moderate inequality would be more likely to act in line with a superordinate goal relative to groups in extreme inequality 6 method our methods and analytical approach were identical to that described in study 1 apart from the deviations detailed below participants and design the sample was comprised of 173 participants and were 2098 yearsold on average our approach to sample size and recruitment was identical to that described in study 1 on average participants reported having a middleclass background see supplementary materials 2 for the full demographic description of the sample used the current study employed a 2 by 2 betweensubjects design where participants were randomly assigned to a condition and a resource group 7 5 to test this we heightened inequality relative to study 1 this decision was made because in our paradigm groups that possess equal resources would have no superordinate reason to collaborate hence heightening the differences between groups is the only feasible way to test the role of inequality in this paradigm 6 we originally preregistered a null hypothesis by mistake and believe this does not accurately reflect the body of research existing at the time we have changed our hypothesis to better reflect the state of the literature prior to creating this study 7 it is worth noting that this manipulation creates a natural confound that is when the inequality changes between the groups we also change the level of resources each group has the low resource group in moderate inequality has more resources than the low resource group in extreme inequality however this is unavoidable as manipulating the gap between the low and the high resource group also varies the absolute amount of wealth each group has we were interested in the effect of these independent variables on several outcomes including compassionate behavior fears of compassion and group cohesion procedure we followed an identical procedure to that described in study 1 with a few exceptions first participants did not listen to an audio meditation and instead were given the task instructions immediately after giving their consent second participants experienced one of two lego brick distributions in line with study 1 participants in the moderate inequality condition were in a context where the high resource group was given 500 colored and 100 noncolored bricks and the low resource group was given 100 colored and 500 noncolored bricks we increased the magnitude of this inequality in the extreme inequality condition where the high resource group had 560 colored and 100 noncolored bricks and the low resource group was given 40 colored and 500 noncolored bricks in addition those in the extreme inequality condition were given additional information about the wealth of their country measures all measures were identical to study 1 however we did not include the manipulation check measure that assessed how compassionate participants felt in response to the meditation results in total 31 experimental sessions were used for the final sample and group sizes ranged from four to nine the full results for each analysis from study 2 can be found in supplementary materials 8 an independent samples ttest was conducted to establish whether the conditions differed in the size of the groups and results revealed no significant difference between the extreme and moderate inequality conditions t 038 p 0708 group size was thus not considered further the conditions and resource groups also did not differ in terms of age and gender see supplementary materials 9 for the means and standard deviations per condition per resource group for each of the dependent variables attention checks overall participants were highly cognizant of the unequal resources between the two groups an lmm was conducted on the effect of resource group and condition on the extent to which the participants noticed the inequality there were no differences between resource groups f 072 p 0401 or conditions f 226 p 0139 in the extent to which participants noticed the inequality likewise there was no significant interaction between the two variables f 002 p 0879 we further assessed the extent to which participants felt they had enough lego bricks to complete the task an lmm was used to assess the effect of resource group and condition on this variable a significant effect of resource group was found f 6823 p 0001 where the high resource group felt more so than the low resource group that they had enough lego bricks to complete the task however there was no significant effect of condition f 0002 p 0969 and no condition by resource group interaction f 239 p 0128 compassionate behavior in total 283 of participants initiated some form of sharing a generalized linear mixed model was conducted to establish the effect of resource group and condition on whether an individual initiated sharing results revealed no significant effect of resource group x 2 002 p 0896 or condition x 2 037 p 0543 nor a significant interaction between the two variables x 2 002 p 0878 see supplementary materials 10 for the number of times each category of sharing behavior was observed altogether individual participants initiated the sharing of 527 lego bricks on average a glmm assessed the effect of resource group and condition on the number of lego bricks transferred when sharing was initiated for this model we used a poisson distribution and the square root link function due to the exponential nature of the dependent variable the low resource group initiated the sharing of more lego bricks compared to the high resource group irr 050 p 0004 likewise more frontiers in psychology 09 frontiersinorg lego bricks were transferred in instances of sharing in the extreme compared to the moderate inequality condition irr 180 p 0012 however there was no significant interaction observed between the two variables irr 081 p 0365 collapsed across conditions and resource groups participants assembled 1114 food pieces on average the effect of condition and resource group on the number of food pieces made was assessed using a linear mixed model more food pieces were made by the high resource group compared to the low resource group f 2589 p 0001 however there was no significant difference observed between the conditions and the number of food pieces assembled f 343 p 0070 nor was there a significant interaction between the two variables f 004 p 0849 on average the groups made approximately 678 food pieces per minute we assessed the effect of condition and resource group on the efficiency of lego brick assembly using a twoway anova the high resource group worked faster compared to the low resource group f 2570 p 0001 however there was no significant difference in work rate based on condition f 173 p 0193 nor was there a significant interaction between condition and resource group f 034 p 0561 exploratory analyses we conducted several exploratory linear mixed models examining the effect of condition and resource group on fears of compassion as well as group dynamics and cohesion as demonstrated in table 3 those in the low resource group reported lower fears of receiving compassion relative to those in the high resource group those in the extreme inequality condition felt there was a greater cohesion in the resource group compared to those who experienced moderate inequality discussion in study 2 we analyzed the effect of the degree of inequality on the adoption of behavior directed toward a superordinate goal we found no consistent support for our hypothesis and results show that participants in the moderate inequality condition did not behave in line with a superordinate goal more than those in the extreme inequality condition overall we found that there were no differences in whether sharing was initiated between conditions however when sharing was initiated in the extreme inequality condition more lego bricks were involved in that transfer compared to moderate inequality importantly we found no differences in the extent to which participants noticed the inequality and both conditions yielded ceiling effects inequality was highly salient to participants in both conditions low resource participants also initiated sharing more than high resource participants and reported reduced fears of receiving compassion moreover our manipulation did not result in differences in feelings of competitiveness or cooperativeness however extreme inequality did result in greater cohesion with the group suggesting that when differences between groups are enhanced participants feel more united with their ingroup these results in combination suggest that our manipulation of the degree of inequality did not promote the adoption of compassionate behavior and attitudes instead interventions that alter the normative structure such as an informal leader promoting a prosharing group norm may result in more compassionate action when groups are unequal study 3 the behavior of others around us and in particular the members of our ingroup can have a dramatic effect on how we choose to act in particular highlighting norms about what individuals should do tends to enhance prosocial behavior we also typically favor members the four lego bricks shared by the confederate at prompt 4 were not counted in the sharing score of our own group over members of other groups even if the group membership is dictated by something as arbitrary as a similar colored shirt however when group members promote a norm that helps outgroup members ingroup favoritism can be overridden likewise when participants are prompted to reflect on what they should do they are less likely to favor the ingroup over the outgroup ambiguous situations present a particular challenge for groups because of this an individual who introduces a prosharing group norm can become an informal leader and guide their group toward superordinate action past research has shown that informal leaders who offer cognitive alternatives that is alternatives to the current reality can have a powerful impact on the behavior of other members study 3 aimed to explore the influence of a prosharing group norm on the emergence of superordinate compassionate behavior when groups are unequal to assess this we utilized the same design from the moderate inequality condition in study 2 this time a confederate was planted in the high resource group in our prosharing group norm condition the confederate gradually prompted sharing between the groups with increasing intensity over the fiveminute task period this was compared to a control condition where the confederate instead discussed their enjoyment of lego bricks while the confederate was acting as a high resource group member they had the potential to sway the behaviour of members from both the high and low resource group in line with prior research we hypothesised that more compassionate behavior would be exhibited by all participants in the prosharing group norm condition compared to the control condition method our methods and analytical approach were identical to the moderate inequality condition in study 2 with exceptions outlined below participants and design the sample was comprised of 160 participants and were 2036 yearsold on average our approach to sample size and recruitment was identical to that described in study 1 on average participants reported having a middleclass background see supplementary materials 2 for the full demographic description of the sample used the current study employed a 2 by 2 betweensubjects design and participants were randomly assigned to a condition and a resource group we were interested in the effect of these independent variables on a number of outcomes including compassionate behavior competitive sentiments fears of compassion and group dynamics procedure the study followed an identical procedure to the moderate inequality condition in study 2 with a few exceptions participants either experienced the implementation of a prosharing group norm or a control condition and this was achieved by including a confederate in the high resource group the confederate took on an informal leadership position in the group and spoke only during the lego brick assembly task in both conditions they spoke at oneminute intervals and were instructed to only speak to group members when spoken to in the prosharing group norm condition the prompts escalated in their intensity the confederate first pointed out the lego brick inequality then created an injunctive norm where they suggested sharing eventually they themselves physically shared bricks in the control condition the confederate spoke about their enjoyment of lego bricks at each minute interval the specific prompts are outlined in table 4 the confederate was instructed to work at a similar rate to the other group members we chose to have a control confederate rather than a no confederate condition to control for any effects consistent discussion might have on participant behavior that is a confederate who speaks frequently regardless of what they speak about might promote a different group dynamic and this may change how participants behave measures all measures were identical to study 2 results an independent samples ttest was conducted to examine whether the size of the groups were identical across the frontiers in psychology 12 frontiersinorg exploratory analyses we conducted several exploratory linear mixed models examining the effect of condition and resource group on fears of compassion as well as group dynamics and cohesion as demonstrated in table 5 there was a significant interaction between resource groups and conditions on fears of giving compassion follow up simple effect analyses revealed a significant effect for the high resource group only f 764 p 0008 such that the high resource group members in the compassionate norm condition had reduced fears of being compassionate compared to high resource group members in the control condition moreover those in the low resource group felt more like the context was competitive compared to those in the high resource group participants in the prosharing group norm condition felt the context was more cooperative compared to those in the control condition likewise participants in the prosharing group norm condition felt the context was less one of us versus them compared to those in the control condition discussion study 3 revealed the effect of a confederate who took on an informal leadership role in the group and changed the status quo by introducing a prosharing group norm we found that a fellow group member who promotes sharing can have a significant influence on the behavior of other groups membersparticipants were more likely to initiate sharing transferred more lego bricks between the groups worked faster and made more food pieces when a confederate suggested sharing importantly participants in this condition felt that the context was more cooperative and less one of us vs them and the high resource participants had reduced fears of being compassionate together these findings suggest that a member who imbeds a prosharing group norm within a group can have a powerful influence on the behavior and mentality of other group memberstheir leadership behavior decreases intergroup competition and compassionate action can be achieved general discussion when covid19 surged wealthy countries hoarded vaccines and poorer countries who were not only battling poverty but also the devastating impact of the virus were left without how do we promote compassionate action under these conditions here we aimed to understand effective ways of orienting individuals toward a superordinate compassionate goal when they were embedded in unequal groups via an individualistic intervention structural intervention and a normative intervention promoting a different way to respond to the status quo we found little evidence that compassion meditation and varying the degree of inequality enhanced the adoption of compassionate action however when a confederate took the lead by introducing a prosharing group norm participants engaged in more compassionate behavior and adopted a collaborative approach to the task frontiers in psychology 13 frontiersinorg the introduction of a prosharing group norm resulted in enhanced compassionate action and attitudes and this finding is in line with past work suggesting norms can have a significant shift on group behavior additionally past research shows that individuals who offer a cognitive alternative to the current status quo can become informal leaders and sway the behavior of their group here participants transferred more lego bricks between the groups interpreted the task as cooperative worked faster and critically created more food for starving people moreover the high resource group had reduced fears of being compassionate relative to the control condition suggesting that the introduction of a prosharing group norm paved the way for group members to feel more positive about behaving compassionately toward others it remains unclear however if the groups would adopt superordinate behavior if the confederate was instead a member of the low resource group and this is a promising direction for future research it is also unclear whether the confederate introduced a norm of sharing as intended or whether their comments drew attention to the unequal resources and this instead prompted sharing while participants reported noticing the inequality more when the confederate introduced the sharing norm they were still highly aware of the inequality in the control condition nonetheless future research should include questions about how participants view the norms of the group and assess whether this altered by condition on the other hand our individualistic intervention a compassion meditation did not promote compassionate action or attitudes while participants reported feeling more compassionate there was no evidence that this translated to behavior a phenomenon that is in line with past research demonstrating a gap between attitudes and behavior this further suggests that while compassion meditations may alter attitudes and behavior in some settings such interventions may be too individualistic to affect compassion in a group setting however we only assessed the effect of shortterm interventions and longerterm interventions may instead prove fruitful likewise our structural intervention varying the degree of inequality between the groups also did not result in any meaningful changes in compassionate actions or attitudes while enhanced inequality did lead to more lego bricks being transferred between the groups this did not result in more food pieces being made this intervention also did not impact attitudes and this may have been because the situation invoked two competing motivations while the need for sharing was more tangible under extreme inequality unequal resources suppress compassionate action together these three studies have revealed several insights about human behavior in a previously unexplored context we assessed the effect of three different interventions from diverse literatures to establish which approach is most effective the efficacy of these interventions was measured across a variety of behavioral and selfreport outcomes giving us greater certainty of the effects in addition to theoretical contributions these studies also have significant practical applications in a world of increasingly complex social dilemmas there have been growing discussions about how to promote a more compassionate world for example by getting rich countries to assist poor countries in their acquisition of covid19 vaccinations our work suggests that leadership by one individual whether it be an individual person or possibly an individual country may set a norm that can have a positive domino effect on compassionate actions more broadly limitations and future research despite these strengths our work has produced several questions that warrant future research while our experimental approach allowed us to gain a high degree of control the assembly of lego bricks is distantly related to the acquisition of realworld resources thus future work is needed to assess effects of these kinds of manipulations in realworld settings additionally the endowments were windfall gains and people tend to be less generous with resources when they are instead earned to test this possibility future work should compare the effect of windfall versus earned resources on intergroup interactions in this context moreover future work may wish to also vary the degree of inequality withingroups and explore how this interacts with betweengroup inequality we have also defined compassion as any action that aims to maximize the food creation for starving people and placed behavior such as sharing and food assembly under this definition however this may not be the only motivation that is driving participants to engage in sharing and food creation for example high resource participants may feel pity or awkwardness directed toward the low resource group due to their lack of lego bricks future work should directly assess the motivations that drive participant sharing behavior and establish whether these are compassionate in origin we also did not directly compare interventions across studies and future research may wish to test which manipulations yield the largest effect size finally participants were disproportionately female largely comprised of firstyear students and came from a weird population frontiers in psychology 14 frontiersinorg future work should extend upon these findings in more representative and culturally diverse samples in conclusion the human capacity for compassion is one of our most extraordinary traits yet we do not always help those who are suffering here we aimed to establish how to foster compassionate action and promote the adoption of a superordinate goal under situations of group inequality we assessed the effect of three interventions compassion meditation altering the degree of inequality and implementing a prosharing group norm compassion meditation and changing the degree of inequality had no meaningful effect on compassionate action the introduction of a prosharing group norm instead had a marked influence on the behavior and attitudes of the unequal groups this work offers new insights into the feasibility of different interventions to foster compassionate behavior which may be critical in promoting a more unified world data availability statement the datasets presented in this study can be found in online repositories the names of the repositoryrepositories and accession number can be found at open science framework iofjp6bviewonlyb51cca6755654a76b8d1c8d77a3cfa53 frontiers in psychology 11 frontiersinorg conditions results revealed a significant difference such that groups were smaller in size in the prosharing group norm condition compared to the control condition t 615 p 0001 this difference emerged despite careful random allocation procedures and we thus used group size as a covariate in all analyses the full results for each analysis from study 3 can be found in supplementary materials 8 the conditions and resource groups did not differ in terms of age and gender see supplementary materials 9 for the means and standard deviations per condition per resource group for each of the dependent variables attention checks overall participants were highly cognizant of the unequal resources between the two groups an lmm was conducted on the effect of resource group and condition on the extent to which the participants noticed the inequality those in the prosharing group norm condition noticed the inequality more compared to those in the control condition f 621 p 0016 however there were no differences between resource groups in the extent to which participants noticed the inequality f 080 p 0374 likewise there was no significant interaction between the two variables f 051 p 0480 we further assessed the extent to which participants felt they had enough lego bricks to complete the task an ancova revealed a significant effect of resource group f 37015 p 0001 where the high resource group felt they had enough lego bricks to complete the task more so than the low resource group however there was no significant effect of condition f 251 p 0115 and no condition by resource group interaction f 066 p 0418 compassionate behavior in total 406 of participants initiated some form of sharing a glmm was conducted to establish the effect of resource group and condition on whether an individual initiated sharing results revealed that participants were more likely to initiate sharing in the prosharing group norm condition compared to the control condition x 2 1832 p 0001 there was no significant effect of resource group x 2 001 p 0945 nor a significant interaction between the two variables x 2 001 p 0972 see supplementary materials 10 for the number of times each category of sharing behavior was observed altogether individual participants initiated the sharing of 602 lego bricks on average a glmm assessed the effect of resource group and condition on the number of lego bricks transferred when sharing was initiated for this model we used a poisson distribution and the square root link function due to the exponential nature of the dependent variable more lego bricks were transferred in instances of sharing in the prosharing group norm condition compared to the control condition irr 288 p 0001 results additionally revealed no significant effect of resource group irr 126 p 0375 and there was no significant interaction observed between the two variables irr 102 p 0926 collapsed across conditions and resource groups participants assembled 1058 food pieces on average the effect of condition and resource group on the number of food pieces made was assessed using an lmm more food pieces were made by the high resource group compared to the low resource group f 1878 p 0001 furthermore more food pieces were assembled in the prosharing group norm condition compared to the control condition f 630 p 0015 however there was no significant interaction between the two variables f 019 p 0661 on average the groups made approximately 653 food pieces per minute we assessed the effect of condition and resource group on the efficiency of lego brick assembly using a twoway ancova the high resource group worked faster compared to the low resource group f 8850 p 0001 those in the prosharing group norm condition were also more efficient at making food relative to those in the control condition f 596 p 0018 accounting for group size the estimated marginal mean for efficiency in food assembly was higher for the prosharing group norm condition compared to the control condition however there was no significant interaction between condition and resource group f 136 p 0248 ethics statement the studies involving human participants were reviewed and approved by human research ethics committee at the university of queensland 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 author disclaimer lego ® the lego ® logo the brick and knob configuration and the minifigure figurine are trademarks andor copyrights of the lego group of companies which does not sponsor authorize or endorse this article supplementary material the supplementary material for this article can be found online at full supplementarymaterial

amid a global pandemic and the climate crisis there is an increasing need to understand how to promote largescale coordinated action between different groups yet certain factors such as inequality can hinder cooperation we aimed to establish how to orient groups toward a superordinate goal when they have unequal resources participants were divided into two countries and asked to assemble lego bricks into food by building pieces in a certain order to prevent starvation among the people one country had few lego bricks whereas the other had an abundance and the only way to maximize food creation was for the groups to work together we assessed the efficacy of three diverse interventions on superordinate behavior and attitudes compassion meditation training study 1 lower inequality study 2 and the introduction of a prosharing group norm by a confederate study 3 compassion meditation training and altering the degree of inequality between groups did not have a clear effect on collaborative action only the introduction of a prosharing group norm enhanced sharing behavior made participants feel more cooperative and reduced fears of being compassionate toward others our findings speak to the importance of leadership in promoting coordinated action to address challenges that face the superordinate group

the lives of millions of displaced individuals are characterized by exclusion xenophobia and global apathy displaced persons may live in formal or informal camps or in other settings with few resources and unreliable access to essential commodities and services forced displacement both in the short term and protracted therefore has complex impacts on health 12 factors that affect the health of forcibly displaced individuals can be split broadly into two realms the physical and the social displaced communities both during migration and when they are not moving are often in locations that have limited access to essential health services the geographic locations also often increase exposure to toxic and unstable environments which can have immediate and chronic health impacts the social attributes of displacement include legal status nationality and other socioeconomic factors that can likewise influence access to health services and force communities to live in a state of fear and anxiety they may also affect the geographic settings in which displaced persons reside as humanitarian crises grow around the world and new humanitarian crises appear in south asia the americas africa and europe so do the camps that are sometimes home to displaced individuals for decades 3 4 5 in many camps across the globe there are multiple generations that have been born and spent their entire lives in camps the populations of these camps are neither fixed nor static which can strongly influence epidemiological dynamics 6 7 8 9 intergenerational factors create heterogeneity that leads to environmental changes including those at microbial scales not excluding changes in the gut microbiome changes in demography and environment are rarely studied from an integrated ecological andor evolutionary lens and are rarely part of the displaced individuals health landscape this absence of scholarship and research allows for the continuation of siloed approaches and creates blind spots in understanding disease dynamics emergence of new health challenges provision of longterm care and inefficient delivery of health services we propose a more integrated approach to understand health challenges of the forcibly displacedone that is multidisciplinary and multiscale and analyzes the communities and their environment from an ecological framework we define ecology as the interaction between organisms and their environment at multiple spatial scales this includes interactions among microbes among humans disease vectors and microbes and between the physical landscape and humans disease vectors and microbes and does not exclude noncommunicable diseases current approaches even in the context of a one health framework can sometimes be siloed or at a single spatial or temporal scale the common siloed approach through which many services are currently provided leads to inefficiencies in the provision of services varying temporal coverage based on funding cycles and incomplete pictures of health environmental ecological and evolutionary considerations are often not even considered posing further gaps in our understanding of the health of populations within such camps though we have information on a higher general level we know few specifics about disease dynamics and the relationship of people and their environment in complex humanitarian emergencies 10 siloed approaches neglect the reality that all components of humanitarian management have important health considerations when using an ecological lens we therefore aim to understand the dynamic ecologies that connect vertically and horizontally in forced displacement camps understanding the ways that upstream factors can influence human health and microbial communities is useful in diagnosing and preventing poor health outcomes likewise this type of bigpicture lens is useful from a public health standpoint a public health system that focuses on all health outcomescommunicable and noncommunicable including mental healthand likewise considers the multidirectional health implications of humanbiophysical environment interactions is useful for preventing disease for those who are planning or administering camps having a holistic view of the linkages between humans and their environments may lead to better planned and managed camps camp locations could often be better chosen with health implications for the dwellers for other communities in the same region and for the environment an approach that prioritizes local knowledge will lead to better understanding of the local ecological systems to achieve this we argue for considering displaced individual environs as adaptive ecosystems with interactions at multiple temporal and spatial scales an ecological lens challenges the siloed approach and allows for benefiting from a new understanding and new tools in the discipline it helps us better understand the evolutionary and environmental pressures in the camps and enables us to improve the lives of those who live in them environmental and social ecologies humans animals and the environment influence each other in a codependent manner that varies with time and space and is affected by both local and global factors this multiscale dependence although well recognized by those who are forced to live in the campshas not been fully understood in research circles to illustrate the importance of a multiscale dynamic ecological model in understanding the health of displaced individuals in camps we offer figure 1 which demonstrates and visualizes some of the ecologies and interactions occurring between the environment and health of displaced populations social factors also play a critical role in the camp ecosystem and include the camps and individuals legal status discrimination mobility employment and host community relations the camps legal status affects the provision and availability of services throughout the camp as well as its development and care the legal status of displaced individuals influences movement out of the camp including being unable to seek external health care or obtain employment employment that is obtained may be in environments where certain diseases are more common differences in race gender legal status and other demographic variables can lead to discrimination inequality and violence these have direct and indirect effects on the health of displaced persons and are compounded further by the individuals vulnerable social and legal position and lack of legal accountability for perpetrators studies have also found an association between gender inequality and environmental degradation 11 these social factors interact with the broader environment and work in tandem to influence health outcomes including those related to mental health table 1 summarizes a sampling of these factors though it is by no means an exhaustive discussion of these factors and interactions discussion the united nations high commissioner for refugees views camps as temporary solutions of last resort yet the formation of camps is so common that it warrants better planning 39 although we fully acknowledge that displaced persons should not be confined to camps and strongly argue for dignified living conditions for those who have been forced to leave their homes we argue that for those who are in camps an expanded understanding of the built environment 12 infrastructure including dwellings and watersewage systems that are poorly constructed and unsafe can increase exposure to toxic and unstable environments and disease physical landscape 13 the physical landscape informs disease ecology affects resource availability and increases vulnerability to weather events camp location 121415 camps are often located in suboptimal environments that would otherwise be sparsely inhabited and affect the provision of humanitarian aid camp creation leads to landscape changes to accommodate the population and built environment fuel demand and supplies 131617 availability of energy has impacts at the individual level such as through the ability to cook or have electricity and at the camp level through provision of health care and waste management an insufficient energy supply often results in fuel poverty increased deforestation and malnutrition 13 deforestation 13 deforestation changes the physical environment of the camps including vector landscapes often quite dramatically it also contributes to climate change and increased air pollution and irritants for chronic health issues uncontrolled fires the use of firewood has immediate dangers related to uncontrolled fires which can spread rapidly in tightly packed camps climate change and extreme weather events 18 19 20 temperature climate and extreme weather events can trigger displacement and affect individuals who have already been displaced 18 these events can also alter the physical landscape exacerbate the spread of infectious diseases and affect the provision of humanitarian aid water and sewage systems 2021 unsafe drinking water and stagnant contaminated water can be sources of infectious diseases and longterm health impacts related to the consumption of naturally derived compounds 22 23 24 25 clean water can also affect the provision of health care groundwater quality 222627 insufficient sewage systems may introduce or reintroduce viruses and bacteria into groundwater and surface water disrupting the natural ecosystem and contributing to disease spread 2227 land clearing and burning food production and development or land hardening also release pollutants into these water sources livestock 28 29 30 livestock serve as reservoirs for diseases and can attract disease vectors and multidrugresistant bacteria especially if practices are unregulated animal waste can also contaminate the water supply livelihood production 28 means of livelihood especially those that rely on waterintensive agricultural practices or livestock can affect water resources 28 such means are also vulnerable to changes in temperature and climate watershed health and viability 2631 longterm viability of water sources depends on watersheds around camps which are affected by the removal of native vegetation changing hydrology alteration of the microbial communities and the addition or increase of pollutants in runoff 31 camp legal status 32 the legal status affects the provision and availability of services throughout the camp as well as the camps development and care political and conflict environment political andor conflictrelated challenges cause variation in camp services over time especially when camps are in areas of strategic importance discrimination inequality and violence 33 34 35 differences in race gender legal status and other demographic variables affect how an individual is treated upon entering and living within the camp women and girls are particularly vulnerable to genderbased violence and lack an established justice system and access to appropriate physical andor mental care 33 34 35 mobility 3637 individuals may have their movement restricted or may be completely unable to leave a camp legally which limits access to health services and their ability to seek employment or education occupational opportunity 38 displaced persons are often limited with regard to occupational opportunities as a result of legal and structural barriers to accessing work because of this many are forced to work in environments where certain diseases are more common or they may work illegally host community relationships host community relationships may be strained by actions such as deforestation unsustainable land use and employment outside of camps these relationships can have marked effects on the longevity of the camp demography demography has impacts across all sectors changes in demography can affect disease burden required services livelihood physical landscapes fuel demands and other important components of the camp ecosystem interacting ecologies will help us improve lives as other policies that provide a dignified existence out of the camps are prioritized we have thus far focused on situations in which displaced persons aggregate in camps though many are instead living in urban environments these environments likewise tend to be unsafe and unhealthy an ecological lens allows us to understand more fully the living conditions in areas such as these though other factors are needed to address the needs of this specific population 40 we recognize that this lens has its limitations individual camps create unique contexts and ecosystems meaning that ecological interactions may vary greatly among camps the adoption of this approach may have numerous logistic barriers though these may be largely a result of the siloed approach this lens attempts to deconstruct developing a better understanding of how different components of this ecosystem interact including at different spacetimescales could lead to better planning and interventions to improve the health of both populations and environments in these difficult settings recommendations we need more partnerships that are crosscutting between silos and that bring together humanitarian aid providers camp planners ecologists public health professionals healthcare providers environmental practitioners lawyers policymakers and other experts of factors that contribute to the ecology of camps integrated policy needs to be developed based on assessing connections among systems so that evidencebased decisions can be made about how interventions may influence outcomes in multiple sectors sharing resources and taking an integrated approach will assist in buffering risk and creating more effective and proactive governance we recommend research and collaboration that increases our understanding of interactions among camps their environments and broader ecosystems to incorporate this knowledge into future camps this includes improving data gathering and analysis to incorporate local knowledge and partners with an emphasis on actively engaging women 11 we recommend having the data ecosystem be considered more seriously and prioritized in these settings making decisions through an ecological lens does not need to preclude immediate aid provision through our recommended collaboration we foresee a pathway to integrate ecological considerations into camp planning development management and sustainment however we must first learn how we can adapt this lens in a way that is practical in realtime camp settings as the first step in this process we recommend a series of workshops that brings together different actors across silos to make concrete pathways for the inclusion of ecological considerations in camps this piece is but the first contribution in what we anticipate and indeed hope will be much larger conversations around improving the care and services we provide displaced persons

health care among forcibly displaced persons is frequently driven by siloed approaches aspects of the built environment social factors and the bidirectional relationship between the changing ecosystem and residents are often ignored in health policy design and implementation while recognizing factors that create a preference for siloed approaches and appreciating the work of humanitarian agencies we argue for a new datadriven and holistic approach to understand the health of the forcibly displaced it should be rooted in the realities of the emergence of new diseases dynamic demographics and degrading environments around the displaced communities such an approach envisions refugee and internally displaced camps as dynamic complex ecosystems that alter and are altered by spatial and temporal factors at the root of this approach is the necessity to work across disciplines to think holistically to go beyond treating single ailments and to develop ethical approaches that provide dignity to those who are forcibly displaced

introduction law enforcement agencies have adopted social media strategies for expanding their scope of communication and benefiting from the breadth and depth of its influence social media is a powerful tool that provides platforms for people to establish interact and also provide information about the individuals social life tang and liu classify the different forms of social media as blogs forum media sharing microblogging social networking social news social bookmarking and wikis law enforcement agencies are increasingly using social media to interact with communities and also collect information required for criminal investigation social media is known for its four major strengths that include collaboration empowerment participation and time organisations and local governments have been increasingly using facebook sites for official purpose to reach out to customers as they live online police departments acknowledge the potential of social media and are using it to enhance citizen input to police investigations establish and strength its image use it as a tool to control crowds and crisis and encourage input in policymaking processes mergel identifies four different social media strategies being adopted by the government agencies which include push pull network and tactic strategies under the push strategy the governments only broadcast information through the web content and there is no interaction the pull strategy demonstrates the government attracts citizens to or users to provide information and usually limiting the level of interaction with them the networking strategy exhibits high interaction whereby the government actively or passively participates in networking with the diverse constituencies the final tactic strategy encompasses government services with actual transactions being implemented through social media applications thus when government agencies choose to apply a social media strategy it also needs to anticipate citizens social behavior and also be proactive in adopting technological trends sultanate of oman has begun its smart government initiatives under the hegemony of the information technology authority omanuna has been introduced as the official oman egovernment service portal which maintains all the eparticipation platforms for government agencies it manages 64 social media accounts of various government entities in comparison to the arab region and the world oman is ranked 2 nd and 43 rd respectively in the 2018 eparticipation index the ranking was a significant improvement to the 2016 position where it stood at 33 rd position in comparison to the world reflecting that the government placed a special emphasis on the effective utilization of eparticipation channels and establishing contact with the public meijer and thaens point out that the police departments are distinct from the other government operations the police are in contact with all citizens and have diversity in their communication the use of social media has been extensively investigated however very limited research exists that explores how police use social media and interact with the public one of the noteworthy extant literature that explored the usage of facebook and twitter by seven police departments in the usa suggested that the contents of the information posted had an impact on how citizens interacted with them lieberman et al investigated facebook posts of 23 largest us police departments over three months in 2010 the findings suggested that departments with a high posting frequency shared more crimerelated information whereas those with a low posting frequency shared more public relations information another research investigated canadian police twitter usage as a response to the 2011 vancouver stanley cup riot the canadian police used media to garner citizen cooperation gather evidence and mediate communication for community involvement there is a dearth of research that explores the social media content from the police perspective world over police departments are adopting social media strategies to connect with the community thus there needs to be a systematic evaluation on the extent and purpose of why social media is being used by the police to have a grasp on the potential of social media for the police department this research specifically focuses on the facebook page of royal oman police the central research question that this research investigates is what type of information does the royal oman police send through its facebook and what is the extent of citizen engagement through the facebook page the article is structured into the following sections section 2 addresses and discusses the literature review related to eparticipation related studies for the government entities and police department section 3 describes the research methodology adopted to investigate the research question this is followed by section 4 that presents results and discussion of the study finally section 5 is on the discussion implications and recommendations related to the results of the research literature review as the world is moving to a more internetbased environment where people are becoming more connected the law enforcement agencies in many of the countries have started using social media as a powerful platform for interacting with communities and collecting information for criminal investigations social media is used frequently by police departments to interact with the public and to get and provide information social media is helping the police departments to gather information for the effective deployment of resources and existing practices the police agencies can get a feel of community sentiment about their policies procedures and practices good policecommunity relations are vital for developing trust between citizens and police the use of various social media helps the police departments to build community ties which in turn improves the peoples trust in police a study was carried out by dai et al to systematically examine and analyze the varieties in the use of social media by traditional american local police departments and their interactions with citizens the study collected data between october 1 2013 and march 31 2014 from facebook and twitter accounts of seven city police departments in the area of virginia in the usa content analysis and text mining were used to identify the patterns of social media posts by police departments and then statistically analyzed citizen interactions on social media with the police the authors have applied a commonly used automated text analysis approach to analyze textual contents in facebook and twitter posts the authors also observed that during the sixmonths of study there were a total of 1293 posts and tweets on facebook and twitter for the seven agencies under observation and every agency had at least one post on facebook or twitter a day the study used a number of facebook likes and twitter followers as indicators of community interaction with the police agencies the findings of the study proved that there was a lot of variation in the way citizens interact with police on social media it was observed that people on facebook did more on networking as they visited the facebook page of police agencies to like posts about the agency and police officers and provided some comments however people on twitter tried to get access to information they like from the police twitter sites such as general information required for everyday life weather updates etc the study finding had important implications for the police agencies to attract more citizen interaction for effective functioning it was observed in the study that the contents of information play an important role in citizen engagement and interaction the authors had recommended police agencies to adopt a problemsolving approach and analyze which category of information on their social media would likely to promote citizen interactions the authors have suggested future research on how the citizen interchanges view with the police departments through social media will give more insight into the understanding of peoples expectations and perceptions on policing recently the use of social media by governmental agencies has been considerably increased for example mossberger et al state that 924 percent of local governments in usa has a facebook page and 87 percent of the municipalities in the usa were active on facebook by 2011 a study conducted by bonson et al in 2015 shows that all german local governments have a facebook page the study by ellison and hardy in 2014 shows that the majority of local governments in uk uses facebook and twitter to interact with people bertot et al state that the use of social media by governments began as a way to improve transparency and openness and also highlighted collaboration participation empowerment and time as major potential strengths of social media bellstrom et al conducted a study to identify the type of information exchange that happens between a local government and its citizens using social media the research involved a qualitative single case study of the facebook page of the karlstad municipality in sweden the authors have used content analysis on facebook data collected between may 2015 and july 2015 to find out different categories that determine the analysis the frequency of content category proves that the municipality has used the facebook page to promote different happenings in the municipality while the page users were asking questions to the municipality the research involved analyzes of the type of information disseminated through the facebook page of local government the type of information received through the facebook page of local government and the relation between the type of information communicated on facebook page and the engagement between the government and citizen the authors have suggested further study on motivational factors of posting comments and community engagement alaufi et al examined the perceptions of omani citizens towards the use of the governments social media for participatory and interactive relationships mainly the study investigated and explained the views of social media users on the transparency engagement responsiveness and trust about the use of social media by the omani government the study found that even though the citizens are increasingly accessing the governmental social media governmental departments are not utilizing social media effectively and failed to engage citizens to design and deliver more collaborative and efficient services the major emphasis of the study was to strategically frame the use of participatory social media by the governmental departments for interactive governance according to warren et al the governmental departments have been obliged to listen and engage with citizens as the citizens are empowered by the use of social media the study states that governments are now expected to regulate and professionalize their engagement with citizens through social media platforms gohar feroz et al explored twitter usage by koreas central government by classifying twitterbased networking strategies into g2c and g2g which are government to citizen and government to government respectively 10 the authors investigated the nature of networking and social media interaction strategies of the korean government by analyzing the tweets of 32 ministries the results found that korean government institutions have made extensive use of twitter in their daily interactions with the public but their networking strategies did not necessarily motivate the public to participate in their social media activities the research findings indicated that the ministries focused more on addressing the needs of the citizens rather than an increase in the number of followers police departments in many countries have started using social media sites widely as the main method of communication with people liberman et al performed a study on facebook messages posed by 23 police departments in usa over a three month period during 2010 the researchers used content analysis and the result finding indicates that the content pattern was related to the frequency of departments facebook postings to some extent crimerelated messages were posted by the police departments who have used facebook more frequently and the departments who have used facebook less frequently have posted mostly public relations messages the researchers also analysed the policy implications of these trends in posting messages a study conducted by sadulski states that twitter and facebook are frequently used by police departments to inform the public about crime incidents the study also informs that police department and other law enforcement agencies can improve community trust through transparency in communication with citizens the police departments use facebook and or twitter for informing the public about progress in case investigations according to the law enforcement use of social media survey law enforcement agencies use social media for a wide variety of purposes the survey results show that 91 percent of enforcement agencies use social media for notifying the people about safety concerns 89 percent use social media for community outreach and engagement with citizens and 86 percent use social media for public relations and managing reputation unlike the developed countries those have utilized the advantage of social media in increasing the trust and transparency of governments the governments in arab countries use social media mainly for news broadcasting and updating information as per the reported information from the omani national center for statistics and information almost 50 percent of the public uses social media regularly in oman the report also states that people with higher educational qualifications use social media more frequently than people with lower education levels according to the report even though the information technology authority oman has been promoting egovernment and eservices through digital oman strategy the use of social media by omani governmental departments remains unregulated research methodology this study uses the case study approach that involves content analysis of the facebook usage of the royal oman police sultanate of oman this approach is suitable as it explores the understanding of a complex and contemporary social phenomena data collection and coding this study uses the manual data collection of facebook content a web content analysis is used to explore the facebook posts for the period 1 st january 2019 to 11 th june 2019 this period is chosen to investigate the communication by the rop during the year that includes the month of ramadan during the holy month of ramadan muslims abstain from eating and drinking from dusk till dawn sultanate of oman is one of the arab countries that has mandated reduced working hours for certain categories of employees the period of study makes it unique as the activities are different for the citizens residents and tourists in comparison to other times of the year the steps observed for investigating the posts are illustrated as follows 1 identification of the official facebook page of rop 2 the capture of the facebook posts in the period 1 st january to 11 th june 2019 3 codes being assigned to the posts based on the content and media type 4 exploration of the engagement rate of the posts 5 analysis of the post types purpose and engagement rate in line with the prior literature netvizz service is being used to collect data from the facebook page netvizz is a facebook application that can archive the page activity by delimiting it based on the number of posts or a time interval this research uses the latter approach to cover the specified timeframe as identified above the page consisted of 43 posts by the rop 37 comments and 738 reactions the data was collected on 13 th june 2019 the research followed the approach advised by miles and huberman to use a first list of codes generated by the extant literature the first list of codes is used before reading the actual data and is modified and expanded based on content analysis the coding took place using seventeen classifications that included crime information law enforcement asking for tips crime prevention safety advice community interaction community events traffic updates agencyrelated information recruitment other government services information sharing holiday greetings nonpolice related advertising and road conditions the data coding and analysis were performed using three steps step 1 involved coding by the first author using the first list of codes and any subsequent inductive modification step 2 involved coding by a second coauthor and also two graduate students not affiliated with the study to ensure the reliability of the coding process step 3 as the final analysis led to clarification of category names a cohens kappa interrater reliability score of 80 percent was found for the coauthors results for the categorization this reflects a substantial agreement between the two coders and is also consistent with the findings of williams et al the framework of bonsón and ratkai was adopted to investigate the stakeholder engagement on the rops facebook page the framework is evaluated using three metrics that reflect popularity commitment and virality all three metrics are aggregated to calculate the overall engagement score the metric components are discussed in table 1 the findings of rop facebook posts collected from 1 st january to 11 th june 2019 are presented in table 2 the facebook page has a total of 29558 followers as of 11 th june 2019 a total of 185 posts are found in this period and based on content analysis these were classified various categories a total of eighteen categories were identified to capture the information posted on the facebook page the highest number of posts were made by the rop under the safety advice category that accounts for 39 percent this suggested that rop is using facebook with a community orientation tactic and disseminate related information this is an interesting finding in comparison to the study by williams et al that suggested its two most common categories were traffic and accidents table 2 highlights that the second most important category of posts was related to rop awareness sessions for schools which accounted for 14 percent also a cumulative of 28 percent is assigned to all awareness session categories that reflect that rop is continuously involved with various sections of the community to educate them table 1 stakeholder engagement metrics for facebook the posts also actively gave information on law enforcement and agencyrelated information on average there were at least 34 posts per month which almost accounts for one post per day consistent with the findings of prior studies the rop tended to have no postings on information that was not related to the police unless it was to do with safety advice which was driven on religious account the safety advice posts were highest during the month of ramadan the post included a verse from the quran that advocated safe driving practices this strategy by the police was being adopted to reduce the number of accidents in the month of ramadan as fatigue is attributed during fasting and it was one of the main reasons for fatal accidents the safety advice posts also advocated child safety belts car maintenance checks tips on driving at night avoiding phones while driving and tips on driving during rainfall the school university and other institution awareness posts communicated the awareness sessions conducted by the rop to propagate traffic safety law enforcement category posts included information on the penalties imposed for wrongly overtaking rash driving speed limits intentionally risking lives by crossing flooded valleys and allowable vehicle load the agencyrelated information included information on their work timings holidays participation in events and meetings the rop posts also covered diversions on the roads and traffic updates in various other categories however at a lesser frequency crime information category did not have many posts considering that it is one of the first job priority of the rop the avoidance of posts on crimerelated information may be due to the sensitivity associated with it and a strategy to avoid creating a bad image it might also be a source of unrest and the possibility of creating fake news in the future this is consistent with the approach followed by the police in the usa on their social media as reported in by williams et al citizens interaction on rop facebook social media is a ubiquitous tool that allows its users to interact with one another in the virtual world the rops facebook page is also a tool for the agency to allow community interactions related to their posts a follower gets the opportunity to like the posted information share with other users or comment on the posted information table 3 presents the citizen interaction on the rop facebook for the period 1st jan to 11th june 2019 the likes shares and comments were classified for each of the eighteen categories there were a total of 2506 likes 136 shares and 127 comments the safety advice posts received the highest number of likes this is also reflective of the fact that the highest number of posts were for safety advice the law enforcement category received the next highest record of likes this was followed by school awareness agency related information and other agencyrelated awareness information the findings of this study are partially consistent with dai et al which also reported the highest number of likes for agencyrelated information and law enforcement categories table 3 reflects the highest number of shares were again for the safety advice followed by the law enforcement categories the remaining shares were negligible for the posts the posts also garnered comments which were in the order of safety advice law enforcement and crime information in comparison to the number of followers the citizen engagement has not been too strong with the posts on the rops facebook page the overall engagement levels of the citizens with the rops facebook post is represented in table 4 the average number of likes per post per 1000 fans score is 046 which reflects on weak popularity the average number of comments per post per 1000 fans is 002 considering that very few comments were made in the period of study whereas the average number of shares per post per 1000 fans was 002 the overall engagement level was only at 051 this indicator is useful to motivate the rop in encouraging more citizen engagement types of facebook posts table 5 presents the statistics on the type of posts found on rop facebook page photos were used extensively for the posts and it accounted for a total of 96 percent of the 185 posts found over the investigated period there were only about six videos and two links posted on facebook conclusion and recommendations this research contributes to the scarce literature on how police are using social media strategies and interacting with the public this study uses content analysis of rops facebook page the findings suggest that there are 18 categories under which facebook posts can be classified rop is active in posting information daily by using more photos than links or videos which is consistent with the recommendation offered by he et al the content analysis reflects that the posts were heavy titled towards the wellbeing of the community therefore there was a high percentage of posts that advocated safety the rop has also been active in community awareness programmes that catered to the schools universities and other organisations citizens engagement in terms of was limited to the posts however in comparison to its followers the engagement is considered weak currently the rop facebook posts can be termed as a push strategy as described by mergel the practical implications of this research suggest that rop can do better in improving its interaction with the community on social media by reaching out to more people the messages on public safety can be more effective in line with the recommendation by dai et al the rop needs to adopt a more problemsolving approach to increase community engagement this study has certain limitations the research is restricted for a few months and can be extended to cover a longer period the investigation is limited to the facebook account only and needs to also consider other social media such as rops twitter account the use of social media by the rop and other government agency are set to promote omans commitment to building smart cities and thus it requires that strategies are set to encourage eparticipation by the community

royal oman police rop began its virtual engagement with the citizens by enforcing its presence in social media such as facebook and twitter the purpose of this paper is to explore the type of information shared through facebook by the royal oman police and analyse the extent of citizen engagement through the rops facebook page this study collected data from 1 st january 2019 to 11 th june 2019 from the rops facebook account and supported through content analysis and statistical tests the findings reflect that rop had posts under 18 categories and the highest number of posts were on safety advice for the citizens followed by the awareness sessions organized for schools universities and other institutions the citizens interacted virtually on the facebook page by demonstrating likes shares and comments for the posts this study contributes to providing detailed insights on the type of information exchanged between rop and citizens the results of this study can be used for developing strategies in increasing citizen engagement as part of omans development plan of building smart cities

introduction the womens march in january 2018 was a worldwide protest to advocate legislation and policies regarding human rights and other issues including womens rights immigration reform healthcare reform racial equality freedom of religion and workers rights most of the rallies were aimed at donald trump largely due to statements he had made and positions that he had taken which were regarded as racist antiwomen or otherwise offensive to vent this anger many protest posters featured offensive jokes at the expense of trumps body mocking his comb over hairstyle his small hands his orange taint and so on such posters were often spotted at protests and shared widely online much to the amusement of the movements supporters while some people suggest that such charged political online humor can mobilize people and serve as a prepolitical gateway to future civic engagement there is also concern that it remains inefficient or even antithetical to meaningful sociopolitical change thus in the context of social media offensive political humor advances the socalled echo chambers where people only speak to likeminded individuals others argue that routine online searches for pleasure and entertainment entrap s us within the circuits of neoliberal communicative capitalisma process that continuously replaces political action with political feeling forever turning activity into passivity by drawing on the literature that explores and adapts bakhtins concept of the carnivalesque this article argues for a more nuanced understanding of offensive political humor as a flexible affective resource that is complexly intertwined with social change based on our analysis of 400 social media posts from instagram and twitter we argue that the online circulation of humorous protest posters creates forms of polysemic undertow that both contest and confirm normative assumptions about white masculinity and the political public sphere for this reason the meanings of these protest posters are not so coherent as to reflect either transgression or backlash politics exclusively rather the contradictory nature of offensive humor holds these circulating online images in tension thereby enabling what reilly and boler call prepolitizationa novel form of civic participation that can mobilize citizens who would not otherwise explicitly participate in civic life thereby creating new political sensibilities and desires we argue that the womens march provides unique insight into how offensive humor can function as a mobilizing force without glossing over its limitations in the realm of civic engagement offending those in power does not replace rational political debate nonetheless it can be an effective tool for drawing attention to situations of injustice for binding people together against formal power structures of authority and for carving out a space for empowering feelings of countercontrol which are necessary ingredients for social and political change in this sense this article contributes to the work of contemporary scholars of social movements and media who rethink traditional understandings of politics and participatory democracy literature review offense online humor and mediated protest the cheerful vulgarity of the powerless is used as a weapon against the pretence and hypocrisy of the powerful giving and taking offense on social networking sites is a contested topic while some celebrate the interactive architecture of social media as a democratizing and diversifying force others warn that these seemingly antihierarchical affordances invite offensive behavior such as cyberbullying or the production and circulation of offensive material that more traditional media outlets would have censored or regulated thus social media and other user content hosting companies are increasingly under the ethical and legal responsibility to make their network a positive and safe space where offense is avoided offense however is an affectively charged slippery subject that escapes clear definitions although offensive material is in principle distinguished from that which is illegal it remains difficult to define the boundaries in a robust and consensual fashion generally media content is judged to be offensive when it is too graphic or explicit in style and content intrusive images of suffering or racist classist or sexist depictions that contribute to stereotyping or bias and inaccuracy in the media are often reported as offending audiences in public discussions offensive media content is often equated with harmful content this equation is based on simplistic theories of media effects that conceive offense as a monolithic bad thing that can be pinned to certain media representations and eliminated through censorship such understandings fail to see the contextual relational nature of offense as well as the emotional messiness of offense offense is far from a monolithic clearcut emotion but contains a wide range of contradictory feelings and emotions such as pain anger and frustration alongside joy and titillation furthermore these approaches overlook the potential for the socalled negative emotions to push us into new critical directions as it has long been theorized by feminist scholars such as audre lorde sara ahmed andsianne ngai taking offense and getting angry is here often conceived as an affective mobilizing force for social and political transformation offensive joking in particular has been theorized as offering temporary relief from oppressive social norms and conventions pickering and littlewood argue that what remains crucial in this context is whether the humor kicks socially upwards or downwards whether comic aggression is directed at those who are in positions of power and authority or at those who are relatively powerless and subordinated such an understanding implies that offense is not in and of itself wrong and that depending on its direction it can have a positive or negative impact the affirmative and liberating possibilities of grotesque offensive humorous transgressions are often associated with the carnivalesque a general mood of liberation mocking of hierarchies and temporary suspension of rules for mikhail bakhtin the popular tradition of carnival has the potential to suspend social hierarchies through mostly bodily and bawdy humor which finds expression in the celebration of bodily grotesqueness and excessiveness fooling around and profanities these markers of indecorum are strictly policed during normal times but during carnival they can be animated and enable comic reversals for instance a jester might be crowned in place of a king and as a result the authoritative voice of the dominant discourse momentarily loses its privilege bakhtinian carnival theory has been criticized for its neglect of carnival violence against women and jews its failure to consider social relations of gender and its failure to deal with the consistence of dominant culture we nevertheless see bakhtins concept as a valuable starting point and draw on the productive ways in which it has been extended through the work of stallybrass and white and rowe first stallybrass and white argue that the carnivalesque should be situated within a wider pattern of transgression in order to move beyond bakhtins problematic folkloric approach to a political anthropology of binary extremism in class society they maintain that this broader focus on transgressive symbolic domains enables us not only to examine cultural hierarchies and binary social structures that underlie the carnival but also to operate far beyond the strict confines of popular festivities second kathleen rowe builds on mary russos work on the female grotesque to adapt bakhtins concept for thinking about female unruliness as rowe argues the transgressive figure of the unruly woman can help sanction political disobedience but is also associated with dirt and pollution she threatens the conceptual categories which organize our lives and this liminality evokes intense contradictory feelings her ambivalence which is the source of her oppositional power is usually contained within the licence accorded to the comic and the carnivalesque but not always our study then draws on these two key extensions of bakhtins work to examine how transgression spills over the confines of the temporary local contexts of the womens march through the online circulation of offensive protest humor here the carnivalesque functions as a malleable resource that can provide spaces for disruption and rebellion without glossing over cultural differences however while some scholars in critical humor studies have argued that offensive humor can operate as a powerful social corrective as well as a strategic and effective commentator on political issues others highlight that its unitinganddividing function draws a sharp boundary between those who laugh and those who are not in on the joke from such a perspective bawdy political humor that predominantly works by deriding and offending those in power is merely further convincing those who agree with it while alienating those who dont agree thus the satirical mission to make laugh not war only serves to polemicise the gap between those who agree and disagree with its political message suggesting its transformative worth is limited this socalled echo chamber phenomenon is often discussed in the context of social media critics argue that rather than enabling debate and deliberative compromise essential for creating political change our social media practices of posting liking and sharing along with algorithms generate filter bubbles and echo chambers with restrictive partisan sentiments where only likeminded people speak to each other nevertheless bivens and cole maintain that the prevalence of social media use like instagram facebook and twitter provides a method through which individuals can push back against the legislative structures in the united states they illustrate in their work on grotesque protest that social media provides individuals with opportunities to resist attempts to control bodies and to reinsert individuals voices in political discourse that is aimed to exclude those bodies in a similar vein tufekci and wilson found that social media use greatly increased the odds of being involved in a protest and that it represent s crosscutting networking mechanisms in a protest ecology thus although commonly understood as like minds speaking to like minds social media can also be seen to diversify protest networks and encourage debate methodology this article builds on our previous study which examined the social media circulation of images from the 2017 womens march one of the key themes we identified was the prevalence of images featuring placards that mocked trumps body we want to explore this tendency further within the context of the 2018 womens march to consider how offensive humor might function as an affective protest strategy we collected our sample by using the womensmarch2018 and womensmarchnyc hashtags to search for public posts of images that were shared on instagram and twitter between january 20 and 21 2018 we chose these two platforms because they are associated with different affordances and cultures twitter is reportedly used by 24 of the us adults and although it facilitates the sharing of imagery it is primarily associated with text content and has often been used for political communication and activism instagram is reportedly used by 35 of the us adults this platform foregrounds imagery and is often considered a feminized online space that is preoccupied with celebrity beauty and style we are interested in images of protest signs as a form of visual and affective political communication and about how protesters and social media users can grab our attention and encourage circulation through the use of offensive humor and spectacle our data collection followed a threestep process on the day of the march we followed the womensmarch2018 and womensmarchnyc hashtags on twitter and instagram and observed recurring images of individuals and groups of protesters holding protest signs many of which were designed to offend donald trump through bawdy and bodily humor this trend confirmed that offensive humor was once again a prevalent protest strategy on january 22 we then used the platform tools to collect the 200 top posts from each of the two platforms for thematic analysis we identified three recurring themes the ridicule of trumps body the association of trump with excrement and namecalling and violence targeting trump finally we selected one illustrative post from each of these three themes for close analysis we include screengrabs of the images here but have removed social media usernames and profile pictures the threecase study images were all widely shared on social media this approach facilitates reflection on how the reiteration and circulation of images invite polysemic undertow that can unsettle trumps intended personae as serious public official and thereby animate political engagement and social change having outlined our theoretical framework and our methodological approach we will now move on to our threepart analysis we begin by exploring the tendency to mock trumps skin color orange skin white masculinity and carnivalesque countercontrol trumps body is often the target of ridicule his orange skin tone has inspired large numbers of internet memes where the president is mocked as agent orange or cheeto trump equally popular targets are his supposedly tiny hands merchandise includes tshirts that read keep your tiny hands off my rights and coffee cups with extra small handles just two of the many physical and digital artifacts through which trumps opponents publicly ridicule his masculinity here we focus on the recurring degradation of trump as failed white masculinity and use bakhtins concept of the carnivalesque to consider the ambiguous workings of this offensive humor in political protest the above poster draws attention to the deferred action for childhood arrivals act that the trump administration has tried to rescind since september 2017 daca an obamaera protection scheme allows those who entered the united states illegally as children to receive a renewable 2year period of deferred action from deportation and to be eligible for a work permit the scheme is now closed to new entrants and puts 800000 registered recipients in danger of deportation trumps attack on daca offended not only many dreamers but also protesters at the womens march thus numerous protest posters in the 2018 march focused on daca and the above placard is one such example under the pink headline daca daca tiny cocka we see a cartoonlike drawing of trump he is naked showing off his orange skin and wearing only a blue jacket and a red tie his signature comb over hairdo is exaggerated and his arms are wide open the lines around his small hands make it look as if he is flashing the onlooker showing off his small penis or his tiny cocka as the poster reads the poster criticizes the imminent changes in daca policy and aims to provoke laughter by offending and shaming trumps body through the use of carnivalesque humor drawing on bakhtins work we employ the concept of the carnivalesque to think about vulgar grotesque bodily humor that is commonly intended or experienced as offensive and that is used to challenge privileged positions and reframe public and political discourse the rhyme daca daca tiny cocka mimics the ways in which small children try to offend each other in the playground it relies on the shared understanding that there is a comic incongruity between our expectations for presidential behavior and the childish and unconsidered ways in which trump presents himself publicly and politically trumps childlike behaviour violates dominant assumptions about the rational male agent in the political public sphere and it can be argued that it is exactly these kinds of transgressions that trumps opponents experience as offensive and which in turn mobilize them to protest and give offense back the poster also makes reference to the running joke of trumps tiny hands and the popular myth that a mans hand size is indicative of his penis size small hands here suggest a lack of masculinity and a lack of gendered attributes such as strength and leadership the link between hands and gender performance is underlined by janice winships influential work about the relationship between the positioning of hands and sexuality in advertising according to her analysis male and female hands are part of an entire message system of representation signifying appropriate gender behavior in other words hands allow us to tap into familiar ideologies of masculinity and femininity because the big and strong hand of the leader is naturally the hand of a man whereas the small and delicate hand of the homemaker and caretaker is naturally the hand of a woman by repeatedly mocking trump for his small hands opponents do not only offend his masculinity on a personal level but they undermine his presidency by insinuating that he is not a real man he is not a leader and therefore not someone we should fear trust or follow furthermore the poster constructs the naked overly tanned trump as the butt of the joke because orange skin is commonly perceived as a funny tanning accident rather than a desired skin hue as graefer argues orange skin invites ridicule and offense giving as it symbolizes excessiveness lack of taste and the pollution of proper whiteness regarded as ugly and tasteless this skin tone stands in stark contrast to the white hue that the proper white middleclass subject should embody the white middleclass subject is controlled and rational in its desire to darken its skin making tanning in this case an acceptable and positive habit orange skin on the other hand is taken as visible evidence of a subjects inner outofcontrolness and illustrates that trump does not have the supposedly innate cultural tastes and decorum that wealthy white people should have his highly visible overand misuse of tanning products also marks him as vain and overly concerned with his appearance characteristics that are commonly associated with femininity rather than masculinity the daca daca protest poster then uses offensive bodily humor to produce trump as a figure of ridicule but this kind of humor is riddled with both transgressive and conservative tendencies one could for instance argue that offensive humor works here to undermine the powerful white man via emasculation yet it ironically also works to restore dominant assumptions of an idealized white masculinity that is free from feminine traces such as tiny hands or vanity and immaculately white rather than orange furthermore the vulgar ridiculing of trumps body can also be interpreted as conservative because women have historically been silenced and policed through these same mechanisms of body shaming however we should not reject offensive humor as a tool in mediated social protest altogether rather we suggest that this online sharing of offensive humor aimed at the powerful can be seen as a contemporary expression of bakhtins carnivalesque despite the fact that online practices in the context of instagram and twitter defy the circumscribed spatial and temporal specificity of carnival it still provides a useful tool for understanding the transformative potential of offensive vulgar humor because it illustrates how the transgression of social boundaries can be a productive act of resistance this potential is grounded in the collective experience of transgression carnival is not a spectacle seen by people they live in it and everyone participates because its very idea embraces all the people it has a universal spirit it is a special condition of the entire world of the worlds revival and renewal in which all take part notwithstanding the inherent problems of bakhtins celebratory universalism it can be argued that posting offensive placards against trump generates new forms of collectivity because it serves as a public act of stance taking where people align with others through the stances they take towards a particular idea object or person offending trump through humor works then not only to vent the protesters anger and frustration but to create a sense of superiority and belonging through the affective experience of shared laughter laughing at faulty behaviour and bodies can also reinforce unity among group members as a feeling of superiority over those being ridiculed can coexist with a feeling of belonging these acts of online offense giving then are performances designed to appeal to likeminded others thereby aligning bodies with antiracist counterpolitics and drawing boundaries between us and them some of the comments below the online image highlight this uniting power of offensive humor expressions such as love it or the powerful arm emoji illustrate that sharing great signs beyond the marches enables new forms of collectivity temporary zones in which feminists are able to take a stance and make their anger visible while enjoying themselves in the process the glee and pleasure that users experienced when engaging with these offensive online images can be seen as producing carnivalesque moments of countercontrol where activists no longer feel helpless in the face of patriarchy and racism but where they feel powerful and impactful our premise then is that offensive humor as communicated through these images is affective and as such drives online exchanges and attaches people to particular platforms threads or groups a direct tangible and measurable effect of activism might not be easy to locate yet it would be wrong to ignore results like the production of feeling which we argue is necessary for social change filth cultural transgression and immigrant bodies we now turn to the second recurring theme in the circulated images from the 2018 womens march which was the degradation of trump through the semiotic resource of filth combining the concept of the carnivalesque with stallybrass and whites notion of cultural transgression we examine a sign shared on twitter and consider how it responded to trumps offensive behavior by shifting the shame and otherness he inscribes on immigrant bodies onto the president himself this sign illustrates the recurring association between trump and feces the image was posted by a private twitter user who photographed and shared his favorite signs from the womens march in new york city at the time of our data collection the tweet had been shared 625 times favorited 17k times and had received 70 comments the sign depicts trumps face as a bottom that emits a brown puddle across his yellow hair the text reads f ing moron while text within the brown puddle reads liar the discursive association between trump and feces work in two key ways here first the sign is a critique of trumps use of the term shithole countries to refer to the nations of origin of immigrants he considered undesirable second the sign uses comic inversion and grotesque imagery to construct trump as abject we explore how these strategies work together and reflect on how they invite onlookers to feel both offense and pleasure trumps shithole remarks were made in a meeting with the us senators on the january 11 2018 and received extensive international media coverage the president of senegal said he was shocked the government of botswana said the remarks were irresponsible reprehensible and racist while an african group of ambassadors at the united nations described them as outrageous racist and xenophobic the remarks then were widely constructed as offensive the protest sign shifts the shithole label from these nations onto trump himself repositioning the offender as the target of offense here trump becomes the shithole reduced to an abject body part and dismissed as a moron as in the grotesque imagery described by bakhtin we see a decentered body that is ruptured by bulges and orifices the closeup image fills the entire sign the buttocks are comically round and disproportionately large the anus protrudes and leaks filth the vulgarity of the picture is echoed by the crudeness of the written language trumps debased body contaminates the world with its shit such rhetorical strategies work to mock destabilize and publicize private parts and activities we are socialized to hide situated within protest culture the sign employed this carnivalesque language and imagery to contribute an affective critique of trump to public sphere debates around his presidency by shifting the shithole label from developing nations onto trump himself it reverted the cultural hierarchy of trumps racist immigration policy simultaneously articulating offense at his racism and giving back offense by degrading and insulting the president the reach of the sign was extended beyond the moment and geographical context of the march through the circulation of the image on social media the twitter user who shared it used the platforms comment function to share a number of other photographs of protest signs while other users responded by expressing excitement laughter calling for trump to be impeached and sharing photographs of other signs that resonated with them we can locate these photographed protest signs within a wider symbolic practice that degrades trump by associating him with the lower stratum of the body trumps buttocks and feces were recurring themes in circulating images from the 2018 womens march while other social media users have also adopted the hashtags peeotus and scrotus to avoid mentioning trumps name and title thereby denying the legitimacy of his presidency this refusal indicates that he is seen as a transgressive figure he is both president and other both insider and outsider drawing on stallybrass and white we argue that the widespread use of grotesque representations signals a dual sense of disgust and fascination with trump his offensive behavior represents base impulses that should have been repressed from the rational public sphere a notion that is also evident in hillary clintons labeling of some trump supporters as deplorables with racist sexist homophobic xenophobic islamaphobic views trumpaspresident is a hybrid of high and low discourse a transgression of established cultural boundaries that creates a powerful symbolic dissonance the recurring use of filth as a semiotic resource in protest signs can be seen as an attempt to reaffirm the classification of him as other suggesting the coexistence of a desire to degrade the high and mighty and a paradoxical reverence for tradition and hierarchy through this mingling of transgressive and conservative tendencies the target of laughter and offense is not the presidency as institution but trump as an illegitimate president challenging the universalism that undermines bakhtins work on the carnival stallybrass and white were interested in examining the cultural transgressions of class binaries our study in turn underscores that class structures intersect with those of race nationality and gender in each case discourses about the body have a privileged role for transcoding between different levels and sectors of social and psychic reality are effected through the intensifying grid of the body trump attempts to classify legislate and control the bodies of immigrants by associating them with excrement while protesters use the same semiotic resource to degrade his body and delegitimize his presidency as stallybrass and white note somatic symbolsare ultimate elements of social classification itself thorogood suggests that crude ambiguous humor can help fight disengagement from formal politics by reducing politics to the excretions of the human body protesters negotiate and challenge geopolitical discourse by connecting contemporary debates to our shared bodily vulnerability as grantsmith writes we all shit and so defecation can be mobilized to demonstrate our common humanity and animality however we would argue that this sign does not work to position trump within a human collective but instead positions him as a repulsive other its strategy resembles that of the daca daca sign as it employs the playground rhetoric of no youre the shithole however drawing on bivens and cole we nonetheless argue that grotesque protest can still work as an effective tool for opening space transgressing boundaries and demanding attention the excess of protest signs like this one invites us to take gleeful pleasure in offending trump reminding him that he is out of place and illegitimate and demonstrating resistance to his attempts to control bodies in this way the grotesque is mobilized to strategically reframe public and political discourse about the body through street protests and on social media across the protest signs focusing on orange trump and trumpasfilth his white male heterosexual and wealthy body is subjected to degrading strategies that have long been used to oppress women and minorities it here becomes violently appropriated as a site of resistance used to articulate feelings of offense but also to cause offense this strategy valorizes anger as a political emotion and invites us to take pleasure in voicing that anger without concern for the decorum imposed on women by patriarchal discourse the last part of our analysis will focus in on this relationship between gender anger and offensive humor the retaliation of the unruly in this final theme of circulated protest signs from the 2018 womens march we examine how female protestors used the characteristics of unruliness such as offense to appropriate trump as the target of carnivalesque humor to illustrate this trend we conduct a close analysis of the sign saying little bitch you cant fuck with me which demonstrates the ambiguity that was evident in some of the offensive trump placards this sign mixes humor politics and popular culture to promote the embrace of unruly feminism and to protest an epidemic culture of sexual harassment and the policing of womens bodies the sign features a quote from music artist cardi bs song bodak yellow a diss track that skewers those who have mocked bs rise to fame from bronx stripper to music history maker in this track b uses the pejorative term little bitch to lambast those who criticize her achievements but in the context of the womens march the term is used to insult trumps behavior and body according to the urban dictionary little bitch is a whiny petty person willing to stab people in the back thus the signs reappropriation of the popular term connects these associations with trumps actions and behavior such as his claim that no politician in history has been treated worse than him his childish exchanges with north korean leader king jong un and the republican partys cutting of medicaid which trumps workingclass supporters are reliant on the gendered nature of the term bitch further attacks trumps inadequate masculinity emphasized by the word little and its connection to the long running joke about his small hands and penis the sign combines this insult with a threat through the phrase you cant fuck with me and the image of trumps head pinned down by a pair of black highheeled feet together they act as a warning that the womens march activists are not to be messed with this threat is supported by cardi bs own clarification of her lyrics i can be humble butif you push me i can really stamp on your head while the song incites violent behavior its meaning within a humorous placard is much more ambiguous as lockyer and pickering argue the line between makebelieve and reality is not clear in a joking context this is because humor can be a form of exaggeration but it can also be used to express real beliefs thus while some may view the signs message as threatening and offensive others may defend it as just a joke or benign violation humor that appears immoral but is essentially harmless because the words are just borrowed from a song and are not the actual words of the protestors this image garnered many affective responses because it was posted by cardi b and circulated to her 17 million instagram followers bs cultural and symbolic capital afforded maximum exposure to the protest sign and this particular womens march message according to d s meyer one of the key benefits of celebrityendorsed protest is the increased mobilization of support and publicity similarly scholars have argued that music has the capacity to mobilize political action and collective identity such ideas are applicable to cardi bs instagram post as it acquired over 1 million likes and nearly 13000 comments the comments were varied some expressed support for trump arguing that he was creating a fuck ton of jobs while some expressed amusement through the crying laughing emoji however the dominant response expressed support for the signs message and bs accompanying comment about the disrespectful treatment of women yaaas supported by the hands up in agreement emoji this is everything and yas girl pussy power the signs divisive humor perhaps resonated with instagram users because it reflects a shift in feminist tone since the 2017 womens march the first event launched as a reaction to trumps misogynistic behavior and the gops attempts to cut female health care but since then we have been confronted with the weinstein scandal and a myriad of sexual harassment cases highlighted by the metoo movement and timesup initiative the shocking extent of abuse identified across different industries has accelerated and widened the objectives of the current womens movement accompanied by widespread expressions of anger and the adoption of a combative tone that tone is evident in this sign where it takes the form of rebellious humor that simultaneously mocks the powerful and creates connective laughter among the unruly women of the march unruly women do not conform to traditional norms of femininity that emphasize womens passivity compliance and agreeability instead their unruliness is characterized by aggression humor and their will to offend and challenge the patriarchal status quo once again these characteristics draw our attention to bakhtins work on the carnivalesque as a form of grotesque resistance for bakhtin the female body signifies the grotesque body because woman is related to the material bodily lower stratum through menstruation pregnancy and childbirth this is a problematic label that highlights the limitations associated with bakhtins claims that the carnival was a liberating event that embraced all people the female association with the lower bodily stratum connotes shame and filth which works in contrast to the cerebral upper body that is associated with higher functions of thought and emotion it suggests that the female body was a victim of the carnivals subversive comedy rather than an instigator of it this argument resonates with the work of other scholars who argue that women were regularly subjected to physical and verbal abuse at the carnival the characteristics of unruliness and the grotesque appear to be grounded in misogyny as they have been used to attack women who do not conform to traditional standards of femininity however rowe argues that transgressing this line of acceptability can be a source of power for women especially when the characteristics or unruliness are recoded and reframed to expose what they conceal the oppression of women through the expectation that we stay silent compliant and do not make a spectacle of ourselves the women of the march use the semiotic resources of unruliness as part of affective strategies to claim visibility voice and agency and to reposition trump as the grotesque body consequently the male body that stands accused of mocking attacking and attempting to police the female body becomes the protestors symbolic target of collective angry and offensive humor while trump may be the signs chief target its humorous political message can also be read as an attack on all those who reinforce the patriarchal status quo its circulation on instagram might be particularly valuable then because of the sites preoccupation with conventional beauty and body standards however while instagram may bolster traditional notions of femininity its audience of 800 million active users and its visualled content make it an attractive platform to challenge these conventions via online activism deluca and peeples stress the power of visual communication in their theorization of the public screen their work attempts to expand our understanding of political debate beyond the emphasis on facetoface rational dialogue of the public sphere by arguing that the use of spectacle across imageled media platforms can expand dialogue and make political issues more accessible consequently cardi bs post indicates that the circulation of feminist content within the feminized sphere of instagram might have the potential to attract new supporters to the womens march movement and create a space for users to deliberate its messages beyond the temporal and spatial confinements of the marches themselves conclusion this article has unpacked some of the ways in which protest signs in the 2018 womens march used offensive humor to challenge trump and reflected on how they were recontextualized and circulated on twitter and instagram through the close analysis of three social media posts we have explored how trump was dismissed as an improper white masculine subject how he was degraded through an association with feces and the lower bodily stratum and finally how he was repositioned as the infantile feminized victim of unruly women emphasizing the ambiguity of offensive humor we identified a recurring tension not only between its uniting and dividing functions but also between conservative and radical tendencies protesters and social media users attacked trumps patriarchal and racist policies and practices through the use of gendered and raced insults that simultaneously reinforced established notions of ideal white masculinity this duality worked in two key ways first protesters identified and punished trump as a transgressive other while redrawing the boundaries of appropriate white masculinity this discourse articulated offense at his transgressions of established norms for public sphere debate and presidential behavior while simultaneously giving offense back through the spectacle of unruly carnivalesque protest second participants repeatedly appropriated aggressive humorous strategies of offense giving that have been associated with masculine cultures and used to oppress female and nonwhite bodies here they reversed that hierarchy by repositioning trump as the abject body malformed leaking and prostrate we argue that the use of offensive humor in feminist protest in online and offline spaces can open up new opportunities for unruly dialogue and civic participation online networks are central to this practice as humorous content grabs our attention and is shared through followers and hashtags this is spreadable media content which is privileged by popular platforms because it is entertaining and drives online traffic as such it floats to the top among representations of the 2018 womens march and becomes part of the popular memory of the event this pattern is evident in the frequent publication of news articles listing the funniest protest signs from the march which promotes the value of humor and spectacle in protest communication the signs at the protests and in their new online contexts offer the pleasures of creative transgressive humor and offense giving this invites us to see the world differently through the carnivalesque lens of affective intensities reversed hierarchies and a grotesque aesthetic thus in addition to laughter offensive humor provides an effective intervention in the dominant regime by allowing unheard voices to be heard and to respond to the issues they face but offensive humor as spectacle is not a tactic solely used by liberal protestors it has also been used by rightwing tea party activists to draw attention to americas economic issues interestingly bar one study on the political content of tea party protest signs there is a deficit of research on conservative movements and humorous collective action strategies therefore we believe that this would make a worthy topic of further research or comparative analysis of oppositional political movements returning to the subject of the womens march we argue that offensive humor is a worthy political tool that readdresses traditional understandings of protest strategy in an attempt to publicize neglected political issues this is because its attention grabbing power might introduce citizens who do not see themselves as political to relevant issues thereby preparing them for civic participation and political engagement furthermore offensive humor appeals to likeminded others thereby aligning bodies with feminist and antiracist counter politics in communities of resistance that include and transcend the geographically and temporally bound march events this process can facilitate new insight and energize participants to continue their feminist and antiracist work in other spaces

at the womens march in january 2018 many protest posters featured offensive jokes at the expense of trumps body and behavior such posters were shared widely online much to the amusement of the movements supporters through a close analysis of posts on instagram and twitter we explore the role of vulgar and offensive humor in mediated social protest by highlighting its radical and conservative tendencies we demonstrate how we can understand these practices of offensive humor as a contemporary expression of the carnivalesque that is complexly intertwined with social change

introduction over the last decade the possibilities and pressures that cities are facing related to complex challenges like climate change have surged the global migration of people into cities has continued and organizations like the international panel on climate change have begun emphasizing the vital role of substate actors in climate adaptation and mitigation in actions related to landuse planning infrastructure transportation housing community development and others 1 national and international networkserving and advocacy organizations working on climate change and other sustainability issues at the municipal level have emerged for example c40 the global covenant of mayors the carbon neutral cities alliance and the urban sustainability directors network political and civil servant leadership from cities is a powerful force for change on the world stage with growing influence on other levels of government business civil society and the public imagination in farreaching ways while city leadership on climaterelated work continues to strengthen it is often treated as a technical engineering land use and financial challenge and the related systemic challenge of ongoing and growing inequity tends to be un addressed in urban climate plans and policies 2 3 4 while cities work to mitigate and adapt to a changing climate the very same people lands and waters who have been systemically excluded oppressed and exploited by the dominant structures and processes of government continue to be left out 5 6 7 this is a compelling impetus for transformative innovation so that in their eagerness to act on climate cities do not recreate and perpetuate problematic practices from the pastpresent that result in inequity and oppression 89 there is an opportunity to reimagine the policymaking and planning processes of local government to ensure that climaterelated concerns are considered in an integrated way with equity justice reconciliation and decolonization work 1011 climate change issues have the same systemic root causes of colonialism capitalism white supremacy patriarchy ableism and cisheteronormativy and can and should be worked on together 12 13 14 the standard policymaking and planning processes used in local governments in many parts of the world and embedded in the new public management western colonial governance paradigms are being reinforced rather than being reimagined in many cases as governments work to innovate in response to complex challenges like climate change 15 16 17 18 19 20 21 this remains the case even as the suitability of these paradigms to respond to complex social and ecological justice challenges at the rate scale and depth required is being questioned with calls for transformation and innovation becoming louder and more urgent 22 23 24 the standard policy making cycle of agendasetting policy formulation decision making policy implementation and policy evaluation is deeply embedded into the thinking structures and processes of governments around the world this cycle offers practitioners a means to conceptually and practically guide an issue methodically through the policy process 25 and has been both described and critiqued for decades with academics seeking further nuance and complexity to the model and practitioners requiring a variety of process interventions that work in the real world on increasingly volatile uncertain complex and ambiguous challenges 26 similar to the standard policy making cycle urban planning is characterized by evidencebased rationality and objectivity established administrative routines rulebound bureaucratic procedures and significant emphasis on a planners ability to know what is good for people generally or the public interest 172728 while planning has evolved over decades to consciously seek to redistribute power through equity planning 29 and to better align with the goals of communities through radical planning planning processes often still involve the analysis of problems the setting of broad objectives the survey of available resources and the establishment of specific operating targets 28 as planning processes continue to impede innovation and adaptation to dynamic pressures planning must evolve to address the unpredictability of the complex challenges we face 27 for instance a pressing challenge for planning is reconciling its role in perpetuating the dispossession oppression and marginalization of indigenous peoples and communities and grappling with the reality that all planning in canadian cities happens on stolen indigenous lands 30 31 32 in decolonizing methodologies linda tuhiwai smith provides a working definition of decolonization which does not mean and has not meant a total rejection of all theory or research or western knowledge rather it is about centring our concerns and world views and then coming to know and understand theory and research from our own perspectives and purposes 33 central to decolonizing methodologies within the context of working to transform complex urban climate equity and decolonization challenges is recognizing the coexistence of distinct knowledge systems and how these distinct knowledge systems can work alongside each other in a good way 34 conventional systemsbased approaches have foundations in the scientific method that pursues knowledge in an analytical way while indigenous ways of knowing is about the pursuit of wisdom in action 35 and using the mind body emotion and spirit to make meaning of the world around us 36 importantly indigenous ways of knowing are innately tied to the land 3738 scholars and practitioners are applying decolonizing principles to their work and central to this process is the idea that change happens from people going inward within themselves 34 planning practice is starting to acknowledge this turn inwards as well and is recognizing that people are not disconnected from other living beings and that we must connect our present lives with nature 39 these principles are a departure from the rational and objective mindsets that planners and policymakers have been trained to use for decades concepts like justice equity and decolonization are not static singular with clear and agreed upon meanings they are contested and actively being worked out in institutions processes and everyday life 4041 and are expressed differently according to place context history and culture tuck and yang point out that settler colonialism and its decolonization implicates and unsettles everyone and argue that decolonization is only about land and indigenous life 42 in other words decolonization is not a metaphor for other things we want to do to improve our societies 42 this article pushes us to think critically about the word decolonization and what it means in planning and policy making practice tuck and yangs settler moves to innocence reveal attempts to reconcile settler guilt and complicity that do not require giving up land power or privilege we agree the central work of decolonization should be the return of land at the same time as planners and policymakers doing research entangled with practice we are motivated to find meaningful entry points to decolonization through practices that every planner and policymaker can enact in this research we take the perspective that settler colonialism is an ongoing structure and not an event 43 our guiding principle at least for now is that decolonization work is for all of us to do and so we are enacting it as practice and expressing these practices in multiple and embodied ways in the specific context of complex policy making and planning challenges that said decolonization work will look different for nonindigenous peoples than it does for indigenous peoples for bob joseph acts of decolonization restore indigenous worldviews restore culture and traditional ways and decolonization replaces western interpretations of history with indigenous perspectives of history 44 here we focus on policymaking and planning practice happening within settler colonial systems of local government and explore what and how we might learn and practice equity justice and decolonization foramong each other in the context of urban climate work the nature of planning and policymaking processes as they relate specifically to climate change mitigation and adaptation challenges are distinct and complex climate change research has rapidly expanded and evolved over the last decade with studies being undertaken in every discipline using diverse methodologies providing insights for every sector and in every part of the world the collective of researchers that forms the intergovernmental panel on climate change is capturing this vast field and then informing motivating and compelling responses from global actors through their working group reports and summaries for policy makers 45 with each report of the ipcc there is stronger consensus about the impacts extent and urgency of a changing climate promising pathways for action are becoming clearer and better evidenced and enabling conditions and barriers to action are descriptive and explicit the processes of activating and scaling robust global responses by elected leaders civil servants financial institutions businesses nonprofits in the short time frames to reduce the most significant impacts on our already changing world remains fraught and inconsistent there is much to gain and much to lose with unequal distribution of burdens and benefits there is an unreliable patchwork of countryand substate level policies plans targets and financing commitments with varying degrees of commitment and impact and very few enforceable accountability mechanisms in place this approach continues to leave those most vulnerable to a changing climate improperly resourced to act 46 the roles of substate actors including cities is becoming more visible in this recent ipcc work and this global climate context plays out in the daily lived experiences of city dwellers there are many tensions and conflicts that exist in urban climate policy and planning with civil servants needing to navigate the complexities of varying political support limited jurisdiction inadequate financing tools challenges with data availability and staff expertise bureaucratic silos and inconsistent regulatory and accountability frameworks what then is demandedrequired of urban planners and policymakers if the dominant approaches taken in their work no longer serve complex intersectional and systemic challenges of climate equity and decolonization theories and practices from the fields of social innovation systemic design and decolonizing methodologies offer promising alternatives for working differently on these complex challenges social innovation theory integrates many fields of social science and systems practice in service of shifting deep structures hearts minds and culture and of scaling and movement building for transformative socioecological change systemic design brings a designerly mindset lineage frame of reference training approach and set of experiences into this mix the experimentationand actionaslearning bias of systemic design ensures that innovations land in the real world in testable experiences withand for the people and places most affected by a particular challenge decolonizing methodologies ensures that social innovations and systemic design do not work within dominant and problematic paradigms of colonization and oppression and inadvertently perpetuate these systems under the guise of innovation instead wisdom and insight is sourced from culture history people and possibility and is deeply grounded in placebased and relational practice together they can inform the evolution of policy making and planning processes in ways that may result in more significant shifts than are possible when working within dominant systems that have oppression inequity and exploitation of humans and nature baked in social innovations work to transform the behaviours structures mindsets and beliefs of a social system with an intent to more skillfully and effectively respond to problems than is possible through existing or commonly used approaches that are less likely to address root causes of wicked challenges 47 48 49 an innovation is social in that it aims to shift social practices ideas beliefs interests power and agency so that innovations are diffused scaled institutionalized or otherwise integrated and made routine social innovation processes follow a series of stages often facilitated as iterations or cycles of experimentation and learning as newdifferent solutions emerge through a collaborative process including the following stages problemchallenge framing action or user research generating ideas developing and testing ideas through experimentation evaluation reframing and iteration implementation at increasing levels of fidelity scaling successful solutions outupdeep and ultimately changing systems 50 51 52 53 54 some social innovation process archetypes stay focused on the specific challenge they are tackling whereas others bring in a stronger personal transformation orientation recognizing that inner work is required for outwardoriented change 55 56 57 58 59 systemic design integrates systems thinking into humancentered and service design approaches for working creatively on complex challenges jones kijima say that systemic design advances an integrative interdiscipline with the potential to implement systems theory with creative methods and mindsets by bringing deep technical knowledge aesthetic skill and creative implementation to the most abstract programmes of collective action 60 systemic design processes tend to oscillate between convergent and divergent thinking and doing hold a strong bias toward action and experimentation and enable rightsized risktaking and microfailures early on as critical pathways for learning examples of systemic design process archetypes include ask try do strategy discover design develop deploy and inquire frame formulate generate reflect facilitate 60 61 62 63 systemic design has roots in humancentred or service design practice which center user experiences however it significantly differs from these modes of design in that it holds deeper attention to mindsets values context power relationships leadership and systems and then connects these activities in a strategic learning system 64 65 66 recent critique of the field and practice of design from an equity and justice point of view is resulting in theory frameworks and approaches to encourageenablerequire centering equity in design processes more skillfully and consistently 67 68 69 70 social innovation systemic design and decolonizing methodologies have strengths that were woven together into a different planning and policy making process in this applied research in the next section we describe how we designed and implemented this weaving in our project as well as into a framework that describes a transformative approach to policy making and planning processes results experimenting with transformative process design and facilitation the transformative policy making and planning process framework described in this section resulted from a yearlong participatory action research study that was delivered in 2021 the learning journey was designed and facilitated by a diverse sevenperson core research team consisting of formal academic researchers as well as researcherpractitioners learning journeygoers also known as our coresearchers included municipal staff from multiple departments working in ten canadian citybased teams and staff from two canadian network serving organizations each team began their learning journey by preparing a design brief that described their understanding of the complex climate equity and decolonization question that they were beginning with the north and near stars for their work the theory of change informing their current approach to transformation description of the peopleplaces most impacted by their challenge and the inner work and learning they committed to do the learning journey was delivered through thirteen halfday virtual workshops over nine months and active invitations to practice in between sessions a visual representation of the process arc and highlevel focus of each of the workshops and stages is shown in fig 1 the learning journey was designed and facilitated as an intentionally transformative alternative to more standard and familiar processes each of the dots represents a half day synchronous virtual workshop led by the core research team each workshop had a specific focus topic and practice and overall the sessions were designed with consistent core elements including slow and reflective experience to enable deeper systemic work mindfulnessembodiment practice reflective practices more formal teaching and contentgiving stories from the field connecting and relationship building team working practice activities and sharing our works in process in between the workshops were specific activitieshomework described as invitations to practice for the teams to apply and experiment with the core research team used interactive slide decks online collaboration tools and templates oneonone and team coaching with the core research team and dialogue as central andragogical approaches the teams experienced a transformative approach to policy making and planning which required them to reimagine and reframe their work the process was designed to open up thinking about potential planning and policy making process interventions outside of what they were practicedexpert in and to inquire into and challenge the fig 1 transforming cities from within learning journey process map paradigms that hold the current dominant ways of working in place as standard practice it was also designed to carefully and lovingly hold the discomfort tensions and ambiguity that this approach generated for people to help them to stay with the learning journey transformative policymaking and planning process framework this framework for transformative policy making and planning was generated through engagement with literature and through interacting with empirical data generated during the learning journey this framework is presented here as two parts a process map followed by a description of the transformative approaches taken at each stage of the process the process map captures key stages of this transformative approach as well as the movement and connections between the stages note that these are not drawn as discrete linear steps but rather as interrelated and entangled stages with iteration between there is a general movement from broadmessyopenexploratory that begins with framing and toward a gradual focusingclarifying process as we move through initiating researching experimenting and eventual implementation at the scaling stage engaging and enabling and evaluation and learning happen throughout as the connecting dotted lines indicate there is iterative movement between stages when insights and learning requireindicate reframing renewed experimentation andor return to learning from those most impacted by the challenge transformative policymaking and planning approaches tables 16 detail the process map into descriptions of transformative approaches at each stage common policymaking and planning approaches are compared to transformative approaches at each stage along with a description of how the transformative approach took shape in the learning journey some additional thinkers informed the ideas about the transformation that inspired these approaches 71 72 73 74 75 76 77 78 79 80 81 this transformative policymaking and planning framework can be considered as a whole and can also be considered as smaller independent interventions into unfreezing standard processes when an overall process redesign is not possible or supported careful creationcuration of transformative processes that centre learning are essential when working with practitioners who are used to being expert professionals in standard policymaking and planning processes with many thoughtful intentional and reflective process design choices required to do this well the next section describes seven of these significant choices and interventions from our research as key moves to provide texture about how policymakers and planners might think about designing and delivering a transformative process discussion the seven key moves toward transformative policymaking and planning processes explained below were intentionally integrated into the learning journey as an attempt to experiment with meaningful entry points into decolonization practices for planners and policymakers the hope was that participants might enact these moves in their everyday professional lives we express these practices as moves because significant reflection and interaction took place during and between each session for both learning journey goers and the research facilitation team for example the research teamfacilitators had to consistently design forwork withbe comfortable with emergence and ambiguity as the learning journey often and intentionally challenged participants to turn inward reflect on their identities and positionality show up as their authenticity selves and encouraged vulnerability in small and large group settings the details of these moves are discussed below move 1 beginning well our core research team members each had previous experience with designing and delivering transformative processes in diverse public sector communitybased and academic environments which gave our team a strong collective foundation from which to grow we began by crafting a compelling invitation to join this process based on the realworld challenges that we knew city staff were struggling with this clarity of invitation and sensing of the field meant that the right people found their way in and we had very little attrition along the way the learning journey started with an intensive virtual retreat in order to cocreate excitement build relationships and establish clarity about what people fig 2 transformative policymaking and planning process map complex systemic and adaptive challenges demand different approaches to working on them they are unknowable unpredictable and emergent these features require different approaches to learning and working withon these types of challenges example practice systems mapping is used to understand dynamics at work in the challenge and to expand the view to include interrelated issues leverage point analysis is used to identify high impact places to intervene in the system through policy and planning work table 2 initiating stage common approach transformative approach brief description of how this transformative approach shapes process design begin with outcome begin with question transformative processes begin with an active relevant and critical question that is framed along the way as user research experimentation and learning reveals insights and possibilities example practice designers often begin work with a creative question framed as a how might we… or what if… possibility good creative questions bound the challenge space and also open up creative possibilities and visionary potential project charter and project management plan design brief and theory of change captures the vision goals values process evaluation and learning and potential outcomes of an innovation process in a concise and compelling way outlines a structure for a process in a way that also allows for nonlinearity not knowing the outcome taking a usercentered orientation having a longterm and shorterterm vision and goals and enabling creativity experimentation and learning clearly describes how a team thinks that change happens and their intended desired contributions to change example practice a theory of change articulates vision goals a description of how a team thinks that change happens and how their work will contribute to that change it is a helpful practice to surface implicit assumptions and uncover differences or tensions and then to design for these in a productive way table 3 research stage common approach transformative approach brief description of how this transformative approach shapes process design scenario planning speculative and visionary fiction imagines possible futures beyond the limited frames that planning and policy making typically take by tapping into creative speculative protopic future worldbuilding through imaginative writing example practice creative writingdrawing and worldbuilding using techniques from fiction can help a team to expand their sense of what is possible and necessary to see potential pathways and to be inspired by one anothers visions policy research and best practices action and user research centres the lived experiences of people most affected by a complex challenge the lived experiences of land water and morethanhuman kin and future generations in research example practice ethnographic andor action research insights are regularly returned to users to test how they are informing a planning and policy making process throughout in generative and reciprocal ways wanted the journey to be for them the retreat series included connecting to land place history context and indigenous pasts presents of each place where cohort members were coming from one cohort member reflected that i think one thing that was probably challenging for us at the beginning was figuring out how these things relate to engineering and our very specific transportation engineering field the retreat series also included cohort members reflecting on their personal and team calls to action and accountability based on their identities and experiences reframing the complex challenges that they were coming in with based on systems practice and imagining possible and desired future states resulting from their transformative work these choices clearly signaled that this process would be different from other planning policymaking andor professional development processes than they were used to move 2 cocreating an equitable just feminist and decolonized space concepts of equity were intentionally introduced throughout the learning journey to practice foundational concepts and develop a shared language grounding the process in placebased relational and decolonial approaches set the tone for how the cohort was invited to bring themselves into the space some features included the practice of abundant time and the dance between this and the sense of urgency associated with the nature of the challenges everyone was working on we did deep selfinsystem work to explore how our individual positionality intersecting identities and life experiences impact how we each see understand and experience the world and the challenges we were working on we worked to transform the construct of being expert and of professional looking and behaving in a particular way characterized by colonial and white dominant paradigms one cohort member described it this way the reimagining of these core city processes has the potential to impact other systemic challenges as well because at its foundation this is a shift toward more placebased peoplecentered experimental and exploratory processes where we collectively need to lean into the emergent solutions that we are working toward because they are not yet known ongoing reflection on how there is no stepbystep guide to do decolonial practice was central in the process as for most of us this is a lifelong learning process filled with discomfort move 3 prolove pedagogy partway through the process our research team began using the phrase prolove pedagogy as a shortform descriptor for a collection of choices we were making in design and facilitation prolove meant that we prioritized being in a caring loving supportive and collaborative community withfor each other as research team members and consequently how the cohort experienced the holding space that we cocreated with them throughout the process 7581 one member of our research team reflected that being in a caring and loving research team changed my perspective about research and what that can look and feel like evidence of this prolove pedagogy looked like an ongoing trust and willingness of the cohort to come along on this journey even when it got uncomfortable and they didnt know where it was taking them it looked like the research team navigating and holding our own and each others discomfort disease and uncertainty and modeling a skillful and honest navigation of this liminal space it looked like an opening up to the diverse experiences and perspectives of the research team to cocreate a rich learningoriented process for everyone even when it wasnt clear how all of the pieces fit together it looked like radically trusting ourselves and each other at every step along the way move 4 focus on practicing not problem solving the process emphasized building and practicing competencies and capacities for transformation rather than on solving problems we thought about this as exercising different muscles and rehearsing the newresurgent we did this by cocreating a learning practice experimentation and reflectionfocused space withfor each other the dominant problemsolving orientation in planning and policymaking processes taps into wellhoned and exercised skills habits approaches and subsequent results we needed the cohort to question reframe for themselves and look beyond this standard approach if they were to have a real chance at getting to a different outcome working on complex ambiguous challenges demands a different set of skills and approaches and practitioners can quickly find this overwhelming and daunting to navigate one cohort member shared that the journey helped them to think about how we can overlap our different programs to create multiple effects instead of just using one program to treat one problem move 5 drawing on different theories and practices our research team carefully curated a set of theories approaches and practices that are not commonly used in city governments including action and user research systems mapping prototyping reflective practice developmental evaluation imagining possible futuresspeculative fiction prototyping and others the cohort worked the techniques made mistakes and had breakthroughs shared their experiences with one another and built their literacy and confidence in approaches more suited to the complex challenges they were working on than their goto approaches an example of this was the regular returning to systems mapping throughout the journey to develop each persons understanding of the deeply connected and shared roots of climate equity and decolonization challenges we worked and iterated these systems maps as people expanded and shifted their perspectives and then used the maps to generate promising fractals and feedback loops where they could intervene one participant captured their experience in this way its so easy to just be in the normal ways of doing and being its so ingrained and easy to go along with it i realized i can question this and that it takes so much presence and intention to hold a different possibility as this isnt part of peoples jobs or recognized as legitimate work move 6 working with fear we also noticed the implicit influence of fear as a motivator of in action and behaviour fear of messing up of saying the wrong thing of offending of failing to have impact surfacing and shining a light on these fears and supporting the cohort to develop different more generative relationships with these fears and what they might contribute or catalyze was an important part of the process a particular fear that many people acknowledged was that they lacked the skills abilities and connections necessary to work in highly relational respectful and mutually beneficial ways with the people and communities whom they serve and who are most impacted by these intersecting challenges one cohort member said that they dont have the relationships with equitydenied people and groups the fear that staff have is projected onto people otherizes them focuses on risks and is based in fear what if the foundations of our work were about good relationships instead another member realized that we need to prioritize the time and space needed to reframe the complex problem asking who have we not talked to and then prioritize action and user research to understand their experiences and perspectives move 7 redefining impact and outcomes standard planning and policymaking processes offer the comfort of a clear endpoint the successful approval of a piece of work by decisionmakers elected officials and community stakeholders transformative processes are not as clear and tidy they are concerned with transformation at the personal team organizational cultural relational and systems scales and in this case on complex intersecting climate equity and decolonization challenges there is no clear finish line in this work as it is longterm ongoing and generational cycles of action learning and reflection are necessary putting planning and policymaking processes in a direct and ongoing relationship with implementation rather than viewing them as separate processes generating other ways to measure understand reflect upon evaluate and tell stories of impact was an important part of grounding the experience of this process for people and supporting them in articulating why it mattered and what resulted we used ongoing developmental evaluation speculative fiction and persuasive storytelling to support individual and collective sensemaking about impacts imagining enabling and enacting transformative policymaking and planning processes will require equipping both new and established planners and policymakers with emergingresurging approaches to complex urban climate equity and decolonization challenges the transformative policymaking and planning process framework shared here intends to support research and practice in this important domain and contribute to enhancing research and action more generally on complex intersectional urban sustainability challenges methods participatory action research bricolage the core method used in this study was participatory action research defined as a participatory process concerned with developing practical knowing in the pursuit of worthwhile human purposes it seeks to bring together action and reflection theory and practice in participation with others in the pursuit of practical solutions to issues of pressing concern to people and more generally the flourishing of individual persons and their communities 82 in par research subjects are coparticipants in the processes of inquiry which includes activities of generating questions and objectives sharing knowledge building research skills interpreting findings and implementing and measuring results recent turns in par call for the method to support transformation while providing rigour and quality in ethics process and outcomes and this provided additional guidance to our approach 82 83 84 significance which informed the method taken in this work 82 par was embedded within an interdisciplinary critical qualitative activist and practiceoriented bricolage 8586 concerned with the depth and complexity of a question what lies below the surface and the form in which that complexity might best be understood and revealed 87 this methodological layer was added to ensure that par would critically engage with the dominant systems and structures of planning and policymaking that this research was aiming to question and reimagine the two authors of this paper along with the five additional members of the core research team each brought diverse lived experiences professional practices distinct disciplinary lineages and diverse positionalities and perspectives together to construct this par bricolage and to design facilitate and generate insights about this learning journey together based on our collective of experiences and perspectives indigenous feminist antioppressive and ecological methods were features of our bricolage and necessary to better support working inwith processes of transformation and to find our ways out of the dominant paradigms of planning and policymaking through our methodological approach 88 89 90 91 92 93 94 95 96 97 using a par bricolage meant that we took an orientation of gathering up and applying what was useful from these different methods in a generative dialogue with these methods and with each other this also helped us to remain focused on being in service to generating insights about our practiceoriented questions and those of our 40 coresearchers in the learning journey this methodological approach enabled our research team to balance theoretical rigour transdisciplinarity practicebased foundations and emergence together we held an entangled and engaged researcher orientation where the opinions perspectives and experiences of our research team and action coresearchers were considered a strength research design the university of british columbia behavioural research ethics board provided approval for this study all research participants provided written informed consent to take part in the study the core research team crafted the learning journey and invited participation through an open call that was distributed through existing networks supporting city governments working on climate and equityrelated work in canada this invitation was open to public sector staff working within city governments and could include team members from communitybased partner organizations if this would be relevant to the challenge that the team wished to work on during the journey it was also open to networkserving organizations that worked to support city governments in their climate equity reconciliation andor decolonization work all of the ten canadian citybased teams and two networkserving organizations that applied to participate in the journey were invited to join city staff were from the environment sustainability social policy planning engineering equity and reconciliation and public engagement departments roles teams completed the application requirements and our research team held the approach of saying yes to as many teams that were ready as we could properly support one team dropped out of the learning journey about halfway through due to their limited capacity to fully participate although they continued to be invited into all learning journey activities through to the end of the project teams were informed that this was an applied research project before applying and upon acceptance into the learning journey their formal consent to participate was confirmed several new people joined the journey partway through with their consent confirmed when they joined each multidepartmental team brought a different locally relevant complex planning andor policymaking climate equity and decolonization challenge that they actively worked on throughout the ninemonthlong learning journey held from april december 2021 social innovation systemic design and decolonization theories processes and practices were used to design the backbone of the learning journey other theories and processes informed the andragogical approach as well including transformative adult learning critical race theory feminist and queer methodologies sustainability transitions complexity and emergence and afrofuturism our core research team shared the responsibility for the overall design of the learning journey with individual team members and external guests invited in to lead and facilitate specific workshops based on their expertise and experience the research team engaged in ongoing reflective practice throughout the whole journey documenting insights and learning along the way and shifting and pivoting the design of the journey in response to what was happening insession with coresearchers and their emerging questions and needs qualitative data was collected throughout the journey and included observation interviews reflection of the research team and cohort members team coaching sessions document review active process design and facilitation interventions and their impacts and shared sensemaking with the research team to uncover themes and insights active and ongoing sensemaking of this data occurred through regular dialogue amongst research team members tracking what was emergent responding through the design of the learning journey and noting themes throughout emerging insights and themes were regularly returned to the coresearchers during the learning journey workshops to ensure that the sensemaking being done by the core research team was reflective of the coresearchers experiences active consent of cohort members to participate in the research continued throughout the journey including reaffirmed consent at their last interview three months after the journey had finished data availability data from this research is not available for other users or purposes as per our behavioural ethics board review and approval reporting summary further information on research design is available in the nature research reporting summary linked to this article competing interests the authors declare no competing interests additional information supplementary information the online version contains supplementary material available at correspondence and requests for materials should be addressed to lindsay cole or maggie low reprints and permission information is available at reprints publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

cities are facing increasing pressures to address complex challenges of climate change equity and reconciliation with indigenous peoples as intersecting issues and innovation into planning and policymaking processes is urgently needed to achieve this it is no longer good enough to work on these challenges discreetly or solely within the dominant western colonial paradigm and practices of governance there are ongoing harms being caused by climate work that does not embed justice and there are missed opportunities for synergies across these domains as they have the same systemic root causes cities must adapt and transform the processes and practices of planning and policymaking in order to work at these problematic roots drawing on an empirical study this article describes how social innovation systemic design and decolonizing practices can shape a different approach to planning and policymaking processes when working at the intersections of climate equity and decolonization

introduction n examining the reasons for the failure of development programs in different countries in the world the neglect of development governance has been emphasized considering that the implementation of development policies is challenging for activists there is a need for innovative governance models of the public and private sectors to go beyond traditional thinking in examining the new governance paradigms network governance as one of the emerging models with the premise of the complexity of issues and the inability of institutions to solve issues independently emphasizes the cooperation and participation of key stakeholders in the decisionmaking process including government and nongovernment actors and society in this form of governance government agencies directly engage nongovernment actors in decisionmaking by consultation and negotiation and take collective action this governance model reflects the participation of the nongovernmental sector government sector and society in a decentralized structure network governance describes the improvement in the ability to solve sustainable problems in social systems by empowering the capabilities of various stakeholders and strengthens the response to the problems of social and environmental systems by supporting participatory and collective actions tehran citys fourth development plan has been compiled based on the opinions of experts in tehran municipality and by paying attention to the shortcomings of the previous plans and the need to be problemoriented and avoid inefficient expansion this plan has determined five key domains transportationtraffic environmentair pollution urban safetywornout fabric culturalsocial issues and intelligentizationmanagement improvement in examining the current situation in the field of safety and disaster management in tehran in addition to the existence of wornout urban fabrics more than 33000 highrisk buildings in terms of fire hazards unsafe buildings of shopping medical educational industrial and warehouse centers more than 100 highrisk unsafe pits accidentprone passages lack of standard firefighting machines failure to complete the dredging of roads river valleys and city canals and lack of attention to the citys safety measures against floods earthquakes and land subsidence have been reported considering the emphasis on participatory governance in the fourth development plan of tehran city this study aims to analyze the network governance of safety and disaster management in tehran by examining the laws of the fourth development plan and with emphasis on the participation of key actors including government institutions private sector public institutions and local communities using social network analysis methods in this study 22 laws with 101 issues were identified and 47 involved organizations including 26 internal institutions of tehran municipality and 21 external institutions involved in the safety and disaster management program in the areas of transportationtraffic urban safety wornout fabric culturalsocial issues and intelligentizationmanagement improvement were evaluated the organizations and institutions were considered as the rows and columns of the governance network matrix and the number of times of cooperation between organizations and institutions was considered as the entries of cells of the matrix the matrix of actors cooperation network was analyzed based on the degree centrality betweenness centrality geodesic distance density and cohesion results the results of the analysis of the degree centrality index for the safety and disaster management actors cooperation network showed that among the internal organizations of tehran municipality the crisis prevention and management organization the deputy of urban and environmental services and the information and communication technology organization had the highest scores followed by the fire department and the municipalities of 22 districts of tehran the internal organizations with the lowest degree centrality were the general department of citizenship education university of applied sciences and technology neighborhood management headquarters deputy of finance and urban economics and the renovation and administrative transformation center regarding the betweenness centrality index the crisis prevention and management organization the information and communication technology organization the deputy of urban and environmental services the deputy of urban planning and architecture and the municipalities of 22 districts of tehran had the highest scores while the urban research and planning center the general department of citizenship education university of applied sciences and technology and the neighborhood management headquarters had the lowest scores in general the results of the analysis of the governance system of tehran city showed the planners belief in participatory governance for solving the safety and disaster management issues of the city however the participation of citizens local communities nongovernmental organizations and the private sector requires improvement and expansion of legal cooperation such that the lack of transparency in determining the roles responsibilities and powers of institutional actors outside tehran municipality such as executive legislative and supervisory institutions and absence of policies for facilitating and encouraging the participation of private sector economic institutions universities scientific and research centers local communities and citizens need to be addressed by legislators and planners they should support the network governance in solving disaster management issues in tehran conclusion the recommendations for improving the governance system of disaster management in tehran for balancing the distribution of legal power among the responsible institutions and actors of tehrans safety and disaster management program include strengthening the cooperation of municipal and interinstitutional actors to solve key issues of safety and disaster management strengthening the communication network and continuously exploiting the capacity of academic elites and consultants strengthening the mechanisms for the participation of citizens nongovernmental organizations and the private sector rising awareness and strengthening citizens trust in safety and disaster management programs using social media developing incentive policies to utilize the capacity and participation of knowledgebased organizations and new and creative firms in solving safety and disaster management issues developing incentive policies for the participation of managers and employees strengthening the legal communication of financial and economic institutions and financing projects and transparency and accountability of responsible institutions ethical considerations compliance with ethical guidelines all ethical principles were observed in this study conflicts of interest the authors declare no conflict of interest

background and objective this study aims to analyze the network governance of safety and disaster management in tehran by examining the laws of the fourth development plan and emphasizing the participation of key actors including government institutions the private sector nongovernmental organizations and local communities using social network analysis method in this study 22 laws with 101 issues were extracted from the fourth development plan and 47 involved organizations including 26 internal institutions of tehran municipality and 21 external institutions involved in the safety and disaster management program in the areas of transportationtraffic urban safetywornout fabric culturalsocial issues and intelligentizationmanagement improvement were evaluated the organizations and institutions were considered as the rows and columns of the governance network matrix and the number of times of cooperation between organizations and institutions was considered as the entries of cells of the matrix the matrix of actors cooperation network was analyzed based on the degree centrality betweenness centrality geodesic distance density and cohesionthe results of the analysis of the governance system of tehran city showed the planners belief in participatory governance for solving the safety and disaster management issues of the city however the participation of citizens local communities nongovernmental organizations and the private sector requires improvement and expansion of legal cooperation such that the lack of transparency in determining the roles responsibilities and powers of external institutions of tehran municipality such as executive legislative and supervisory institutions and absence of policies for facilitating and encouraging the participation of private sector economic institutions universities scientific and research centers local communities and citizens need to be addressed by legislators and planners they should support the network governance in solving disaster management issues in tehranthe recommendations for improving the governance system of disaster management in tehran for balancing the distribution of legal power among the responsible institutions and actors of tehrans safety and disaster management program include strengthening the cooperation of municipal and interinstitutional actors to solve key issues of safety and disaster management strengthening the communication network and continuously exploiting the capacity of academic elites and consultants strengthening the mechanisms for the participation of citizens nongovernmental organizations and the private sector rising awareness and strengthening citizens trust in safety and disaster management programs using social media developing incentive policies to utilize the capacity and participation of knowledgebased organizations and new and creative firms in solving safety and disaster management issues developing incentive policies for the participation of managers and employees strengthening the legal communication of financial and economic institutions and financing projects and transparency and accountability of responsible institutions

introduction public stigma related to mental illness involves the general publics negative misconceptions about people with mental health conditions 1 these negative misconceptions motivate individuals to fear and discriminate against pmhc resulting in pmhc being shunned by society and losing opportunities 1 public stigma related to mental illness is becoming a significant concern and is detrimental to pmhc as it also leads to unemployment 2 stigma is a major issue because it leads to bullying and a recent study has focused on public stigmabased bullying 3 the structure of public stigma related to mental illness can be explained using the social cognitive model 4 based on this model stigma comprises three components stereotypes prejudice and discrimination 4 stereotypes are public attitudes prejudice is the emotional reaction to agreeing with the public attitude discrimination is the behavior that results from stereotypes and prejudice 24 in other words stereotypes are associated with knowledge of the mental illness prejudice is related to emotional reactions toward patients and discrimination is associated with behavior change such as social distance 4 a review in 2013 based on studies from 2001 to 2011 found that japan has intense stigmatization of pmhc 5 this strong stigma was suggested to be in part a result of the culture of japan 5 discussing mental illness in japan has been taboo in the past 6 given the influence of the honnetatemae culture which promotes maintenance of harmony 7 japanese are hesitant to express their true feelings and provide their real opinions and are more inclined to give opinions that are less likely to cause disputes to maintain harmony in addition insufficient education antistigma campaigns and the high institutionalization rate of pmhc decrease the publics opportunity to have contact with pmhc and have been sugmental illness stigma in japanese employees j clin med res 202315139147 gested to contribute to the stigma of mental illness in japan 5 therefore the japanese government has tried reducing public stigma and improving knowledge about mental illness in 2002 the japanese society of psychiatry and neurology changed the name of schizophrenia to remove the harmful impact of the old naming term on patients and their families 8 as a result patients reporting their diagnosis increased from 367 to 697 from 2002 to 2004 8 since then the mental health system in japan has undergone continuous changes for reasons such as a lack of mental health literacy and a shift toward communitybased care 9 one of the more notable reforms was the 2004 reform vision for health medical care and mental health welfare which promoted the transition to communitybased care 10 and decreased the number of psychiatric care beds by approximately 25000 from 2004 to 2018 11 in 2014 the japanese government passed the act on promotion of preventive measures against karoshi and other overworkrelated health disorders which enhanced the publics knowledge of occupational mental disorders 12 researchers have also adopted educational interventions to reduce stigma since 2013 which have proven effective 13 14 15 as a result a new educational curriculum on mental illness will be implemented in schools in 2022 16 various surveys on the level of public stigma of mental illness have been conducted in japan in 2003 a japanese survey found that respondents below 30 years old have lower understanding and knowledge on stigma implying that those below 30 years old have had less chance of interaction with patients or attended lectures 17 another study in 2005 found significant effect of age on stigma with older participant tend to be less socially accepting towards patients with schizophrenia 18 the association between sex and mental illness stigma is more complex as it varies from regions to regions 19 but prior studies found that male tended to have lower understanding of mental illness compared to female 1719 employment position such as being a workplace manager who is a decision maker in employment is associated with knowledge of mental illness 20 consequently those with experience in employing pmhc were more knowledgeable about mental illness 20 concerning employment status regular employees in a japanese company are given induction training which may include mental health and work stress management 21 affecting their knowledge of mental illness in addition to the demographic information attendance in mental health lectures also affect knowledge on mental illness 17 as for prior contact experience a prior study 5 suggested that the lack of prior contact experience due to pmhc being admitted into the hospital resulted in a more substantial stigma among the japanese however most of the surveys in japan used different stigma scales 71719 and it may be difficult to look at the trend of public stigma in the past 20 years based on the results of different stigma scale although it was an indirect comparison a survey conducted in 2012 19 found that respondents associating depression to personal weakness to likely have decreased compared to the previous study 7 another survey in 2018 22 found that most japanese believed that mental illness could be cured via treatment but still have slightly strong stigma towards schizophrenia as such it is expected that the state of mental illness stigma in japan at present might have improved much more compared to the past survey conducted on knowledge of mental illness 17 or social distance towards mental illness 7 among the japanese thus the purpose of this study was to clarify the characteristics of public stigma toward pmhc in japan in recent years focusing on knowledge about mental illness using the mental illness and disorder understanding scale and social distance toward pmhc using attitudinal social distance scale employed in previous survey 71517 materials and methods participants and procedure this study was a crosssectional populationbased design healthy participants without mental health conditions were recruited from employees of three companies located in a standard regional city with a population of 270000 in japan in this study we requested the participation of occupational health physicians and public health nurses affiliated with the company by using the kinship method the survey instrument was designed using google forms so participants could complete it online the advantages of using online google form were that it was convenient and can be completed anonymously at any time but was less accessible to the older generations who were not familiar with recent technologies in the second week of january 2022 1468 participants were informed of the online survey by the occupational physician at their workplace they were provided a quick response code to access the survey online via mobile phone once a week the occupational physician reminded participants to complete the survey online data collection lasted about 3 weeks and ended on january 31st 2022 of the 1468 participants 970 did and 498 did not respond to the survey respectively thus the response rate was 661 the protocol received approval from the ethics committees of the university hospital medical information network clinical trials registry and the research ethics committee of the faculty of medicine and graduate school of medicine of the university of tokyo all procedures performed in this study followed the ethical standards of the institutional research committee and the 1964 helsinki declaration and its later amendments survey questionnaire the stigma of mental illness is typically measured using a selfreported stigma scale 23 together with demographic variables such as age 17 18 19 sex 17 18 19 employment position 20 employment status 24 attendance at mental health lectures or training 17 and prior contact experience of pmhc 5 the knowledge component of the stigma of mental illness was measured using the midus 1517 the social distance component of mental illness stigma was measured using the asd scale 7 prior contact experience of pmhc was measured using the reported intended behavior scalejapanese 2526 we used the midus asd and ribsj because their internal consistency and validity have been confirmed 7172527 the survey had two parts part one consisted of the demographic characteristics of the participants in the form of multiplechoice questions sex and age group measured in years 17 employment position employment status and attendance at mental illness stigma training part two consisted of questions on knowledge of mental illness measured by midus social distance toward pmhc measured by the asd scale and prior contact experience of pmhc measured using the ribsj accurate knowledge of mental illness the midus assessed the participants accurate knowledge of mental illness 17 the midus consisted of 15 items with three subscales treatability of illness the efficacy of medication and social recognition of disease all items were rated on a 5point likert scale the midus scale was developed in japan confirming its internal consistency and validity 17 the cronbachs α was 081 in the present sample we used the mean total midus score as in the prior survey 17 a low total score indicates good understanding social distance the asd measured the social distance of participants in relation to pmhc 728 the five items were rated on a 5point likert scale we used the mean total asd score with a low score indicating favorable attitudes the five items of the asd were 1 move next door to the person 2 spend an evening socializing with the person 3 make friends with the person 4 work closely on a job with the person and 5 have the person marry into the family participants were given a vignette depicting a patient with depression and were instructed to rate their social distance in relation to the person in the vignette the vignette using patient with depression was chosen in this study because depression has been closely associated with malingering such as being absence from work using depression as an excuse 29 which may influence the stigmatized view of public towards patients with depression in a workplace environment the asd scale was developed 30 and has been validated 27 and we used the japanese version of the scale 728 prior contact experience with mental illness patients we measured the prior contact experience of participants with pmhc using the ribsj 2526 the scale consisted of four binary items for prior contact experience with patients of mental illness 1 are you currently living with or have you ever lived with someone with a mental health problem 2 are you currently working with or have you ever worked with someone with a mental health problem 3 do you currently have or have you ever had a neighbor with a mental health problem and 4 do you currently have or have you ever had a close friend with a mental health problem the participants data were analyzed based on having prior contact experience to no previous contact experience the japanese version has good reliability and validity 25 the cronbachs α was 081 for present sample statistical analysis demographic variables and public stigma a ttest was used to compare the midus and asd scores separately by the independent variables sex employment position employment status attendance at mental illness stigma training and prior contact experience with mental illness patients age and public stigma oneway analysis of variance was conducted on the midus and asd scores by the independent variable age group post hoc pairwise comparisons between the age groups were performed using bonferroni correction independent variables that achieved significance were added as covariates to a oneway analysis of covariance by age group to test their effects on the midus and asd scores a onetoone casecontrolled anova controlling for covariates that achieved significance was conducted to confirm the effects of these covariates on the anova results relationship of the independent variables on midus and asd score a multiple regression analysis was performed to assess the relationship of the independent variables on the midus and asd scores for the current sample comparisons with previous studies we calculated effect sizes using welchs ttest by subtracting the mean midus and asd scores from the mean midus 17 and asd 28 scores in the previous studies and dividing the results by the pooled standard deviations of the mental illness stigma in japanese employees j clin med res 202315139147 respective surveys we refer to effect sizes as small medium and large based on benchmarks suggested by cohen 31 comparisons between past contact experience and our results could not be made because no previous study used the same evaluation scale participants with no midus or asd scores as well as those with missing data for the key demographic variables were not included in the analyses because these variables were required for weighing statistical analysis was performed using the statistical package for social sciences version 25 for windows the level of statistical significance was set at p 005 results demographic characteristics among the 970 participants 474 were males 481 were females and 15 refused to provide information on sex thus these 15 participants met the exclusion criteria of the 970 participants 955 had no missing values among the midus score asd score and demographic variables and were eligible for analyses among the 955 participants 40 49 years old was the largest age group regarding employment positions 217 participants were managers and 738 were nonmanagers for employment status 511 participants were regular employees and 444 were nonregular employees among the 955 participants 20 had attended mental illness stigma training concerning prior contact experience with pmhc 665 participants had previous contact experience and 290 did not the demographic characteristics of the participants are provided in table 1 there was no significant difference in the mean midus 291 p 006 and asd 060 p 055 scores between the companies effects of demographic variables and age on accurate knowledge the midus scores are listed in table 1 there were statistically significant differences in midus score by employment status and prior contact experience but ancova comparing age groups was performed with employment status and prior contact experience as covariates the results showed statistical significance in midus scores by employment status 540 p 003 and prior contact experience 2575 p 001 the participants were matched according to age group based on employment status and prior contact experience with pmhc the resulting four categories were divided by age group as follows regular employees without prior contact experience regular employees with prior contact experience nonregular employees without prior contact experience and nonregular employees with prior contact experience for the regular employee without prior contact experience group the age group of ≥ 60 years was insufficient for comparison purposes oneway anovas of these four matched categories showed no significant difference in midus score by age group effects of demographic variables and age on social distance the asd scores are listed in table 1 anova revealed significant differences in asd score by age group 254 p 004 the bonferroni test for multiple comparisons showed that the mean score was significantly different between participants 30 years old 397 and those 50 59 years old suggesting that the younger group had the less social distance concerning pmhc no significant differences in asd scores were found by sex employment position employment status attendance at mental illness stigma training and prior contact experience relationship of the independent variables on midus and asd for the multiple linear regression analysis the midus and asd scores were entered into the multiple regression model along with possible confounders including sex age group employment position employment status attendance at mental illness stigma training and prior contact experience with pmhc employment status and prior contact experience significantly affected the midus score whereas no variable had a significant effect on the asd score comparisons with previous studies although the current sample size is different from the prior surveys 717 the usage of the midus and asd scales which were employed in the prior surveys 717 allow for an indirect comparison in the level of public stigma the difference in mean midus score between this study and the 2003 survey 17 was statistically significant 607 p 001 d 028 the difference in mean asd score between this study and the 2007 survey 28 was statistically significant 346 p 001 d 016 albeit an indirect comparison these results suggest that the level of accurate knowledge of mental illness is higher in the current sample compared to the 2003 survey yet the social distance level was similar to the 2007 survey discussion accurate knowledge of mental illness was significantly higher among regular employees and those with prior contact experience while social distance was significantly lower among participants 30 years old for the current sample age and public stigma in our study although the midus score did not differ significantly by age group accurate knowledge of mental illness 1 as reported previously 17 the 2003 japanese survey which used the midus score 17 showed that respondents 30 years old have lower understanding and knowledge of stigma implying a lower likelihood of interacting with patients or attending lectures our results suggest that participants in the older age groups were less socially accepting of pmhc especially those of 50 59 years old compared to those of 30 years old this result agrees with a previous report that social distance towards such patients worsens throughout life 32 another study 33 also identified a significant effect of age on stigma older participants tended to be less socially accepting of pmhc and unwilling to have them marry into the family a study suggested that the increase in social distance with age may be a result of accumulated negative experiences or unpleasant contact experiences with patients throughout life 18 this is not impossible because negative contact experience reportedly increases stigma 34 sex and public stigma a prior study 19 found that the association between sex and mental illness stigma varies regionally in japan males tend to have a lesser understanding of mental illness than females 1719 another study 35 found that female has stronger stigmatizing attitudes than male due to their beliefs suggesting that it varies based on sociodemographic profile however we found no significant differences between sex knowledge and social distance scores likely because the population examined may have been derived from a relatively homogeneous population education and public stigma a prior study found that individuals who attended mental health lectures tended to understand mental illness better than those who did not 17 however only 2 of the participants had training related to the stigma of mental illness this result might be because such training and lectures are still uncommon in japan with the implementation of mental health education in high school the younger generations will be exposed to an accurate knowledge of mental illness at an early age and can be reinforced with more training and lectures as accurate knowledge of mental illness tends to increase with age prior contact experience and public stigma prior contact experience influenced the midus score indicating that previous contact experience enhances understanding of mental illness this suggests that prior contact experience may decrease stigma 36 and the lack of contact opportunities may increase stigma as reported elsewhere 5 lack of prior contact experience due to hospitalized pmhc increases stigma among the japanese 5 as part of the 2004 reform vision for health medical care and mental health welfare the japanese government took measures to reduce longterm hospitalization such as moving from institutionalized care toward communitybased care and improving the quality of mental health care 10 these ongoing reforms by the government in mental health welfare policy have resulted in a 50day decrease in the average length of hospital stay 11 length of stay among newly admitted patients has also decreased with 857 of patients discharged within 1 year in fy2014 and fy2015 37 a shorter average stay means more comprehensive care in the community and the public may have more opportunities to interact with patients compared with the 2003 survey 17 these government initiatives aimed at increasing knowledge and contact opportunities may have worked as intended employment status and position and public stigma regular employees had a significantly better understanding of mental illness than nonregular employees regular employees are more knowledgeable than nonregular employees because most japanese companies provide onthejob training 24 which may include mental health and work stress management affecting their knowledge and understanding of mental illness the ministry of health labor and welfare reported that more regular than nonregular employees receive training 24 as such there is a need for mental health and stress management for nonregular employees there was no significant difference in accurate knowledge of mental illness and social distance between managerial and nonmanagerial employees therefore being a managerial or nonmanagerial employee did not affect the individuals understanding of mental illness and social distance in this study being a workplace manager or a person responsible for personnel matters is reportedly associated with better knowledge of mental illness 20 but another study yielded disparate results 38 a companys human and material resources may influence managers understanding and behavior toward pmhc 39 the results of this study differ from those of prior works warranting further investigation relationship to intervention policies over the past 20 years the japanese government has taken measures to improve knowledge of the mental illness one of the most noticeable changes was the 2002 change of the japanese term for schizophrenia 8 from seishinbunretsubyo to togoshitchosho in a survey of psychiatrists after the renaming 82 regarded the new term as more suitable for obtaining consent from patients and effective in reducing stigma 8 the results suggest that citizens impressions of schizophrenia changed after the name change leading to greater understanding and more willingness to disclose their illness in response to overworkrelated disorders and mental disorders due to overwork the government passed the act on promotion of preventive measures against karoshi and other overworkrelated health disorders in 2014 to improve mental health in the workplace and to promote a healthy worklife balance 12 the act promotes public awareness of overworkrelated disorders by for example designating labor thanksgiving day in japan which may have indirectly improved the publics knowledge of mental health 12 using the exact same midus scale to the prior survey 17 we found that the level of accurate knowledge of mental illness in the current sample is significantly higher than the prior survey mildly suggesting that the level of accurate knowledge of mental illness may have improved compared to the past due to the efforts by the japanese government however the level of social distance toward pmhc was similar to the past survey 7 compared to other countries a study in the united states found that social distance towards depression improved compared to the past 33 a study in england also found improvement in behavior towards pmhc compared to the past attributing success to the effectiveness of time to change campaign which lasted from 2009 to 2017 40 on the other hand a study in germany 41 found that social distance has not improved despite having national antistigma initiatives at reducing stigma on mental health conditions although the midus score has a weak positive correlation with the asd score in this study 018 p 001 our results confirmed the conclusions of stigma experts that behavior change in response to stigma is a complex process and that knowledge alone is unlikely to reduce social distance substantially 4243 in addition other than the japanese governments renaming schizophrenia in 2002 8 none of the mental health initiatives have directly targeted mental illness stigma this lack of direct efforts to address stigma at the national level 44 may explain the absence of improvement in the social distance concerning mental illness therefore governments should adopt direct initiatives and interventions targeting the stigma of mental illness beyond office workers and highschool students interventions using sophisticated techniques such as perspective taking and empathy induction using modern technology may also enhance public understanding of the suffering of pmhc and promote prosocial behavior toward them limitations this study has a few limitations the population differed from those in the prior surveys 71728 thus a direct comparison was not possible and an indirect comparison using effect size estimation was conducted with welchs ttest although respondents were informed that the survey was anonymous 45 the results were selfreported and the possibility of social desirability bias cannot be excluded such that the actual level of stigma might be more severe than the results of the survey the participants were recruited from companies in the same city resulting in a risk of homogeneous sampling the proportion of respondents who attended mental illness stigma training was significantly skewed the vignette used for asd were based on depression and the level of social distance may not be a good representative of mental illness in general as different conditions may lead to different level of social distance 33 other possible factors which may have affected the stigma score such as personal belief or cultures 4647 were not surveyed in this study which warrant for further investigation conclusions accurate knowledge of mental illness was significantly higher among regular employees and those with prior contact experience social distance was significantly lower among participants 30 years old data availability the datasets generated andor analyzed in this study are available from the corresponding author upon reasonable request conflict of interest the authors declare that they have no competing interest informed consent informed consent was obtained from all participants abbreviations

the public stigma related to mental illness is the general publics negative misconceptions about people with mental health conditions pmhcs the public stigma of mental illness is detrimental to pmhc as it leads to loss of opportunities and unemployment the aim of the study was to clarify the status of public stigma related to pmhc focusing on knowledge about mental illness and social distance concerning pmhca survey was conducted among 970 japanese office workers aged 20 to 60 years accurate knowledge of mental illness was assessed using the mental illness and disorder understanding scale midus the attitudinal social distance asd was used to determine social distance in relation to pmhc the demographic characteristics of the participants evaluated were sex age group measured in years employment position employment status and attendance at mental illness stigma training results regular employees p 003 and those having prior contact experience p 001 had more accurate knowledge participants between 50 to 59 years old m 1587 standard deviation sd 335 had greater social distance than those under 30 years old m 1478 sd 397 p 005 the results of multiple linear regression analysis found that employment status partial r 007 p 005 and prior contact experience partial r 015 p 001 significantly affected the midus score whereas no variable had a significant effect on the asd score conclusions accurate knowledge of mental illness was significantly higher among regular employees and those with contact experience social distance was significantly lower among those under the age of 30 years

introduction the slovene roma are usually classified as members of the lowest social classes even though their social status varies from region to region it is still significantly lower than that of the rest of the population which also affects among other things their low level of education roma pupils academic success depends on many factors ie their linguistic and cultural differences teaching content that does not take into account the characteristics of the roma community poor preexisting knowledge before entering school differing behavioural and thought patterns different habits an undisputed environment poor work habits inadequate living conditions for homework assignments uneducated parents pupils skipping and leaving class the absence of trained professionals who have experience in working with roma children low expectations regarding their school performance lack of confidence in the school system and roma parents poor involvement in the educational process and their lack of cooperation with the school pupils performance and academic success are also significantly influenced by the school itself especially its dominant culture the school atmosphere and interpersonal relationships school is not only a place for obtaining knowledge but also a space in which pupils can encounter other individuals with whom to shape important relationships numerous studies have confirmed that pupils relationships with their peers and teachers are significantly linked to the wellbeing and acceptance of the pupils into the school environment their learning performance and their academic success vonta and jager state that schools cannot resolve all the factors that affect the educational success of roma pupils but that they can change or have a significant impact on at least some of them thereby increasing the pupils chances for academic success based on this we decided to explore how roma pupils and their mothers from roma settlements in prekmurje and dolenjska perceive the pedagogical work and attitude of teachers towards roma pupils in slovene elementary schools and whether their attitudes and relationships with the children contribute to the poor academic performance of roma pupils we wished to determine whether the teachers attitudes towards roma pupils were encouraging supportive understanding and nondiscriminatory through this study we aimed to give a voice and an opportunity to the members of the roma community and thereby raise awareness of the current challenges in the primary school education system the article consists of a theoretical section and an empirical section the first focuses on a fair and inclusive school that considers the varying needs of its pupils and thereby offers quality education for all we considered social acceptance respect and a sense of belonging as important indicators of social inclusion and emphasized that with the realization of all cultures within the school community we could help to create a tolerant coexistence at the same time this type of school community could help the pupils that belong to vulnerable groups to have different and more pleasant interpersonal experiences than in wider society next we focused on the importance of the teachers willingness to establish good interpersonal relationships with their pupils which significantly influences the involvement and activity of those pupils in the classroom we also introduced the results of our study to confirm that positive relationships between teachers and pupils are not only related to the wellbeing of the pupils at school but also to their learning success and behaviour in the empirical section however we will introduce the results of our qualitative study that focused on roma pupils and mothers perceptions of teachers pedagogical work and their attitudes towards roma pupils we aimed to determine whether their relationships affected the inclusive orientation of the studied elementary schools and whether the teachers attitudes towards roma pupils were an important factor that contributed to the lesser academic success of roma pupils creating a fair and inclusive school pupils enter school with varying prior knowledge experiences skills abilities interests as well as wishes and plans for the future thus it is the schools job to take into consideration all of the childrens unique traits and desires and offer them a fair successful satisfying and quality education in modern democratic societies fair education is one of the most important characteristics of national education systems when we talk about justice within the educational system we also refer to social justice in general a fair school according to peček and lesar is one in which the processes and activities are equally accessible to all pupils in this case it is allowed or even necessary for underprivileged and privileged pupils not to be treated equally so that the underprivileged can also benefit from the learning process among the latter rawls mentions those with lower social status and the less naturally gifted it is important to add that the privileged are not supposed to be punished because of their initial advantages which are neither fair nor unjust only the ways in which the fundamental social institutions deal with the pupils basic differences can be considered fair or unfair in the past slovene primary schools had to deal with various cases of group exclusion which confirm that the school system was unfair as these groups did not have the opportunity to develop to their full potential according to lesar these groups included pupils with special needs and ethnic minorities in contrast it is necessary to advocate for an inclusive school which tends to reduce all exclusionary procedures and devaluation of pupils based on disabilities race gender age ethnicity sexual orientation religion and other factors that make school life even more difficult inclusive schools are meant to introduce a series of adjustments that take into account the unique and varying needs of its pupils lesar highlights social acceptance respect and a sense of belonging as important indicators of inclusion namely inclusive schools are supposed to create a culture that does not give priority to the values of certain dominant groups but rather focuses on including all the cultures of its pupils and promotes tolerant coexistence at the same time lesar highlights that teachers and schools the latter embedded in the socioeconomic and cultural relations within an individual society can help their pupils have more positive experiences in society with their knowledge and engagement as well as the awareness that they can influence their pupils teachers can prevent the migration of existing relationships from wider society to the school environment as well as stop enlarging the differences between individuals especially between the nations members of the majority and the members of marginalized groups the importance of establishing good relationships between teachers and pupils teacherpupil relationships can significantly influence pupils development and their success in various areas of life according to the pisa survey positive and constructive relationships between teachers and pupils are key to promoting the pupils social and emotional wellbeing the results of this survey showed that on average in oecd countries pupils who reported having good relationships with their teachers also made friends more easily were more satisfied with their school and had a stronger sense of belonging a study by chiu et al also confirmed that teacherpupil relationships have a significant impact on pupils wellbeing and their sense of belonging to their class or school the same study demonstrated that pupils sense of belonging to the school depends not only on relationships with their peers but also on those with their teachers in another study uslu and gizir concluded that relationships between teachers and pupils can strongly influence pupils sense of belonging and feeling that they are a part of the school other authors have even stated that pupils wellbeing at school depends on their relationships with their teachers and peers hamre and pianta similarly determined that having a positive relationship with teachers is crucial as they can help children feel more comfortable at school build more meaningful relationships with peers and have a greater sense of safety furrer and skinner pointed out that a teachers relationship with their pupils is not only related to the pupils wellbeing in the classroom but also to their perception of learning in this study pupils who felt valued by their teachers were more likely to report feeling happy in the classroom they even found school activities more interesting and fun on the other hand pupils who felt unimportant or ignored by their teachers reported to be bored and angry when they had to participate in learning activities based on previous research juvonen pointed out that relationships between teachers and pupils that are based on support and characterized by a low level of dependence and conflict make it much easier for children to function at school such relationships are especially important for pupils who lack social support in their home environment moritz rudasill et al came to similar conclusions confirming that highquality relationships between teachers and pupils have a positive effect on children especially on pupils who come from less stimulating environments hamre and pianta determined that negative attitudes reflected in conflicts and dependence on teachers can be an important predictor of pupils grades and achievements on standardized knowledge tests they can also predict the work habits of pupils in elementary schools corneliuswhite studied the relational characteristics of teachers in connection with pupils achievements he found that the associations of these variables with cognitive variables were above average especially criticalcreative thinking and academic achievements while associations with iq grades and perceived achievements were at a medium level associations with scientific achievement and performance in the field of social sciences however were very low another study also confirmed that teacherpupil relationships significantly impact pupils academic achievements mccormick and oconnor stated that conflicts between teachers and pupils are more frequent at schools associated with lower reading achievement of elementary school pupils we can also draw conclusions about the connection between teacher support and pupils academic achievements from another slovene study conducted by puklek levpušček and zupančič the authors found that younger adolescents who perceive their teachers positively express more positive motivational beliefs and achieve better results in mathematics pupils who rated their mathematics teachers as responsive and helpful and who evaluated their work positively were more successful at mathematics compared to their classmates with negative teacher experiences research further showed a connection between teacherpupil relationships and pupil behaviour oconnor et al determined that quality relationships between teachers and pupils predict fewer behavioural problems and help prevent behavioural issues in the later stages of pupils development obsuth et al concluded that a positive relationship between teachers and pupils serves as a protective factor against behavioural problems in adolescents children aged 10 who reported having better relationships with their teachers were less likely to be involved in delinquent behaviour later on at the age of 12 15 and 17 similarly archambault et al found that pupils who had close relationships with their teachers reported greater behavioural adjustments compared to those who had less positive relationships with their teachers conflicting relationships between teachers and pupils have proved to be especially harmful for boys research has also confirmed that relationships between teachers and pupils are strongly related to the occurrence of peer violence thus marengo et al found that pupils who were victims of violence or bullies perceived their relationships with teachers as more conflictual compared to other pupils who were not involved in any form of violent behaviour pupils who were both bullies and victims reported having more conflictual relationships with teachers than those who were just bullies on the other hand pupils who were only victims of violence reported having a similarly conflictual relationship with their teachers as the pupils who were both victims and bullies the latter turned out to be the group that had the worst relationship with their teachers the research presented above shows a significant connection between teacherpupil relationships and the pupils academic success behaviour and wellbeing at school these findings further point to the importance of good and healthy teacherpupil relationships peček and munda investigated the attitude of teachers towards roma pupils on a sample of 77 roma elementary school pupils from maribor the results of their study showed that the majority of pupils who were included in the study had positive experiences with their teachers while 4 pupils gave negative descriptions of their teachers and mentioned cases of discrimination of the pupils14 gave a mixed description of their teachers however we should not forget that the study also confirmed that teachers are not fully aware of the importance of their influence on the learning performance of roma pupils empirical research in the following section we present the results of our empirical research in which we tried to find out how roma pupils and their mothers perceive teachers pedagogical work and their attitudes towards roma pupils the paper introduces some of the results of a more extensive empirical study which was conducted as the basis of a masters thesis at the department of pedagogy at the faculty of arts of the university of maribor research method and sample we used an empirical qualitative research method and included a nonrandom occasional sample of 20 roma pupils in the third educational period of primary school in the 20192020 school year we decided to conduct the interviews in prekmurje and dolenjska because these two regions are known to have the largest number of community members with the most noticeable social differences the interviews in prekmurje were arranged directly with the interviewed subjects most of whom just like the first author of the article originate from the roma settlement in dolga vas and have children in the third educational period of primary school some interviews however were conducted with the residents of another roma settlement in prekmurje the interviewees were not the authors acquaintances but were recommended by them for the interviews in dolenjska we contacted the roma activator employed at the novo mesto developmental education centre who made appointments with the interviewees and accompanied us to the roma settlements during the interviews these were conducted in the months after the distance education period right after the first wave of the covid19 pandemic in slovenia the pupils had just returned to school and had only spent a month back in the classroom we interviewed 10 roma pupils from prekmurje and 10 from dolenjska of which 12 were girls and 8 were boys one of the interviewed pupils had failed that year nine had finished school with a 2 sufficient knowledge seven pupils had finished with a 3 good knowledge and two girls had finished with a 2 very good knowledge one of the interviewed pupils from prekmurje could not provide information on her grades the interviewed roma pupils from prekmurje lived in two roma settlements and attended four different primary schools while the pupils in dolenjska who also came from two separate roma settlements attended three different primary schools besides roma pupils the study also included the mothers of roma children of these ten were from dolenjska and ten from prekmurje to be precise our sample included 16 mothers of the interviewed roma children and four other mothers whose children we did not interview on average each of the interviewed mothers had 32 children ten of them had not completed primary school seven had a primary school education and three a secondary vocational education of the mothers eleven had work experience the remaining nine had never been employed nor had they taken on any occasional jobs research instruments and data collection procedures we collected our data from a semistructured interview with predefined basic openended questions which in some cases were followed by subquestions that arose naturally during the interviews the data was collected between july 2020 and august 2020 which is when the interviews in the roma settlements in prekmurje and in dolenjska were conducted in prekmurje the majority of the participants were interviewed on the premises of the multipurpose roma centre dolinskodolga vas while the rest of the interviews were conducted in the subjects homes all interviews in prekmurje were conducted in a calm environment without any disruptions in dolenjska the subjects were interviewed at home mostly in their backyards some of which were located next to the road or in family yards and louder environments where it was not possible to ensure enough peace and quiet some of the interviews were disrupted by small children the interviews were conducted by the first author of the article who explained the purpose of the study to all the interviewed subjects and asked them to answer the questions honestly in dolenjska where the author did not know the interviewees she also had to introduce herself and inform them of her origin during the relaxed informal gatherings in dolenjska we had the opportunity to get to know the subjects and explain the purpose of our visit nevertheless some of the mothers were slightly tense and less relaxed during the conversations since they were not actively involved or included in their childrens educational process we also encountered quite a few organizational obstacles as we had to wait for or even go in search of the interviewees who forgot about our appointment we did not encounter such problems in prekmurje all interviews were conducted individually and in private the conversations during the interviews were held in the slovene language before each interview the parents of the interviewed children had to sign a written consent form in which they were informed about the purpose and course of the study by signing this form they also confirmed that their children would participate in the interviews in accordance with the ethical principles of voluntariness and that their answers would remain anonymous this consent also gave them the right to change their mind and withdraw from the study at any time without any consequences all interviewed subjects consented to being audio recorded the average interview lasted about 20 minutes the shortest 12 and the longest 32 minutes data processing procedures the audio recordings were transcribed into written form and changed into word format after repeated listening in order to analyse the results for the purpose of this article we separated the interviewees into two groups and marked them with consecutive interview numbers after the transcription was done we listened to the tracks again to make sure that everything had been transcribed correctly to process the collected data we first carried out a qualitative content analysis and then marked the parts of the transcribed text which we thought were relevant to and important for our research next the text was broken down into its smallest meaningful components thus obtaining coding units with information relevant to the purpose of this study following this we gave code names to the latter coding units and divided them into categories based on similarity during the last step we sorted the categories according to their meaning and determined the central themes of the study results and interpretation following this we introduced the way in which pupils and their mothers perceive the attitude of teachers towards roma pupils in the context of the previous chapter we were initially interested in how roma pupils perceive their teachers and what they think about their pedagogical work and knowledge assessment in the second part of the introduced results we focused on how roma mothers perceive the teachers pedagogical work and attitudes towards roma children the pupils perception of the teachers attitudes towards roma pupils first we presented the teachers attitudes towards roma pupils from the perspective of roma pupils which as seen in table 1 were divided into two categories perception of the teachers attitudes towards roma pupils the roma pupils mostly described their teachers in a positive way they stated that they are kind helpful and really make an effort one of the pupils said they were friendly and liked to help if you did not know things they tried to help so you could finish the class with a positive grade the pupils also stated that the teachers explain things well are very understanding and are open to negotiation and common agreements some of the pupils pointed out that the positive attitude of the teachers is the main reason why they like coming to school some of the pupils stated that not all teachers are the same some are friendly while others are not this was also confirmed by the following statement make by one of the interviewed pupils the best teacher is the math teacher but the class teacher and the physical education teacher are also very good they are very nice they listen to what we want to say while the others just shout at us the same pupil used the slovene teacher as a negative example in his opinion the slovene teacher is a bad teacher because she screams all the time however he did not say that she only screams at roma pupils similarly other roma pupils who gave a negative assessment of their teachers stated that teachers often yell at pupils but none of them said that this only applies to roma pupils most of the roma pupils said that their teachers treat them the same as they treat their nonroma schoolmates and that sometimes they even defend roma children in front of other pupils the following is the statement by one of the pupils that confirms this at this school the teachers stood up for us roma pupils and told the other children that we are the same as anybody else they even told them not to behave like this note be discriminatory the interviewed pupils stated that the teachers attitudes towards roma pupils depends on the roma pupils attitude towards the teachers and other children in the class when asked if the teachers were equally kind to all students one of the pupils replied they are equally nice to everyone however if the roma pupils are not nice to the teachers or their peers the teachers react in the same way the interviewed pupils also believe that the attitude of the teachers towards roma pupils depends on the actual effort made by the roma children one of the interviewed pupils even said i consider the teachers nice they are nice to me note teachers because i am trying harder than the others the opinion that the teachers attitudes towards roma pupils depends mainly on the roma pupils attitude towards their teachers was more common among the interviewed subjects from dolenjska they admitted that roma pupils often disrupt class which then affects the teachers attitude towards them the interviewed pupils had negative experiences and admitted to having discriminatory teachers as well this can be confirmed by the following answer given by one of the pupils we were doing something i dont remember what exactly and she note teacher told me that i dont have the same rights as the other children she kept telling me i will never be like my mother because i am lazy she was also rude to others but she told me that i dont have the same rights as others she said that because i am a roma another pupil described a discriminatory experience with a teacher as follows there was this one time when me and him note a classmate quarrelled i was yelled at he was not because he has problems with his nerves at the same time the pupil pointed out that this does not happen very often perception of the roma pupils knowledge assessment most pupils believed the teachers were fair in assessing their knowledge as they always got the grade they deserved sometimes even a higher one one of pupils stated i always got the grade i deserved sometimes an even higher one some of the interviewed pupils pointed out that teachers are unfair and strict in assessing their knowledge and that they give unjustified negative grades one of them said yes the history teacher is like that some pupils dont do what they are asked during class and she starts screaming and then gives them a negative grade she should first warn them before giving out negative grades some of the interviewed pupils also thought that teachers when assessing knowledge are more considerate of the academically more successful students which was confirmed by the following answer yes for example the … teacher … when writing a test i was only missing one single point for a positive grade just one point and he immediately gave me a 1 to others who were one point short he gave a 3 not a 2 when asked why she thought she didnt get that extra point like the others she said because i was apparently stupider when the interviewed pupils talked about why their teachers were unjust none of them with the exception of one student from dolenjska stated that the reason for it was their ethnicity some of the answers regarding the teachers assessment of knowledge insinuated that teachers treat roma pupils differently the latter is clearly highlighted in the following answer if we know everything they still do not give us an 5 if i know everything they only give me a 2 while the civilians note students from the majority population even if they know a bit they get an 5 or a 4 during the interviews roma pupils repeatedly pointed out that teachers adapt the teaching process to their capabilities they explained that during exams and oral assessments of knowledge teachers adjust the tasks or questions so that they can get a positive grade or that they only ask them questions or give tasks for a positive grade one of the pupils summed up her thoughts as follows in some subjects not everyone is treated the same way and emphasized that the teachers ask her easier questions or give her less challenging assignments the pupils from dolenjska talked about the adaptation of tasks and assessment while the pupils from prekmurje did not mention any of that the teachers attitudes towards roma pupils from the perspective of roma mothers this topic was divided into two categories both of which are presented in table 2 source own data perception of the teachers attitudes towards roma pupils the interviewed mothers perceived the attitudes of the primary school teachers towards their children as friendly and equal they evaluated that the teachers attitudes towards roma pupils depends mainly on the childrens attitude towards the teachers and their peers as well as on the work and effort the roma pupils are willing to put into their school obligations one of the interviewed mothers stood out with her statement as she said that teachers go easy on roma pupils continuing with … as far as i can tell it is harder and stricter for those other kids the slovene ones the roma mothers referred to their kids teachers in a rather positive way they believed that the teachers are friendly helpful and always available if the children or parents need them we detected a slightly more positive description of the teachers in dolenjska some of which even conducted home visits especially during school closures due to the covid19 pandemic one of the interviewed roma mothers who does not attend school meetings because she communicates with the teachers over the phone or through a roma assistant described the teachers as follows as far as i can see they have come here a couple of times during this corona period they are very friendly also the class teacher i have nothing bad to say about them they are normal they help if we need them when roma mothers described the teachers attitudes negatively they mostly referred to unequal treatment of the pupils but the reason behind it was not always ethnicity some of the interviewed mothers however warned that the teachers attitudes towards roma pupils is discriminatory they believed that teachers are not fair to roma children especially in conflicts with nonroma children one of the mothers shed light on the problem saying well maybe sometimes there are conflicts if they fight its almost certain that the roma child will be to blame another mother shared examples of verbal abuse a teacher insulted her daughter by saying she is a gypsy another interviewed subject even mentioned a case of physical violence yes the class teacher he threw chalk at him … they were loud in the class and he threw a piece of chalk at him then he and i note husband went but he did not tell us note son the other children told us that he threw chalk at him so we went to school and had a meeting he note husband warned that this can never happen again we had peace for a while but after two months the teacher hit him on the head again from the statements of the interviewed mother it is hard to tell whether the teachers actions were committed because of the childs ethnicity or for other reasons the same mother also said that the teacher probably hit the other childher sons classmate who was also involved in the same conflict roma pupils knowledge assessment from the perspective of roma mothers the roma mothers pointed out that their childrens teachers are fair when it comes to assessing knowledge and added that teachers used to be more unfair when they themselves attended elementary school one of the interviewed mothers explained the situation as follows because when i was at school we were learning the same stuff well actually we werent they gave us something else to learn but even if we knew a lot they would only give us a d now it is different when school started and the teachers came to talk to us four roma mothers from prekmurje perceived their childrens knowledge assessment as unfair two of them even pointed out that the reason behind it is the childrens ethnicity one of the mothers stated i think they are treating them differently the roma children and those others some deserve it note a bad grade but the slovene children get fewer bad grades than the roma children the other two mothers said that it is the teachers from smaller schools who are problematic they explained that the teachers and parents from smaller schools know each other and as a result the teachers prefer the children of certain parents one of the interviewed mothers added acquaintances are a problem some come from the same village live nearby and know each other he will deserve a b make mistakes and still get an a some note children whos parents do not know the teachers privately outside of school try really hard and have it note knowledge yet the teachers will not acknowledge it they will even give them a lower one note grade there are huge differences but thats acquaintances another critical description came from a mother who stated that the teachers are not experts in their field do not take into consideration the differences between pupils or know how to adjust their work to kids with special needs ugh the teachers at this school are really terrible well not to be rude to all of them there is one young teacher who is new and she is great but the others especially the older ones they dont behave like teachers at all you know that my older one note son got a written confirmation he is dyslexic still they always bothered him with handwriting and were telling him he should write bigger or smaller when he received the official diagnosis they still didnt take this into account even though everything was official and written on paper he could have taken the tests orally that was his right but they did not care and it is not just my son … they dont understand that pupils are different mine cant be like the others and the others arent all good either they dont know how to adapt to anyone on the contrary some of the interviewed children and mothers from dolenjska pointed out that the teachers adapt their teaching methods and content to roma pupils which means that they prepare easier questions and tasks for them all of these mothers with one exception perceived this as a positive thing the mother that was critical on this matter pointed out that this is not correct and that roma pupils should be treated the same way as any other pupil in the class discussion the purpose of this article was to investigate how roma pupils and their mothers perceive teachers pedagogical work and attitudes towards roma pupils namely the teacherpupil relationship can have a positive impact on the pupils wellbeing sense of acceptance and academic performance in the case of roma pupils this relationship is even more important since roma are considered one of the most marginalized groups in slovenia this group faces many challenges both in the educational system and in other social realms although school is embedded in the socioeconomiccultural side of society explains lesar it can give pupils a different perhaps more positive experience than what they are experiencing outside of school in wider society we use the term positive experiences to encompass interpersonal relationships social acceptance respect and a sense of belonging to the school which are all important indicators of an inclusive school based on the obtained results we could not connect the poor performance of roma pupils with bad teacherpupil relationships at least in our study the latter did not contribute to poorer academic performance in roma pupilsnamely the interviewed pupils rated their relationships with their teachers as quite good therefore we believe that in the future our research should focus on other potential factors that may have an impact on lower academic performance of roma pupils these other factors were discussed in the introductory part of the article the results of our study collected from the answers of roma pupils and mothers showed that roma pupils from prekmurje and dolenjska generally perceive their teachers as kind and fair they even pointed out that the teachers are helpful and good at their job explaining and passing on knowledge good social relations with teachers proved to be important to roma pupils their teachers according to the pupils statements are the reason why they like attending school both the pupils and mothers assessed that the attitudes of teachers towards roma pupils often reflects the attitude of roma pupils towards teachers another study that refers to roma elementary school pupils in grosuplje which was conducted by koščak showed similar results and confirmed that roma pupils look for shelter and attention in their teachers which is primarily a result of nonacceptance by their nonroma peers based on this we can conclude that the roma pupils included in the study feel accepted and respected by their teachers both the interviewed pupils and their mothers stated that teachers in primary schools treat roma pupils the same as other pupils which is definitely encouraging and confirms the inclusive attitude of primary schools according to one of the interviewed subjects teachers are warning nonroma pupils not to discriminate against their roma peers however the personal attitudes of the teachers towards roma pupils sets an example for other nonroma pupils and has a significant influence on the extent of the roma pupils being accepted by their nonroma peers the relationship between teachers and pupils is therefore essential for the social inclusion of pupils in the classroom even though roma pupils and their mothers perceive teachers mainly in a positive way the study also revealed a few cases which are less encouraging the teachers negative assessments pointed towards an unfair assessment of knowledge and an unfair attitude towards the children however there was no confirmation of this attitude deriving from ethnic discrimination towards roma pupils the described examples and issues with the teachers could also apply to nonroma pupils only one interviewed pupil from dolenjska referred to teachers as being ethnically discriminatory when assessing knowledge and grading roma pupils in comparison to the interviewed pupils more roma mothers gave negative assessments of the teachers the mothers from prekmurje also gave more negative teacher assessments than the mothers from dolenjska at this stage we should point out that in most cases the negative teacher assessments did not stem from discrimination against roma pupils the roma mothers from dolenjska stated that teachers adjust schoolwork for their children by giving them simpler tasks or evaluating them on the basis of preprepared questions and answers which enable them to achieve the lowest positive grade some mothers perceived this as a discriminatory act this way their children unlike nonroma pupils are not given the opportunity to attain a higher grade such adjustments for roma pupils show that teachers demand less from them compared to other pupils the latter was also confirmed in other previously conducted studies this kind of attitude towards roma pupils is problematic not only because it is discriminatory but also because the teachers low expectations lead to the roma pupils low academic results at the same time it shows disrespect towards roma pupils who are being deprived of the same opportunities knowledge and progress other pupils are granted the unfair teaching methods and knowledge assessment could be related to the ingrained stereotypes about the roma which eg say that they are not interested in education this stereotype probably derives from a lack of knowledge regarding the home environment of roma children bešter and medvešek found that most teachers in slovene primary schools try to encourage roma children in their educational process and help them achieve the best possible results however they still lack knowledge and understanding of intercultural differences at the same time the teachers do not go beyond an ethnocentric attitude and worldview and they are also not too engaged in overcoming the existing social relationships of inequality between the majority population and minority groups the authors pointed out that there are a few exceptions among teachers who have welldeveloped intercultural competences these result from training openness and the teachers individual efforts rather than from systemic incentives and support which teachers could really use we believe that all the aforementioned difficulties could be at least partially omitted if the educational programs of future pedagogical workers as well as the programs for continuous professional development included more inclusive and romarelated topics therefore it would be wise to assess the curricula of university programs that train future teachers and if necessary enrich them with additional content on the typical characteristics of roma culture and roma communities in slovenia as well as national and other documents related to the roma community and the education of roma pupils the universities that educate future teachers could connect their students with representatives of the roma community who could directly introduce them to roma culture and the roma community itself or give the students an opportunity to visit roma settlements and explain to them the specifics of living in such communities these are just a few ideas with which students and future teachers could become familiar with the specifics of roma culture in the course of their studies get a better understanding of roma pupils gather knowledge on how to approach roma pupils properly and learn how to introduce roma pupils nature and characteristics to other nonroma pupils in the class and at school the latter is extremely important in light of the reasoning pointed out by vonta and jager who said that professionals in slovene elementary schools seem to be aware of the importance of including roma culture in the educational process but that they are currently pursuing this step only by encouraging roma pupils to perform and introduce their culture at school events to fully understand and properly interpret the results we have taken into consideration that the interviews were conducted during the first wave of the covid19 pandemic in slovenia in the months after home schooling when the pupils had only spent a month back in the classroom after the long period of home schooling most pupils could not wait to go back to school which of course could have affected their perception regarding the teachers attitude towards them the longterm distance education is also likely to have been reflected in the childrens schoolwork bešter and pirc investigated this topic further and wanted to determine how distance education affected roma pupils in slovenia during the quarantine period based on the data they collected from roma assistants and teachers the authors of the study concluded that approximately half of roma primary school pupils were in regular contact with their teachers during quarantine while the proportion of nonroma students who were in regular contact with teachers was much higher almost half of the roma pupils in primary schools maintained contact with the school through roma assistants the same survey showed that in schools with roma assistants a quarter of all interviewed teachers estimated that during the quarantine period most roma parents were not in contact with the school at all while another quarter of teachers pointed out that the parents were in regular contact with the roma assistants but not directly with the teachers only a fifth of the interviewed teachers stated that roma parents were in contact with them directly most of the teachers in schools with roma assistants also reported that cooperation between roma parents and the school remained the same as before the pandemic slightly more than a tenth noticed an improvement and about a fifth a deterioration in this area in schools without roma assistants the situation was pretty much the same the authors also determined that some teachers made home visits and brought roma pupils class materials as well as gave instructions for schoolwork in our study two interviewed mothers from dolenjska also reported having home visits from teachers one of these two mothers had no contact with the teachers prior to the pandemic but during the homeschooling period thanks to home visits she came to regard the teachers in a very positive way we must also point out some of the limitations we faced during the study one of the major limitations were the interviews in dolenjska where it was not always possible to ensure a calm and relaxed environment the interviews were often interrupted by the interviewed mothers young children or by the brothers and sisters of the interviewed children as well as by the noise coming from outside we could have avoided this issue if the interviews had been conducted in a common space within the roma settlements but the interviewed subjects wanted to talk to us in their homes so we did as they asked some of the interviewed mothers in dolenjska were very nervous we even detected slight mistrust which may have influenced their answers even though the results do not apply to the entire population of roma pupils and their mothers in slovenia they still present a valuable insight into the experiences of roma pupils with teachers and their pedagogical work the extra value of this research lies in giving voice to the ignored roma community by including roma pupils and their mothers in this study and giving them the opportunity to speak up and share their perception of teacherpupil relationships and the pedagogical work of the teachers we can better understand the communities experiences and perspectives the findings are also important for raising awareness among teachers and school management not only about the impact of teacherpupil relationships on the pupils wellbeing and academic performance but also about the fact that all pupils regardless of nationality or special needs deserve equal opportunities the results can potentially contribute to a more subtle perception and understanding of the wellbeing and the situation of roma children in slovene schools and as a result help raise the quality of pedagogical practice in the field of roma education in slovenia the study also opened up a number of new research questions namely the interviews were conducted during the covid19 pandemic which could have affected the results so it would be wise to repeat the entire procedure in the upcoming school year in the study we focused on two locations dolenjska and prekmurje however for an even better understanding of the relationship between teachers and roma pupils it would be wise to include roma pupils and parents from other regions as well another interesting thing to investigate would be how teachers perceive their relationships and work with roma pupils our study confirmed that the relationships between teachers and roma pupils are mostly encouraging but it also revealed some discriminatory behaviour in teachers that prevents roma pupils from achieving the same learning results as the rest of the population we should focus on these practices during future research and study the remaining factors that could have an impact on the learning success of roma pupils in slovene schools we should also focus on exploring examples of good teaching practice in the field of roma education conclusion in the empirical qualitative study based on the answers of roma pupils and their mothers we focused on the experience and perception of teaching methods as well as teachers attitudes towards roma pupils based on the interviews conducted with the members of the roma community in prekmurje and dolenjska we can conclude that the elementary school teachers in the two mentioned regions are successful in providing a safe and inclusive environment for roma pupils even though the results are mostly encouraging we should not ignore those few examples that indicate a discriminatory attitude in teachers towards roma children such cases should not be swept under the rug they call for further efforts to eliminate discrimination reduce differences and promote the inclusion of minority groups in slovene schools considering both the positive and the negative experiences of roma pupils and their mothers the results indicate that we need to continue with measures that will help not only improve relationships between teachers and pupils but also provide adequate support and resources for equal opportunities learning and progress of roma pupils however we should also explore other factors that affect roma pupils wellbeing in school their learning performance and advancement in the educational system

in this article we will discuss the case of fair and inclusive schools that are considerate of the specific and unique needs of their pupils and offer quality education for all we will highlight the most important indicators of inclusive education and focus on research that confirms the importance of the teachers willingness to establish good interpersonal relationships with their pupils in the empirical section we will introduce the results of our qualitative study based on interviews conducted with 20 mothers and 20 primary school pupils in two slovene roma settlements we explored how pupils and their mothers perceive teachers attitudes towards roma children our findings were very promising for they showed that the interviewed pupils and their mothers had a positive experience with the teachers and their pedagogical work with roma children however we should not ignore the few cases that pointed to ethnic discrimination towards roma pupils

introduction the family is a unit formed by interconnected and interacting parts that have a special structure or in other words have ties in the form of marriage and blood relations that influence religion emotional ties and customary law the family environment is the most important environment for children to learn about their cultural norms values attitudes and beliefs so that children can grow into children who have a positive attitude to act in a wider environment afterward in instilling these traits the family has a very important role namely the nuclear family and extended family both of whom influence each other on the spiritual development of children for example in worship the family nucleus consists of a father a mother and children the existence of the elderly who live together with the nuclear family is referred to as a large family or extended family extended family is one of the characteristics of families in indonesia the extended family consists of family members not only the father mother and children but also other family members the extended family means that the family relationship between parents children and grandparents can be said to be very close so that the duties and responsibilities in caring for children are gradually given to grandparents who have entered their final age or are elderly because the childs parents are working or so on cases of divorce and death are other factors that reasons for children to be cared for by grandparents besides being busy working to fulfill the familys economy in addition to caring for grandparents grandparents also instill spiritual qualities in their grandchildren which are useful for embedding themselves in perfect religion such as reciting the koran praying at the mosque or something else mlaten village is a village where grandparenting occurs due to many things such as infidelity divorce and being left to work abroad so that parents are not directly involved in raising children the task of caring for children is transferred to grandparents who mostly work as farmers therefore the description of the problems above is the reason for researchers to study more deeply about grandparenting in the spiritual development of children in mlaten village mijen district demak regency research method the research in the article above uses field research field research is research in the form of descriptive analysis namely research that is focused on certain events to be observed and analyzed and researched data analysis in qualitative research begins with preparing and organizing data where data is taken from interviews observations and others according to moleong the qualitative data analysis process begins with reviewing all available data from various sources such as interviews and observations that have been recorded in field notes personal documents official documents photographs and drawings after reviewing the next step is data reduction unit arrangement categorization and finally data interpretation findings and discussion background of the occurrence of grandparenting in mlaten village mijen district demak regency forms of parenting grandparents can influence the formation of a childs personality after he becomes an adult this matter is due to the characteristics and elements of the character of an individual maturing long before the seeds are already implanted into the soul of an individual from the very beginning that is when he was a child that is the treatment of grandparents of their grandchildren since childhood will have an impact on their social and moral development as they growing age it is this socialmoral development that will shape character the nature and attitude of the child later although several other factors influence the formation of reflected child attitudes in his character such as the main factor in the occurrence of grandparenting which was stated by mrs nurul wahidah in mlaten village mijen district demak regency because his parents had an affair with another woman but his father still provided for his child after this incident his father divorced his wife and then married siri to his mistress therefore to make a living for his child his mother was willing to work as a migrant worker in arab saudi some researchers have grouped affairs into two types among others sexual infidelity and emotional infidelity in which individuals share an emotional bond deeply with someone who is not a partner according to guitar when someone is in a relationship or marriage and engage in sexual activity with other individuals who are not partner it can be said that the individual is having a sexual affair some of the things included in this affair are having the intention to have a relationship sexual intercourse with other people engaging in pseudosexual behavior engaging in activities of sexual intercourse and intimacy with other people either directly or through electronic devices by sharing things of an erotic nature then someone is said to do emotional infidelity if the person has created emotional distance from the main partner and spending too much time with or thinking about other people outside of the relationship in other words the main partner becomes neglected or emotionally rejected according to guitar that was included in the affair above type is deceiving a partner about his feelings towards someone else dedicating yourself emotionally to others not emotionally satisfying your partner compared to others falling in love with others lying to a partner discussing relationships with other people and having romantic feelings for other people outside partner it is not only infidelity that causes grandparenting but also divorce as interviewed by sumartis mother as follows because the father and mother are divorced then the father is not responsible for providing a living for his wife and children therefore to make ends meet for her children her mother is willing to work as a female worker abroad according to agoes dariyo a divorce is an event that is not planned and desired by the two individuals who are both bound by marriage divorce is the breaking up of a family because one or both partners decide to leave each other so they stop carrying out their obligations as husband and wife divorce doesnt only cause emotional disturbances for couples divorced but also the children will be affected the impact of divorce on children will be heavier than on their parents sometimes the child will be feeling caught in the middle when the parents divorce anger fear separation anxiety sadness and shame are reactions for most children from the effects of divorce divorce that occurs in a family has an impact that affects the soul and condition of the child children experience obstacles in their fulfillment related to love and belonging parents must face the fact that their parents are divorced the child gets a bad picture of family life in a childs feelings divorce is a shameful deficiency divorce almost always makes children sad angry and weak in spirit the point is that children are in deep dilemmas and feel various problems psychologically on the other hand the factors that affect grandparenting are not only infidelity and divorce but also being left to work by their parents as said by mrs suwarti and mr muji as follows mother and father work and i live with them and my grandchildren because the father and mother work every day working every day or traveling is a normal and very common phenomenon in indonesia especially in mlaten village mijen district demak regency community factors for working especially in mlaten village mijen district demak regency are as follows cultural factors and economic factors 1 this cultural factor occurs because most of these people choose to migrate or work every day as the main alternative to earning a living so that wandering becomes rooted and the culture of wandering becomes hereditary 2 economic factors another explanation is population growth that is not accompanied by an increase in natural resources that can be managed if previously agricultural and plantation products were their main source of residence to support their family now the results from natural resources which are their main source of income are no longer sufficient to provide results to meet their common needs because they must be divided among them several families someone who develops a childs spiritual intelligence must pay attention to opportunities to develop a childs selfawareness through activities related to art such as drawing playing drama or playing music these activities can develop childrens selfawareness e invite children to often ask why or what if and look for basic answers when solving problems f provide opportunities and rewards for children to show good behavior and empathy g teach children to try to overcome pain and suffering h provide opportunities for children to think about the meaning and values of life in calm and solitude grandparenting in strengthening children not only does the above understanding strengthen childrens spiritual intelligence but also instills an attitude of honesty that can be carried out through simple daily activities and as a habit for young children namely behavior that can distinguish personal property and that of others the basic ability to differentiate is the basis for being honest honesty is stated as a positive value because this behavior is beneficial both for those who commit it and for other people who are affected by it honesty is one of the principles that must be upheld by everyone as early as possible not only important for students students and students honesty is very valuable for oneself society people or a nation honesty will bring peace inner peace and even happiness to someone in society so that people judge as someone good not only in the family but to the wider community as applied by suwartis mother in strengthening the spiritual intelligence of her grandson invited to socialize with new people in terms of goodness an example of joining jamiyyah and little by little introduced to the obligation of prayer and often advised not to lie try to tell the truth wherever he is according to baumrind the above parenting style is included in the demandingness dimension dimensions demandingness is a dimension related to caregiver demands regarding the desire to make children part of the family hope for mature behavior discipline provision of supervision and coping with problems in child behavior these demands are the hopes and efforts of caregivers so that children can fulfill their standards of behavior attitudes and social responsibility are high or have set claims vary depending on the degree to which caregivers maintain supervise or try to make the child meet the demands spiritual strengthening does not only introduce worship but motivates people to do good because humans have spirits that sometimes go up and down so when humans are in a state of low spirits they need to be motivated humans have the potential that when motivated they will show even better performance because motivation has a very good and positive impact on the development of the human soul especially the development of childrens education childhood is a period of ups and downs in terms of learning so we must always provide motivational methods as expressed by mrs nurul wahidah and mrs suwarti in motivating their grandchildren in spiritual strengthening as follows i often motivate my grandchildren about this incident in terms of patience in dealing with all problems give motivation and respect to others dont like lying be honest and from your parents also give awards when you can memorize prayers or short letters motivation can be defined by everything that drives demanding behavior or encourages someone to meet his needs at this point motivation becomes the driving force of behavior as well as a determinant of spiritual motivation and enthusiasm are the same units in strengthening the spirituality of their children because enthusiasm is a condition to take an action to be motivated so enthusiasm has a function as a driving force for the human mind to act with strong determination selfmotivation is also very necessary in grandparenting to raise grandchildren where is the parenting style in grandparenting this also has an impact on grandchildren the impact of grandparenting in strengthening childrens spiritual intelligence in mlaten village mijen district demak regency the form of parenting grandparents to their grandchildren is carried out according to the experiences and insights of grandparents grandfathers and grandmothers provide opportunities for their grandchildren to carry out their activities make light work schedules and give verbal rules to their grandchildren with the hope that children will obey them however in applying the oral rules grandparents include explanations that use words that are good and easy for children to understand so that harmonious interactions are created between grandparents and children and with people around their environment like the parenting applied by suwartis mother in educating her grandson as she has expressed there is a significant impact quicker to understand responsive and quicker to accept new things than his age from this expression it can be interpreted as a comprehensive understanding of early childhood needed to achieve the goals of each child that will be carried out becoming a capable person by socializing requires three processes one of which is learning to behave socially acceptable play acceptable social roles received and develop social traits using spiritual intelligence means functioning with the ability to have an impact and meaning of worship on every behavior or activity through steps and thoughts that are natural towards a complete human being and have an intergalactic and principled mindset only because of allah all of that has been done by sumartis mother in spiritual development for her grandchildren as follows grandchildren can study the koran and perform prayers at the mosque from the expression above there are several steps to grow and develop a typology of childrens spiritual intelligence namely independence instilling independence in children from an early age may be so that the child is detached from the characterdependent personality of others and providing motivation in children is the most important thing in growing childrens courage in knowing knowledge through a caregiver the actions carried out by these children can be categorized as characterbuilding values which have several components including religious religion is an aspect related to the level of connection which includes the frequency and intensity of several behaviors where the behavior has been determined by religion such as procedures for carrying out worship and religious rules so it can be said as behavior in worship is determined by religion such as procedures for carrying out worship and rules in religion in this case the religious character of a child who is raised by his grandmother is expected to be used to diligently carry out worship daily and can develop his religious values advice this advice can open childrens inner eyes to the essence of something push it toward the situation sublime decorate it with noble character and equip it with islamic principles in cultivating prayer worship or studying the koran in children and always giving advice so that children understand the importance of carrying out worship such as praying and studying the quran discipline according to hurlock said that discipline is behavior and discipline following the rules and objectives to train and provide direction for children to be orderly cooperative and have noble character so it is disciplinary behavior following rules that exist around or in the life child every day the discipline itself can be seen through diligence and adherence to disciplinary conduct applied such as praying in congregation and learning to study the koran discipline education is very important in a childs life disciplined children will be successful in in their life and life in society discipline will reflect calm and serenity conversely children who are not disciplined will lose their life and harm others method good at giving understanding to children in the discipline of prayer is to provide an understanding of fiqh about good prayer and true performing prayers is guided by good discipline time and obedience discipline is control over the behavior of a person to always obey the rules of other people or yourself instilling principles so that children have a firm stance is a very important part of the strategy for upholding discipline and not just choosing friends because friends can eliminate discipline if children are influenced by a bad culture as for the method of enforcing discipline carried out by mrs nurul wahidah and mrs sukarti to their grandchildren as explained by her there is a positive impact from my grandson with my firmness and supervision my grandson does not dare to hang out with naughty friends because i educated him firmly and hard the impact was that he was more independent and diligent at school and studying the koran according to baumrid this form of parenting suggests that family care for their grandchildren is an authoritative form namely encouraging children to be independent but still applying limits and controls to their actions authoritative grandmother show fun and support in response to her granddaughters constructive behavior they also expect the behavior of their grandchildren to be mature independent and ageappropriate grandchildren who have an authoritative grandmother are often cheerful selfcontrolled and independent and achievementoriented they tend to maintain relationships friendly with peers work together with adults and can cope with stress well in the pattern of care above this parenting has rigid rules for raising her grandchildren each violation will be subject to punishment is pushy and tend to be uncompromising and deep oneway communication caregivers apply this parenting style when interacting with grandchildren caregivers provide directions to grandchildren firmly without any resistance from the child himself but when directed given is positive it will have a good impact on grandchildren and if the direction given is negative it will have a bad impact on grandchildren in their daily interactions conclusion grandfather is the activity of caring for raising and educating grandchildren in survival some of the factors for the occurrence of grandparents are cases of divorce the occurrence of affairs and doing work every day then the identification of grandfathers in strengthening childrens spiritual intelligence above is religious education such as reciting the koran diligently carrying out worship at the mosque and being able to instill honesty in all matters then the impact of grandparents in mlaten village mijen subdistrict demak regency is always carrying out their obligations as muslims namely worshiping at the mosque getting used to reciting the koran and being able to choose friends who can be invited to join they good and not bad grandchildren who are cared for by grandparents can also live independently and be disciplined and have the same abilities as children who live with both parents

grandparenting is childcare carried out by surrogate parents grandparents where grandparents are part of a large family that is trusted by parents to care for their children either temporarily or permanently in their care grandparents educate their grandchildren in the ability to strengthen spiritual intelligence which is covering a wide variety this study uses qualitative field research where data is obtained through interviews the results of the study stated that the background of the occurrence of grandparents was due to various things infidelity divorce or being left by their parents to work then grandparents in strengthening childrens spiritual intelligence by familiarizing themselves with religious activities such as learning the koran praying in congregation and training themselves to be honest in all things then the impact of grandparents is being able to strengthen religious traits in everyday life such as worship activities socializing well and being able to distinguish between good and bad traits

summary the onceina100year coronavirus disease 2019 pandemic has resulted in over 44 million confirmed cases and 12 million deaths by the end of october 2020 1 due to the airborne humantohuman transmission of the infectious disease global governments issued restriction orders of social distancing selfisolation and travel bans to reduce transmission risk and consequently caused crucial impacts in particular the labor requirements decreased across all economic sectors and unemployment numbers increased 23 to record measure and reduce the negative influence on the society and economy caused by the pandemic a comprehensive socioeconomic factor collection for the pandemic period is urgently needed for comparing modeling and predicting the socioeconomic impact of covid19 there are numerous scientific papers on modelling the mechanisms of disease spreading in a spatiotemporal perspective 4 5 6 in such studies geography matters in that place both absolute location and relative spatial relationships have been widely recognized as an essential dimension of epidemiologic research 7 the regionbased characteristics and the interconnection among spaces have attracted more attention from both public health experts and policy makers for understanding the mechanisms and controlling the spread of disease the interdependent processes of health political economic and social issues work together and construct the complex social system many scholars have attempted to discover the correlation and determination factors of the novel disease from the socioeconomic aspects 89 under the background of regional or global epidemic events the affected countries always have social and economic issues for example during the spanish flu the sars pneumonia and the ebola virus areas including europe various parts of china and west africa experienced different degrees of recession including dropped gdp population and even sparked diplomatic conflicts and local wars 1011 during the severe acute respiratory syndrome coronavirus in 2002 there were serious economic consequences including a collapse of stock markets in asia europe and the united states disruption of trade and tourism stagnation and recession in manufacturing and reduced supplies of goods food and medicine 12 similarly a large number of studies have shown that socioeconomic conditions have a strong relationship with the covid19 pandemic and strong interrelations exist among the internal social and economic factors of geographic regions 5 13 14 15 16 for example individuals with low socioeconomic status are more likely to suffer from harsher conditions with less accessibility to medical services and financial hardships moreover regions with lower gdps have limited abilities of public healthcare additionally the demographic issue would also make the region more vulnerable to the pandemic furthermore the mitigationpolicy plays a pivotal role in the current process of pandemic control that restrict transportation lock down cities and shut down business which all have great impacts for helping society combat the virus financial markets recorded continuous plummeting with four trading curbs in the usa stock market in march 2020 with covid19 international trade slowed down after international transportation limitation businesses went bankrupt and people were left unemployed a variety of government departments and agencies offer datasets with raw measurements and variables but the criteria for data publishing are very mixed as all of the different information rushes from different sources a precise focused timely and standardized data collection distributed by a stable platform is needed urgently to provide integrated and convenient data sources for users and decision makers in different domains due to the diversity of socioeconomic data sources the access pipeline and data format are not uniform over all sites thus users must access raw data files through timeconsuming manual manipulation or customized operational tools to integrate the multisource information for example the personal income tables 17 from the bureau of economic analysis are accessed by url links while interactive actions of selecting target options are required to obtain the unemployment insurance data from the us department of labor 18 moreover not all the indicators from the original datasets are readily meaningful for pandemic research and it is necessary to effectively screen out attributes to highlight the desired characteristics of socioeconomic measurements for example the census bureau 19 provides thousands of fields for multiple geographic scales each year but less than 20 factors are widely recognized and used in covid19related analysis and studies 1120 socioeconomic factors such as the policy stringency index 2122 are broadly accessed and utilized at country level but not at the statelevel in the usa it is necessary to leverage the data 2020 5 118 3 of 18 state policy as a quantitative constrain with other dynamic spatiotemporal attributes in covid19 data collection to fill the aforementioned gaps we propose a preprocessed filtered and standardized covid19 socioeconomic data collection of the usa the data collection is validated and contains intensive quality control based on integrity consistency and effectiveness requirements it offers a crucial data basis for the decision makers to assess loss due to the pandemic and make further mitigation and reopening plans researchers can easily implement studies between covid19 and socioeconomic factors with the data and the public can be better informed about the crisis impacts the paper is organized as follows section 2 introduces the raw data selected attribute values and metadata of the derived data product section 3 describes the methodology concerning how derived attributes are organized and produced how data are processed and stored and how data quality is controlled and finally section 4 illustrates the data publishing methods and provides access methods data sources raw measurement of socioeconomic factors qualitative restriction policy orders to date every state of the usa has made great efforts through policies and orders to mitigate the spread of the virus and support testing and treatment of affected communities the official emergency declaration policy orders and law documents that allow state governors to execute emergency forces and are a valuable and straightforward data source for researchers to evaluate the policy context governmental policy data were originally collected by the oxford covid19 government response tracker program during the pandemic to serve as an indicator of governments responsiveness to the crisis among countries globally 21 we also proposed and generated us statelevel restriction policy orders including the social distance restriction and financialeconomic supporting policies to measure and evaluate the policy stringency index the raw context documents and quantitative data are searched and identified from each states official covid19 website alongside executive orders that announce related policies and authoritative news websites by a team of over 10 students and volunteers in the national science foundation spatiotemporal innovation center the collection of these policies mainly follows the categories proposed by hale et al 21 and only policies that either fall under these categories or have a great impact on peoples lives under covid19 are collected since the documents are available online the original policy materials are recorded as uniform resource locator in notes for coding and retrospect collecting governmental policy data not only informs us about the actions that each government takes but also enables us to conduct studies and analyses on the effectiveness and influence of the policies the governments responsive policy is directly related to the spread of covid19 the combination of constructive policies and practical implementation can effectively stop the spread of virus for example closure schools and businesses and cancellation of public events helped china control the situation successfully moreover a public information campaign at an early stage can raise the publics awareness of the pandemic and inform them of the actions that can be taken to protect them from being infected additionally policies restricting national and international travel can help countries that have not had covid19 to stop its spread from the start overall policies and executive orders issued by governments are necessary to inform and unite the whole public together to combat the current covid19 crisis data 2020 5 118 4 of 18 macroeconomic indicators several macroeconomic variables are utilized to reflect overall economic conditions and play an important role in the analysis and reference of macroeconomic regulation and control during the covid19 pandemic from global to country scales 223 factors such as gross domestic product personal income and international trade amount per capita could be used in analysis and to predict the mortality trend finances and economic performance furthermore the economic indices are expected to decrease with the second or third outbreak waves of covid19 in the usa gdp by state is defined as the sum of value added from all industries in the state and it includes all private and public consumption investment government outlays and net exports the bureau of economic analysis provides the statelevel gdp quarterly from the first quarter of year 2016 and will release the third quarter of year 2020 on 23 december 2020 real gdp and currentdollar gdp and chaintype quantity indices from raw products are collected in this dataset 24 the business shutdown and job loss affected the personal income in many industries according to pew research center around half of the american lower income class lost jobs because of covid19 and only 23 of them have enough money to last three months 25 since the lower income class is more likely to find labor jobs or jobs that do not require an educational background it makes more financial sense for business owners to find a replacement after the pandemic ends 26 the personal income data are another statelevel product provided by the bureau of economic analysis which has been reliably collecting us personal income quarterly data since 1948 the agency has been releasing reports on a quarterly basis and also at the national state and local level 17 we selected four attributes from this dataset overall compensation which refers to the compensation including all categories farm compensation which is compensation for farm related employees nonfarm compensation which is compensation for nonfarm related employees and lastly the per capita personal income which is a ratiobased index calculated as the total personal income of the residents in a state divided by the total population of the state the attributes were updated to the 2nd quarter of 2020 and the 3rd quarter of 2020 data will be released on 17 december 2020 international trade of goods and services information for the state are collected from the us census bureau in which the data have been tracked since 1960 every month by examining and comparing the attribute values of the usa between 2019 and 2020 there are noticeable decreases for both exports and imports ratios starting from march to june of 2020 due to the limitation in importexport transportation policy and resource demand changing during the pandemic 2728 four attributes were picked as the overall indices of international trade business including the export and import values in the manufactured and nonmanufactured commodities the manufactured commodities refer to the trading amounts of manufactured commodities that exportimport in millions of dollars the nonmanufactured commodities cover the products from agricultural forestry fishery industries in milliondollar units employment the covid19 pandemic has created a major impact in the us labor market 29 unlike the recession that happened in 2008 in which the labor market faced a slow hit this pandemic impacted the labor market with an intense speed 29 by late march 2020 the seasonally adjusted initial claims were 3283000 which was the highest number of initial claims filed in the history of the us labor force 18 to illustrate the impact of covid19 crisis in employment we collected unemployment insurance claim and nonfarm payroll datasets published by the united states department of labor every week the dataset includes initial claims insured unemployment rate continued claims and covered employment an unemployed person separated from an employer files an initial claim 4 and if the unemployed person experiences a week of unemployment heshe will file a continued claim to claim benefits for that week of unemployment 30 the nonfarm payroll represents the total number of paid employees in the us workforce excluding farm employees government employees private household employees and employees of nonprofit organizations 30 it is one of the most significant economic indicators because it shows the number of new jobs created during the reference period thus it has the potential to indicate that businesses are actively hiring additionally it also indicates that employees can positively contribute to the economy by consumer spending the bureau of labor statistics publishes nonfarm payroll data based on two comprehensive surveys the household survey and the establishment survey 18 the household survey pertains to individuals and provides the unemployment rate report as well as details on employment demographics the establishment survey pertains to jobs and provides the number of new nonfarm payroll jobs added within the national economy our nonfarm payroll dataset includes the total number of employees from major sectors which are obtained from the establishment survey and labor force participation rate employed persons and the unemployment rate obtained from the household survey housing market the covid19 pandemic created an unprecedented disruption in the us housing market during spring 2020 home sales and the median housing price dropped significantly due to stayathome orders in comparison to a normal busiest season this has been attributed to buyers not willing to invest huge amounts in housing and sellers not willing to list or sell their home due to the reluctance of strangers entering their home during the pandemic however the housing market immediately surged across metropolitan and rural areas and across house sizes in the summer and fall because of low loans rates and economy rebound triggered by the reopen and stimulus package 31 after careful consideration the data collection on the housing market includes the building permits survey federal housing and finance agency house price index and housing inventory these three housing factors are captured before during and after the pandemic period for policymakers economists and researchers to understand the housing market under the influence of the covid19 crisis the us census bureau and the us department of housing and urban development have jointly announced building permits data since 1959 monthly and annually 32 it provides statistical information on new privatelyowned residential construction on the national state and local levels the attributes of building permits include total housing units single housing units and multiunits the fhfa hpi measures average price changes in repeat sales or refinancing on the same properties 32 this index information on house prices is based on reviewing repeated mortgages that have been purchased or securitized by fannie mae or freddie mac on singlefamily properties 32 the fhfa has provided house price index data since the mid1970s the attributes of hpi include alltransactions expandeddata and purchaseonly the housing inventory focuses on the market trends and monthly statistics on active homes forsale listings in a specified geography the realtorcom website publishes housing inventory data based on accurate mapping of housing units in listing statuses at national state and local levels 33 the attributes of housing inventory include median listing price days on market and price increase count medical resources medical resources show the capabilities of the health care system to support disease testing diagnosing and treatment three fundamental elements of ventilators hospital beds and medical staff were identified and widely reported as medical resources to plan for or deploy under covid19 34 a countylevel dynamic medical resources deficiency index based on medical staff and intensive care unit beds data are generated to measure the local medical burden from the accumulated active confirmed cases 35 in this collection hospital number licensed and intensive care units beds registered nurses and medical doctors for populations over 1000 are collected and calculated for each state the number of hospitals and licensedicu beds information is provided by definitive healthcare consulting services via arcgis online repository 36 in a pointbased shapefile format which records the attributes of each unique hospital the medical staff is separately accessed from the national council of state boards of nursing 37 and the national provider identifier registry database 38 the number of registered nurses was counted by ncsbn at the end of 2019 based on data 2020 5 118 6 of 18 the records of active nursing licensure of the electronic information system the number of medical doctors was extracted and summarized from the npi database based on taxonomy codes of healthcare providers which indicated the areas of specialization although these collected medical recourses are not a dynamic dataset that reflects the realtime medical capacity during covid19 they can be used as a baseline to estimate the geographic disparity of health resources in each state censusbased socioeconomic data with the changes in the economy data from the decennial censuses are far from enough for governments and businesses to rely on for planning as they are published too late and could be out of date so the census bureau began the american community survey program a nationwide survey that collects demographic and socioeconomic housing and other characteristics about the nations population each year more than 35 million households across the country would be contacted every year by acs the data are published on several geographical levels including state metropolitan areas as well as counties cities and smaller areas for smaller areas like census tract or census block groups it would take 25 years to acquire enough samples for estimation so the census publishes three types of data for users 1year 3year and 5year estimates to choose the data product the reliability precision currency and geography unit need to be considered the 5year estimate data are the most reliable but least current data the acs program was proposed in 1996 and scheduled to be fully implicated in 2003 the oldest data available for acs 1year estimates are in 2005 with an annual release and 2009 for the 5year estimates the 3year estimates data have been discontinued and only 20072013 will remain available and no new data have been produced later 19 censusbased socioeconomic data are widely used in covid19 research as determinant factors per capita to show the heterogeneity of locations the statelevel attributes for topics of population age sex ethnicity education poverty and income housing and employment status are selected from the american community survey in this dataset the 2019 acs was released recently on 17 september 2020 and the 1year estimate data were extracted and integrated manually into the proposed data collection data description based on different utilization purposes and characteristics of temporal frequencies three separately derived and aggregated datasets are provided to the public including dailybased policy stringency index dynamic economic indicators through the covid19 pandemic and the socioeconomic determinants for us states the spatial resolution of these three datasets is statelevel and the spatial coverage is the 50 states of the us with the district of columbia a usa base map with the standard state name state abbreviation code and federal information processing standards code is used in each derived dataset to connect the geographic regions figure 1 illustrates the conceptual model and its derived attributes for the state level of the usa the fips column is used as the foreign key for a joint table of indicators within the same location and each attribute table is stored separately based on time frequency the timestamp column for each table stands for the first day point of the updated time range eg 1 january 2020 in the quarterly table for the first quarter of 2020 all timeseries based datasets are presented in two data formats timeseries summarized product which holds historical data for every single attribute in a specific data table and periodic temporal report which records all attributes with the same updating frequency in a different timestampbased data table daily policy stringency index the government response stringency index was first introduced by the oxford covid19 government response tracker 21 it is an indicator of the governments responsiveness to the crisis of covid19 and the extent of lockdown in the specific region on a scale from 0 to 100 this index is used to graph the temporal dynamic policy change for both the global and the us in our research to quantitively measuring of the restriction policy inside the us started from early march 2020 the response stringency index for each state is recorded coded and calculated based on raw policy documents from the local state government the raw data collection with original recording notes coded scores in the specific coding division and links to the specific policy used for coding is provided in a daily manner based on the global countrylevel index standard the seven geographicalbased categories of policy are used to indicate the scope of the policy based on the literature and data accessibility we selected 29 features from the public dataset which have statistical values at the state level those data are from a variety of government and nongovernment agencies with relatively high reliabilities and have been widely used in different research projects compared with the annual report data the aforementioned indices have higher temporal resolutions ranging from weekly to monthly and quarterly those data mainly focus on economicrelated statistics such as gdp employment import and export in international trade and retail many core indexes are included under each category and also some expanded indices are listed with more detail for example the unemployment rate is a core indicator in all kinds of employment discussions also we considered some related features such as daily policy stringency index the government response stringency index was first introduced by the oxford covid19 government response tracker 21 it is an indicator of the governments responsiveness to the crisis of covid19 and the extent of lockdown in the specific region on a scale from 0 to 100 this index is used to graph the temporal dynamic policy change for both the global and the us in our research to quantitively measuring of the restriction policy inside the us started from early march 2020 the response stringency index for each state is recorded coded and calculated based on raw policy documents from the local state government the raw data collection with original recording notes coded scores in the specific coding division and links to the specific policy used for coding is provided in a daily manner based on the global countrylevel index standard the seven geographicalbased categories of policy are used to indicate the scope of the policy based on the literature and data accessibility we selected 29 features from the public dataset which have statistical values at the state level those data are from a variety of government and nongovernment agencies with relatively high reliabilities and have been widely used in different research projects compared with the annual report data the aforementioned indices have higher temporal resolutions ranging from weekly to monthly and quarterly those data mainly focus on economicrelated statistics such as gdp employment import and export in international trade and retail many core indexes are included under each category and also some expanded indices are listed with more detail for example the unemployment rate is a core indicator in all kinds of employment discussions also we considered some related features such as insured unemployment rate total nonfarm employees manufacturer employees and so on for unemployment insurance we also list initial claim numbers and continuous claim numbers these features could give users a more indepth view of the current situation when combined more detailed descriptions of attributes are list in table 2 methods cloudbased data warehouse and spatiotemporal aggregation a data warehouse is a large centralized data repository of integrated data from one or more disparate sources 39 in this study we adopt the dw workflow to aggregate opensource socioeconomic datasets described in section 21 as the data pipeline shows in figure 2 data files from raw format are first obtained and stored in the staging area then loaded into the dw as raw data manually coded or automatically converted the processing scripts and formatted rules are developed based on a standardized spatiotemporal collection framework for covid19 to collocate in time and space among multiple factors 4041 next the formatted raw data are converted into summarized data products with corresponding metadata for sharing under opensource data policies last but not least users will be able to visit access download and leverage the proposed products for their specific analysis mining and reporting applications methods cloudbased data warehouse and spatiotemporal aggregation a data warehouse is a large centralized data repository of integrated data from one or more disparate sources 39 in this study we adopt the dw workflow to aggregate opensource socioeconomic datasets described in section 21 as the data pipeline shows in figure 2 data files from raw format are first obtained and stored in the staging area then loaded into the dw as raw data manually coded or automatically converted the processing scripts and formatted rules are developed based on a standardized spatiotemporal collection framework for covid19 to collocate in time and space among multiple factors 4041 next the formatted raw data are converted into summarized data products with corresponding metadata for sharing under opensource data policies last but not least users will be able to visit access download and leverage the proposed products for their specific analysis mining and reporting applications from a computational infrastructure perspective cloud computing techniques are used to establish the operation system by george mason university nsf spatiotemporal innovation center based on the virtualization technique cloud computing enables users to utilize computing resources on demand 39 the operational environment of the staging area data warehouse and data sharing services are deployed in a private cloud in real practice data retrieving and processing tasks are scheduled based on the updated frequency of original data sources in the cloud and the scriptscheduling approach could reduce the consumption of computing storage resources since the frequency of the socioeconomic factors varies from daily weekly monthly to quarterly it is necessary to establish a data framework to build the relationships among different from a computational infrastructure perspective cloud computing techniques are used to establish the operation system by george mason university nsf spatiotemporal innovation center based on the virtualization technique cloud computing enables users to utilize computing resources on demand 39 the operational environment of the staging area data warehouse and data sharing services are deployed in a private cloud in real practice data retrieving and processing tasks are scheduled based on the updated frequency of original data sources in the cloud and the scriptscheduling approach could reduce the consumption of computing storage resources since the frequency of the socioeconomic factors varies from daily weekly monthly to quarterly it is necessary to establish a data framework to build the relationships among different datasets in time and space this study takes advantage of the proposed spatiotemporal data collection cube 40 of covid19 to collocate spatial and temporal scales with virus cases and environmental factors the data cube is a threedimensional structure with locations timestamps and attributes to record spatiotemporal measurements and corresponding factors all attributes with multiple topics are organized to show the spatiotemporal variation before during and after the pandemic period the time update report of each factor is provided based on timestamp and summary report according to the attribute variation across time series sections 32 and 33 detail manual policy index extraction the coding process and the automatic web crawler in the data extract transform and load process policy index extraction and coding standard this stringency index by state in the usa is used to graph both the global and us temporal dynamic policy changes in our research the response stringency index includes seven categories of policy as shown in table 4 such as school closure business closure public event cancellation etc as well as a generalization code to indicate the scope of the policy the calculation of the index includes three steps 1 first we code the qualitative policy into quantitative numbers according to the policys stringency for instance a governments official announcement that recommends business closure will be coded as 1 and a strict requirement of business closure will be coded as 2 another example is when there is no policy restricting internal movement the code would be 0 and if governments recommended movement restrictions the code would be 1 and if the government adopted and implemented the stay at home order that requires people to stay at home then the code for this policys stringency would be 2 additionally there is another code for the nationalregional coverage of the specific policy for example the code will be 0 if the policy is only targeted at some countiescities of the statecountry and the code would be changed to 1 if the policy targets the whole statecountry 2 then the code numbers of each policy category are summed up and rescaled to create a score between 0 and 100 3 in the end the seven scores are averaged to obtain the overall stringency index for that region shows the policy index extraction is conducted manually by the nsf stc group policystringencyinex 1 7 rescaled rescaled rescaled rescaled rescaled rescaled rescaled in order to ensure the quality and reliability of the raw policy data it is constantly evaluated through dimensions including data selection integrity consistency and validity to ensure that the policies included in the current dataset are reliable and up to date the initial set of statelevel policies of closure are collected only through each states official website and only state governors executive orders or official announcements are taken into consideration then the relevant usa statelevel policy collection site from the wellknown and reliable news platforms third party nongovernmental organization kaiser family foundation and academic institutes are tracked and considered in our collection procedure by comparing and evaluating the relevant data products in an operational mode the integrity and validity are guaranteed to ensure the consistency of the statelevel policy data the policies are encoded by the same research using the same standard through the whole datacollecting process ondemand web crawler there are several ways to obtain useful information from web pages while some websites provide an application program interface to extract data in the structured format others do not contain this kind of api in this case web scraping can be an ideal technique to obtain web content web scraping includes extracting useful information from a web page by understanding the web page structure 42 a web page is composed of hypertext markup language tags and is translated by a web browser in a humanreadable format with python packages like selenium beautifulsoup4 urllib2 etc we can directly extract the needed information from web pages understanding the document object model is essential for web content extraction because dom defines the logical structure of a web page and provides an insight on how or what page element to access 43 it defines the attribute of a page element such as a class and name which is used to identify a page element for page actions the first step is to identify an officially authoritative and reliable website for the research demands the website should satisfy both the spatial and temporal requirements of the dynamic socioeconomic datasets the next step is to analyze the format and structure of useful datacontent on the website some websites provide data in comma separated values or spreadsheet format that can be readily downloaded processed and converted additionally few websites provide data in a semistructured or unstructured format such as javascript object notation and portable document format files then we need to develop and perform a customized web crawler to extract useful information this procedure is shown in figure 3 the web crawler section comprises a sequence of steps to acquire information from a website 1 first we interpret and understand the dom structure 2 the next step is to provide the users with inputs in the required fields and submit the form this is achieved by selenium api which automatically interacts with a web page by calling browser drivers such as chrome gecko and internet explorer subsequently by inspecting the input field web elements we provide input values and submit the form using a button click data 2020 5 118 13 of 18 3 the next step is to obtain the page source for example to extract unemployment insurance data from the united states department of labor website 18 we used selenium to automatically a select the state radio button b select 2019 from the dropdown options for the start year c select 2020 from the dropdown options for end year d and select all states from the textbox e finally we submit the form by clicking the submit button and obtain the page source information 4 once we have the page source with the required information we use the beautifulsoup4 python package to identify the table that holds the unemployment insurance data and extract the text content from the table the final step is to format the dataset in a standard format ondemand web crawler there are several ways to obtain useful information from web pages while some websites provide an application program interface to extract data in the structured format others do not contain this kind of api in this case web scraping can be an ideal technique to obtain web content web scraping includes extracting useful information from a web page by understanding the web page structure 42 a web page is composed of hypertext markup language tags and is translated by a web browser in a humanreadable format with python packages like selenium beautifulsoup4 urllib2 etc we can directly extract the needed information from web pages understanding the document object model is essential for web content extraction because dom defines the logical structure of a web page and provides an insight on how or what page element to access 43 it defines the attribute of a page element such as a class and name which is used to identify a page element for page actions the first step is to identify an officially authoritative and reliable website for the research demands the website should satisfy both the spatial and temporal requirements of the dynamic socioeconomic datasets the next step is to analyze the format and structure of useful datacontent on the website some websites provide data in comma separated values or spreadsheet format that can be readily downloaded processed and converted additionally few websites provide data in a semistructured or unstructured format such as javascript object notation and portable document format files then we need to develop and perform a customized web crawler to extract useful information this procedure is shown in figure 3 the web crawler section comprises a sequence of steps to acquire information from a website 1 first we interpret and understand the dom structure data quality control we evaluated the socioeconomic data in three dimensions including data integrity data consistency and validity to ensure quality datasets are delivered to geospatial researchers and policymakers raw data selection cleaning qualification the first step for socioeconomic data collection is to select appropriate raw input data we implement an extensive literature review related to the impact of covid19 on socioeconomic factors thereby making a factor justification of datasets we have selected we also ensure that the selected data are of the most significance to show the economic hit in the us during the pandemic the next step is to identify reliable official websites to download the datasets that satisfy both the spatial and temporal needs of the data collection process during the data cleaning step we filtered or discarded the invalid attributes and values that are not included in the research domain for example we filtered out the us territories such as the virgin islands and puerto rico as we were focused on the us states and the district of columbia in certain cases we faced issues in downloading datasets directly in a structured format such as in spreadsheets or csv we overcome the issues by first obtaining data in a text format and then converting it to a structured format data integrity ensuring data integrity means that the collected datasets are complete comprehensive and accurate this includes verifying datasets for manual errors logical errors and data type consistency we stored the socioeconomic datasets in a relational database the table constraints such as primary key ensure duplicate records are not inserted not nullable fields prevents inserting null values data type ensures consistent data are inserted into each field for example raw data for personal income farm compensation for the district of columbia is this is converted to 0 to satisfy the data integrity data consistency the socioeconomic dataset in the repository is required to be consistent with the other sources this means that the collected data should be consistent with the values of data sources and should also be consistent with the dynamic change of economic factors during the pandemic for example the covid19 saw the worst hit on the us economy during the start of march in which the covid19 cases were at a peak the economic factors were comparatively lower than the preand postpandemic periods data validity to ensure the data reliability of socioeconomic factors we provide data sources to the consumers along with the collected data consumers can investigate the collected data against the data sources thereby ensuring the validity of the data data sharing the derived data are all in csv format which is automatically published in the github data repository promptly based on the timefrequency and publishing timestamp as one of the most popular opensource communities github is a solution for data consumers and application developers to share data and codes publishing the data cube on github assures data release and sharing and facilitates the following allows data consumers to report issuesproblems through the github repository allows data consumers to folk or mark the repository to trace a data update for timely analysis and allows data analysis code to be published with data to facilitate the data cubes utility in research and decisionmaking further notes on the usage of the dataset that will help other researchers to quickly access the dataset and work with it to enable public users to explore search and quickly identify the covid19 relevant data features and attributes a comprehensive knowledge archive network based the open resource portal is created to provide metadata for the data collection and analysis models for the spatiotemporal covid19 rapid response studies both collected and processed datasets are prepared for querying browsing and sharing the covid19 data discovery portal also enables data ownerseditors from longtail sections to register user accounts organization pages and create resource pages multiple data licenses are used for data reusing copying publishing distributing transmitting and adapting all datasets can be accessed and cited for noncommercial purposes more importantly a welldesigned tagging and grouping system is constructed based on research communities topics and interests and it can be used to filter out the most relevant dataset for researchers all socioeconomic datasets in this collection can be filtered out by the social economics group under the spatiotemporal innovation center organization time trend analysis of typical attributes several socioeconomic indicators are selected for visual analysis for time change patterns before and after covid19 pandemic including daily new confirmed cases policy stringency index percentage change of real gdp and employees compensation weekly unemployment rate median listing price in housing market as well as export and import amounts of manufactured commodities in each plot of figure 4 a line represents a states dynamic change from the period of before emergence to outbreak and to when covid19 was under control the four typical states chosen in these time series plots are new york georgia texas and illinois the visualization provides a straightforward way to understand the trend of the social economic situation and corresponding significant impacts with exact time periods can also be identified conclusions to combat the covid19 pandemic the reported socioeconomic data collection provides valuable spatiotemporal factors for research and decision support by disease control experts decisionmakers government officials sociologists economists and humanists the spatiotemporal data collection framework could be a baseline for integrating other spatial and temporal based factors the collection includes datasets of the daily updated policy stringency index economic attributes in multiple timefrequencies and a socioeconomic determinant for all the states in the us gmus nsf stc is maintaining data processing quality control storing and sharing in an operational mode the raw data tables are automatically accessed from multiple authorized departments of the us by customized python scripts and the processed attributes are extracted and converted into the github repository according to the quality control and framework in near real time in the future more metadata of data sources will be provided by a crowdsourcing approach through a ckanbased portal and its inclusive socioeconomic factors and attributes under covid19 topic will be integrated into this spatiotemporal standard collection from the new case numbers and policy index we can find that new york has implemented and kept stricter policies which helps to decrease new infected cases of covid19 in addition relaxation of restrictions causes a rebound of the new cases number in texas and georgia due to the lock down nationwide the gdp and compensation of employees fall sharply for the 1st and 2nd quarter at the same time the unemployment rate increases dramatically even though loose policy after june and july decrease the unemployment rate it is still at a high level around 10 which was usually 34 the housing market did not show a big change and a slightly increase for the real estate listing price after june was recorded texas has a large portion of international trade of manufactured commodities and the import and export rates for all states have risen back to normal amounts after the policy index trend to decrease occurred spatiotemporal analytics 44 can be easily conducted with the collected and published datasets conclusions to combat the covid19 pandemic the reported socioeconomic data collection provides valuable spatiotemporal factors for research and decision support policy making academic research and public is the data repository link to access the latest data collection with wellformatted documents data 2020 5 118 7 of 18 socioeconomic driven factorsdeterminantsindicators the census data are a traditional source used to extract demographic education income poverty housing and health resources information with geographical units socioeconomic determinants for the state level are mostly from census acs 2019 data and partially from other sources for demographics we extract the attributes for the total size density and by groups of age gender and race and ethnicity for education information the attributes contain percentages of the population with high school education a bachelors degree or a higher degree the two types of regional information internet accessibility and medical resources are recorded in separate columns all mentioned attributes are considered as the factor strongly related to regional health in response to the pandemic covid19 funding this research was funded by the nsf

the outbreak of covid19 from late 2019 not only threatens the health and lives of humankind but impacts public policies economic activities and human behavior patterns significantly to understand the impact and better prepare for future outbreaks socioeconomic factors play significant roles in 1 determinant analysis with health care environmental exposure and health behavior 2 human mobility analyses driven by policies 3 economic pressure and recovery analyses for decision making and 4 short to long term social impact analysis for equity justice and diversity to support these analyses for rapid impact responses state level socioeconomic factors for the united states of america usa are collected and integrated into topicbased indicators including 1 the daily quantitative policy stringency index 2 dynamic economic indices with multiple time frequency of gdp international trade personal income employment the housing market and others 3 the socioeconomic determinant baseline of the demographic housing financial situation and medical resources this paper introduces the measurements and metadata of relevant socioeconomic data collection along with the sharing platform data warehouse framework and quality control strategies different from existing covid19 related data products this collection recognized the geospatial and dynamic factor as essential dimensions of epidemiologic research and scaled down the spatial resolution of socioeconomic data collection from country level to state level of the usa with a standard data format and high quality

of understanding cultural issues and linking social factors to better understand the barriers and facilitators of obesity risk in immigrants recommendations for developing culturally tailored weightcontrol programs matched to the ethnicity of immigrant populations are provided the study investigating the role of acculturation as measured by generational status on bmi in canadian youth reported that firstgeneration immigration was significantly related to higher bmi zscores in adolescents as compared to second and third generations specifically firstgeneration immigrants had more weight gain compared to other generation groups in adolescence these findings expand on a growing literature demonstrating that generational timing of immigration may be a risk factor for obesity and that maintaining traditional cultural orientation is associated with lower rates of obesity although the relationship between firstgeneration immigration and higher prevalence of overweight has shown mixed results in some previous studies findings in the article in this issue showed that race and ethnicity were also important factors to consider in understanding these complex relationships specifically analyses stratified by race showed that this relationship tended to be stronger in black south asian and other firstgeneration immigrant groups these findings suggest that firstgeneration youth may be at greater risk for developing unhealthy lifestyle patterns such as poor dietary and physical activity habits however further research should explore how acculturation and race may be related to barriers for engaging in healthy lifestyle habits for example a recent qualitative study by shelton and colleagues showed that both african american and latina women reported having many stressors including economic hardships demanding caretaking relationships inflexible work policies and mistrust of health care providers those who were immigrants also reported that they experienced social isolation and were experiencing high levels of stress in general thus health promotion efforts should take into account the additional stressors experienced by ethnic minority women and their families and how immigration challenges may further impact these difficulties the study on acculturation and obesity reported in this issue is also one of the first to examine longitudinal patterns of overweight status across generational status in children and adolescents overtime bmi change for firstgeneration immigrants was associated with greater weight gain but no direct measures of acculturation were integrated into the study measures making it difficult to know exactly what the mechanisms are by which generational status is related to the development of obesity in young immigrants as noted in a growing body of literature more qualitative studies that address longitudinal and developmental issues related to engaging in healthy lifestyles are needed in underserved and ethnic minority populations in particular research on intergenerational effects of culture may provide important insights into family and generational issues that are protective or which may increase the risk for developing obesity for example in a qualitative study by renzaho green mellor and swinburn somali and ethiopian migrant families indicated that intergeneration themes related to immigration included challenges with maintaining traditional parenting family functioning and family relations in addition these families reported that maintaining a healthy lifestyle of physical activity and diet was challenging and that parents were more restrictive in controlling their youths behaviors and discouraged autonomy thus future efforts to develop policies and health promotion programs among immigrant populations should integrate a parenting focus to better assist parents with how to communicate with their youth about the importance of engaging in healthy lifestyles given the transition to a new cultural environment recently investigators have argued for an ecological approach to understanding lifestyle factors that relate to obesity in underserved and ethnic minority populations that incorporates a stronger focus on social factors including social context recent studies demonstrate that social factors are important for improving health behaviors in underserved low income ethnic minority populations in particular research is needed to better understand social interactions and parentrelated supports specific to acculturation of young immigrants who may be at increased risk for developing obesity understanding the socialization and cultural integration of immigrants may increase our understanding of how to address the barriers and create more positive social environments that encourage increased activity healthy eating and supportive climates for engaging in healthy lifestyles there is an increasing body of literature that indicates that parent support and positive neighborhood conditions are both important for buffering the negative effects of poverty and poor environmental conditions on the development of obesity in youth in a recent study by sussner lindsay greaney and peterson immigrant latina mothers reported that beliefs about feeding practices lack of physical activity lack of social support and increased social isolation all contributed to a lifestyle that was prone to developing obesity taken together these studies reviewed highlight the need for health promotion efforts that address the specific barriers related to parental beliefs and understanding of how to build social relationships that could reinforce health behaviors for engaging in physical activity and healthy eating health promotion efforts among immigrants need to address multiple systems within the familys environment including the neighborhood schools and religious and cultural affiliations health promotion programs for obesity prevention in culturally diverse populations have focused on incorporating cultural tailoring approaches that address the specific needs of the target population with respect to promoting healthy lifestyles the most successful health promotion interventions for underserved and ethnic minorities have incorporated culturally targeted and culturally tailored intervention components using multisystemic approaches and these approaches could be applied to young immigrants furthermore in a recent qualitative study by lindberg and stevens mexicanamerican women indicated that they wanted more opportunities to engage in behavioral interventions that provided culturally centered behavioral strategies for improving nutrition and food choices within the family context kreuter and colleagues have provided an overview of cultural tailoring for improving health behaviors they propose that interventions can incorporate peripheral strategies that give program materials the appearance of cultural appropriateness by using certain images and pictures of group members in addition linguistic strategies have also been used to develop program materials that are dominant to the native culture of the ethnic minorities interventions that have sociocultural or deep structures typically integrate cultural values and norms into the intervention programming and have been demonstrated to be effective tailoring approaches for health behavior change deep structures or sociocultural strategies have also been shown to be successful when integrated within the healthrelated context of interventions that target culturally diverse ethnic populations all of these tailoring strategies could be implemented within immigrant families for promoting healthy lifestyles and obesity prevention in summary the article on acculturation and risk of obesity in this issue raises important questions about why and how immigration may lead to greater prevalence of risk for developing obesity in youth obtaining contextual information for understanding the social and environmental processes will continue to inform future research for developing effective culturally tailored health promotion approaches in these highrisk populations of immigrants in addition developing culturally tailored approaches for improving parent support and social integration as well as broader environmental supports for healthy lifestyles will be critical to reversing and preventing these trends in childhood obesity among immigrants future research should replicate these findings presented in this issue and explore the mechanisms across different ethnic and cultural groups to better understand how to best tailor obesity prevention efforts for immigrant youth conflicts of interest none declared

understanding risk factors related to acculturation and the risk of developing obesity is important given the increasing number of immigrants in the united states a summary of key findings from the generation of immigration and body mass index bmi in canadian youth article in this issue are presented and the implications for future research and health promotion efforts are discussed in this commentary an emphasis is placed on the importance

introduction as early as the 17th century there were attempts by international lawyers protect indigenous peoples from the massacres of the spanish conquistadors in the americas through legal and moral theories deriving from natural law 1 yet these prepositivist conceptions of natural law could not withstand the legal positivism of the 19th century since positive international law in its classical form was only applicable to states hence indigenous peoples were not considered subjects of international law and were not subject to international legal protection at that time 2 the few remaining guardians of indigenous peoples in the americas were christian missionaries such as the jesuits whose efforts are viewed as a mixed blessing they tried to protect the indians from killing and slavery but introduced a policy of assimilation attempting to civilise and discipline them since vibrant indigenous cultures were in fact antithetical to the missionaries aims 3 not only was indigenous peoples physical existence threatened but also their cultural survival 4 indigenous peoples have had a tragic history of forced assimilation and deprivation of their lands in many parts of the world while descendants of european settlers achieved political independence from the colonial powers indigenous peoples within the former colonies remained the target of discrimination and subject to invasion of their lands as indigenous peoples did not hold title to land in a way that european legal systems of registration recognised it was easy for colonial rulers to dispossess them from their ancestral lands indigenous tribes were assigned to reservations on marginal land yet these are rarely sacrosanct even today in light of competing interests of economic operators and national governments regrettably indigenous cultures are still viewed today by some governments as an anachronistic stage in human development however the growth of international human rights law has challenged this view demanding modernisation of classical international law so as to place individuals and groups of individuals as beneficiaries of international human rights 6 although neither the universal declaration of human rights the two 1966 covenants 7 the un covenant on racial discrimination 8 the european 9 nor interamerican human rights instruments 10 refer specifically to indigenous peoples indigenous peoples human rights have been developed in particular in instruments adopted by the international labour organisation and the un general assembly 11 this paper focuses on one aspect of postcolonialism population policies it assesses the extent to which these policies can be invalidated light of the right to selfdetermination and to health under international law this paper argues that the right to reproductive selfdetermination of indigenous peoples should be recognised as a subcategory of their rights to selfdetermination and to health under international law moreover this paper argues that governmentsponsored population policies must be understood in light of the broader context of state failure to effectively protect indigenous peoples from harm and their land from invasion which pose a serious threat to the health and longterm survival of indigenous peoples this paper thus contributes to the literature on indigenous peoples rights under international human rights law by exploring the limits of their rights to reproductive health and autonomy in this context this paper challenges the legality of governmentsponsored population policies impacting on indigenous peoples rights a field which has been understudied from the perspective of international human rights law given that the longterm survival and generational continuity of distinctive indigenous groups depend on the effective protection of their reproductive rights this is a crucial area for study from the perspective of international human rights law the second section of the paper discusses estimates of indigenous populations worldwide and the related problem of defining an indigenous identity that could guide population policies including governmentsponsored family planning programmes the third section presents an overview of international developments that have led to forceful birth control programmes being imposed upon indigenous peoples with particular focus on australia and peru it is argued that these past and contemporary policies suggest that indigenous peoples are particularly vulnerable to the impacts of national population control programmes the fourth section assesses the extent to which substantive norms recognising a human right to selfdetermination to health and to reproductive health have been elaborated in international human rights law which provide the legal basis for the right to reproductive autonomy the fifth section analyses the procedural guarantees and remedies available for indigenous peoples to assert their reproductive autonomy in particular the rights to prior and informed consent and to participation in decisionmaking further it discusses the international regional and national judicial and extrajudicial avenues for the condemnation of and for reparations for forceful interventions in 9 european convention on human rights ets 5 213 unts 221 10 see for example organisation of american states american convention on human rights oas treaty series no 36 1144 unts 123 9 ilm 99 11 indigenous reproductive affairs this paper finally concludes that a rightsbased approach as established by the right to selfdetermination to heath and to prior and informed consent under international law provide the essential legal basis for the protection of indigenous peoples reproductive autonomy population politics and the indigenous ethnic and cultural identity recent estimates have suggested that there are around 370 million indigenous people worldwide equating to just under 6 per cent of the worlds total population 12 this includes at least 5000 distinct indigenous peoples in over 72 states 13 a considerable majority of indigenous peoples are from asia 14 there are approximately 40 million indigenous people in latin america and the caribbean 15 it has been further estimated that there are around 50 million indigenous peoples in africa 16 in the us it was estimated in 2010 that there are approximately 52 million indigenous people 17 a 2011 national household survey estimated that the indigenous population of canada is just over 14 million 18 there are approximately 670000 indigenous peoples in australia or 30 per cent of the total population 19 in new zealand the māori represent 15 per cent of the total population of 43 million 20 yet it should be noted that indigenous peoples do not always form part of minority groups within states while for example indigenous peoples account for only 045 per cent of the population of brazil latin americas largest country they account for the majority of the total population of bolivia 21 with a total of over 15 million indigenous peoples mexico has the highest indigenous population in absolute numbers in the americas 22 the demographic survival of indigenous peoples is continually threatened by repression dispossession of their lands and the socalled mcneill effect 23 that is the transmission of diseases arising from the contact of indigenous peoples with white colonial rulers despite these challenges it has been suggested that the indigenous population in some parts of the world is recovering the programme for action of the international conference on population and development 1994 stated that 24 in some regions of the world indigenous people after long periods of population loss are experiencing steady and in some places rapid population growth resulting from declining mortality although morbidity and mortality are generally still much higher than for other sections of the national population in other regions however they are still experiencing a steady population decline as a result of contact with external diseases loss of land and resources ecological destruction displacement resettlement and disruption of their families communities and social systems latin america and the caribbean for example present a picture of population recovery citing several authoritative studies montenegro and stephens provide the following figures the estimated total population of indigenous peoples before european invasion ranged from 529 to 150 million … within 100 years the estimated total indigenous populations dropped… to 11 million henceforth in the 18 th century indigenous populations represented merely 16 of the total population however some demographic recovery seems to have taken place in 1960 the total indigenous population of latin america and the caribbean was estimated as 141 million by 2003 it was more than 484 million 25 nevertheless they point out that even though the total indigenous population may have recovered there are fewer distinct groups 26 for example in brazil the total number of indigenous groups is estimated to have fallen from around 1000 to 222 in 2006 27 it has been suggested that the development of selfdefinition of indigeneity may help explain the apparent recovery in population numbers in some parts of the world 28 indeed estimates of indigenous populations vary according to the way indigeneity is defined and measured and depends on the extent to which indigenous peoples distinguish themselves from the rest of the population in this vein it is their distinctive language that has been used to define indigeneity in most census counts 29 language is a paramount means of selfidentification and groupidentification and in latin america alone there are roughly 400 different indigenous languages 30 on the other hand it has been suggested that official census estimates of indigenous populations in some countries is likely to be distorted given that discrimination can lead to underreporting of indigenous identity 31 hence the way in which indigeneity is defined and measured has a major impact on estimates of indigenous populations and will ultimately influence national policies of fertility control 32 the subject of population politics has become a taboo for much of the past century not least because of practices such as sterilisation and other controversial birth control programmes as discussed in this paper malthus claimed in 1798 that population growth would outstrip food supplies 33 leading to a continued debate as to the extent to which government intervention is necessary to control population growth while cordorcet claimed in 1795 that targeted and voluntary change in reproductive behaviour could lead to a reduction in population growth 34 postmalthusians have claimed that state intervention was required to control population growth 35 the food crisis in 2008 led to a degree of scepticism in the postmalthusian theory that technological development would invariably match any deficiencies in food supplies and thus challenges the idea that population growth would not inevitably outstrip food supplies due to changes in technological development 36 moreover concerns over climate change and migration have led to a recurrent debate on global population policies in this regard although it was rejected on evidentiary grounds the petition submitted before the interamerican commission of human rights by the inuit peoples against the us government 37 for its green house gas emissions provides an indication of how states may be held accountable for the dislocation of indigenous populations due to the impacts of climate change 38 there is also litigation before us courts in which indigenous peoples rights are implicated in the context of climate change 39 population policies have tended to be topdown and based on aggregated national targets and goals disregarding the particular situation of indigenous peoples the un millennium development goals are based on comprehensive targets and numbers at national and international levels 40 so in the 1994 icpd there was consensus that states needed to shift emphasis from a topdown imposition of population control 33 see thomas malthus an essay on the principle of population 34 see marquis de condorcet esquisse dun tableu historique des progres de lesprit humain in ceuvres de condorcerm vi 256 this view was generally accepted by thomas malthus 35 see further shalini randeria malthus versus condorcet population policy gender and culture from an ethnological perspective in s berking and m zolkos between life and death governing populations in the era of human rights 2829 36 see malthus indeed the global food crisis in 2008 which has arisen from the food shortages and the hiking of prices of a great number of agricultural commodities has been largely blamed on the increasing global demand for biofuels and consequent exhaustion of agricultural lands to meet this global demand measures to communitybased programs that better respond to the needs of individuals and families 41 most states monitor progress towards meeting the mdgs targets through aggregate data therefore the data uses averages from the whole population 42 such nationwide population targets fail to take into account that indigenous peoples are in some instances represented by small numbers a few deaths within indigenous populations are irrelevant for the attainment of a national target of mortality control but have a significant impact upon groups that are demographically fragile therefore while health indicators can be declining among marginalised communities the country as a whole may appear to be making steady progress towards meeting a national target 43 although there has been resistance to disaggregation of data in population and health indicators in recent years there has been increasing recognition of importance of data disaggregation in particular the 2010 mdgs summit declaration highlights the importance of taking account of inequalities within countries and the need for countries to have adequate timely reliable and disaggregate data that can be used to improve policies and programmes 44 this position is reiterated in the more recent framework of actions of the icdp 2014 conference which had as one its main objectives to assess the implementation of the programme for action adopted under the first 1994 international conference on population and development 45 indigenous peoples and forceful birth control programmes it is widely recognised that there is need for lawful government intervention and programmes of birth control including the distribution of contraceptives and family planning the state has a duty to guarantee the health of the population and to ensure that resources are available to future generations which could be undermined by uncontrolled population growth especially as the rates of fertility tend to be higher in the poorest parts of the world 46 in fact it has been suggested that reproductive health and access to family planning is a fundamental human right 47 even though reproductive health is not specifically mentioned in the udhr nor the two 1966 covenants it could be seen as 41 see the programme of action of the icpd 42 forming part of the broader right to health as enshrined in those international agreements48 moreover other civil and political rights could be invoked to uphold reproductive health and freedom in particular the right to life 49 the prohibition against inhuman and degrading treatment 50 and the right to private and family life 51 these rights could be raised to secure safe abortions and childbirth confidentiality of patients seeking reproductive health services respect for those living with hivaids and measures to reduce violence against and trafficking of women 52 however the principle of noncoercion is open to abuse for example where a state or racist practitioners within the state may seek to control an ethnic or social class within its borders this could lead to forceful interventions aimed at controlling the population growth of one or more specific communities this would offend the principle of reproductive freedom defined as the individuals choice to reproduce or not to reproduce 53 eugenic practices leading to medical and scientific experimentation amount to acts of torture and inhuman and degrading treatment as recognised under the 1966 international covenant on civil and political rights 54 indigenous peoples have been targeted by forceful statesponsored sterilisation and other coercive birth control programmes that violate their reproductive rights a notorious statesponsored programme led to the mass sterilisation of nearly 250000 poor women by the fujimori government in peru between 1996 and 2000 55 the peruvian congress legalised sterilisation for family planning shortly after fujimori announced in his second inaugural speech in july 1995 that family planning would be a priority for his government 56 the programme was undertaken in the remote rural areas of the andean sierra and peruvian amazon region which are heavily indigenous 57 although perus family planning public policy was officially considered to be part of a voluntary programme the women underwent sterilisation without a proper consent process and monthly quotas led doctors to forcibly sterilise women 58 moreover some health workers did not provide women with information regarding other available birth control methods and many times deliberately gave inaccurate information about the risks and consequences of surgical sterilisation 59 as put by jaichand and oconnel the peruvian state ultimately viewed family planning as a means to reduce poverty rather than to promote womens rights 60 the peruvian human rights ombudsman office played a vital role in documenting gross human rights violations during the implementation of the programme yet it was not until president alejandro toledo assumed power in 2001 that formal investigations were launched into the reproductive health programme the findings of the two investigations were that gross violations of womens reproductive rights had taken place and were thus denounced further the ombudsman office issued another report in september 2002 61 which found that in the case of sterilisations local healthcare workers were required to meet quotas creating incentives for coercive and negligent behaviour 62 in another example the australian governments forceful removal of aboriginal children from their families between 1900 and 1969 breached the fundamental rights of the indigenous populations 63 the 1997 bringing them home report found that at least 100000 aborigines in particular mixed race children from white and aboriginal parents were taken away from their parents and placed in the care of institutions religious missions or white foster families 64 the policies were supported by a legal framework particularly disadvantageous to aboriginal peoples until the 1960s the white australia policy encouraged white settlement while a protectorate system was applied to indigenous peoples this protectorate system prohibited indigenous peoples from marrying and forming families without the consent the state 65 responsibility for aboriginal affairs in effect remained with the former colonies which became state governments after federation 66 since british colonisation happened with almost no recognition of the existing legal order aboriginal peoples were not even counted in the census 67 the notion of terra nullius was not rejected until 1992 when the australian 59 high court delivered the mabo v queensland 68 judgment recognising the aboriginal land rights of torres strait islanders 69 other welldocumented examples of forceful interference with indigenous peoples reproductive rights are the us governmentsponsored sterilisation programmes of indigenous women in the 20th century 70 in each of the above cases the dominant society argued that it was acting in the national interest and for the communities own good though the indigenous people themselves are dissenters from this view other states have tried to control childbirth through coercive programmes notoriously chinas onechild policy 71 and the sterilisation abuses in india in the 1975 emergency and the subsequent reemergence in india of provider targets and disincentive schemes 72 these practices are in direct violation of the 1994 international conference on population development 73 and the 1995 beijing world conference on women declaration 74 which held noncoercion to be fundamental to population and reproductive health programmes and that coercion in any form is unacceptable 75 forceful child removals are expressly condemned in the 2007 un declaration on the rights of indigenous peoples 76 yet according to the 2014 framework of actions of the icdp a considerably high number of states have not implemented and enforced national laws against coercion including forced sterilisation 77 reproductive policy should address both the socioeconomic forces which contribute to high rates of fertility as well as offer comprehensive reproductive health 68 mabo v queensland 166 clr 186 australian law reports 107 and mabo v queensland hca 23 175 clr 1 69 see sanders 70 there is an extensive literature on the subject see for example mary dog crow lakota woman 75 babor 118 76 see article 7 para 2 i ndigenous peoples have the collective right to live in freedom peace and security as distinct peoples and shall not be subjected to any act of genocide or any other act of violence including forcibly removing children of the group to another group resolution adopted by the general assembly on 13 sept 2007 united nations declaration on the rights of indigenous peoples 61295 77 only 60 per cent of countries have promulgated and enforced a national law protecting against coercion including forced sterilization and forced marriage this proportion is lowest in the americas see framework of actions for the followup to the programme of action of the international conference on population and development beyond para 317 care and informed choice for every inhabitant 78 but this is antithetical to the use of force policies focused on birth quotas and sterilisation inevitably conflict with the basic right of women to decide how many children they will bear there may be need for limited incentives in order to guarantee the overall effectiveness of family planning programmes this is particularly so in light to prevent the spread of sexual infectious diseases among indigenous peoples yet a statesponsored practice of forceful sterilisation would most clearly contravene a states obligations under international human rights law 79 while this paper focuses on statesponsored programmes that violate indigenous peoples reproductive rights this is not to say that the problem is limited to indigenous peoples women in general and women belonging to minorities groups in particular have suffered violations of their reproductive rights in many parts of the globe including recently the roma minority in slovakia and hungary 80 therefore the analysis of violations of indigenous peoples reproductive rights developed in this paper will include a discussion of the international legal mechanisms for protection of womens and minorities rights in general including decisions of international and regional courts and treatymonitoring bodies relating to the protection of reproductive rights it is pertinent that this paper focuses on the question of indigenous peoples reproductive rights given the distinctive way in which their human rights have developed under international law this paper argues that it is fundamental that international law recognises the illegality of practices that violate indigenous peoples reproductive rights and establishes effective mechanisms for the prevention of and reparations for past population policies that have breached indigenous peoples fundamental rights substantive rights in support of indigenous peoples right to reproductive autonomy this section of the paper examines the extent to which certain substantive rights under international law could define the basis for indigenous peoples reproductive autonomy it discusses in turn the development of the rights to selfdetermination to health as well as the right to reproductive health as a subcategory of the right to health indigenous peoples right to selfdetermination under international law the right of selfdetermination could be a powerful basis for securing an element of autonomy and selfgovernment for indigenous and minorities groups selfdetermination allows peoples 81 the right in full freedom to determine when as they wish their internal and external political status 78 babor 118 79 ibid at 114 80 without external political interference and to pursue as they wish their political economic social and cultural development 82 selfdetermination only emerged as a principle of international law at the san francisco conference preceding the draft un charter and has been included in both articles 1 and 55 of that instrument 83 in addition an express reference to the right of selfdetermination can be found in article 1 of both un 1966 international covenants on civil and political rights 84 and economic social and cultural rights 85 yet neither the un charter nor any other human rights instrument define who the peoples entitled to be beneficiaries of selfdetermination are 86 it could be argued that if selfdetermination in international law is a right accruing to all peoples then indigenous people should be recognised as beneficiaries of that right given the legal and political constraints for the recognition of the right to secession 87 it is the right to internal selfdetermination that is more realistically achievable and thus could provide the legal basis against undue interference to the physical wellbeing and reproductive autonomy of indigenous peoples james anaya the un special rapporteur on indigenous people between 20082014 88 signalled that governments have increasingly moved away from the tendency to equate the word selfdetermination with an absolute right to form an independent state 89 therefore if external selfdetermination is not realistically available nor politically feasible the question arises as to whether another form of selfdetermination can be substituted for its external application 90 the un human rights committee used the term internal selfdetermination for the first time 91 and it is now the terminology followed by most authors referring to forms of selfgovernment autonomy territorial integrity or exclusive enjoyment of the indigenous lands and resources significant progress towards the recognition of international rights for indigenous peoples happened with the adoption of unga declaration on the rights of indigenous peoples on 13 september 2007 following 20 years of difficult negotiations the right to internal selfdetermination of indigenous peoples is at the heart of the declaration which defines it as the right to autonomy or selfgovernment in matters relating to their internal and local affairs as well as ways and means for financing their autonomous functions 93 although resolutions of the unga are not legally binding given that the undrip was adopted by so many states with so few objections and abstentions it may very well attain the status of customary international law 94 although australia canada new zealand and the us had originally withheld their support for it those four countries subsequently endorsed the undrip 95 even if not accepted that the undrip could be said to represent customary international law a number of rights enunciated in it already form part of customary international law 96 indeed a number of indigenous rights enshrined in the undrip have been recognised by international courts and tribunals as having evolved into customary international law 97 selfgovernment is the overarching political dimension of ongoing selfdetermination 98 the emergence of values such as democracy and the major notions of cultural and political pluralism have reinforced indigenous claims for governmental and administrative autonomy for their communities which include claims for reproductive health and generational continuity the idea in many societies that decisions should be made at the most local level possible reinforces the view that indigenous communities should be able to maintain their traditional decentralised system of governance and to 93 make decisions relating to fertility in their communities in this respect indigenous peoples should maintain their own institutions of autonomous governance including their customary and written law and dispute resolution and adjudication mechanisms which have existed not only de facto but as the indigenous peoples correctly claim also de jure as recognised in the ilo convention on indigenous peoples no 169 99 in order to give effect to the right to internal selfdetermination effective procedural rights must be established under international and national law including the indigenous right to prior and informed consent and to participation in decisionmaking 100 international and regional human rights bodies have played a significant role in recognising indigenous peoples right to internal selfdetermination in particular by recognising the obligation of states to protect indigenous peoples land and natural resource rights and to respect and protect the values customs and traditions of indigenous communities 101 some of the most prominent regional developments are the decisions by interamerican human rights bodies 102 which have taken a progressive stance on indigenous peoples land rights 103 for example in sawhoyamaxa indigenous community v paraguay 104 the interamerican court of human rights ruled that paraguayan legislation failed to provide an effective judicial remedy that protected legitimate land claims by indigenous communities 105 this constituted a violation per se of the american convention on human rights 106 and the displacement and expropriation of indigenous lands amounted to a violation of the right to life 107 importantly in saramaka people v suriname 108 the iacthr referred for the first time to the right of selfdetermination in its interpretation of indigenous land and resource rights under article 21 of the achr 109 moreover in the more recent decision of kichwa indigenous people of sarayaku v ecuador 110 the court found that ecuador had violated article 21 of the convention by awarding a private company an oil exploration and exploitation concession that partially covered the ancestral lands of the kichwa people of sarayaku without a consultation process or their free prior and informed consent 111 the right to internal selfdetermination is applicable to the context of policies for fertility control of indigenous peoples given the specific vulnerability of indigenous peoples in most societies and what makes them distinct as a people the right to internal selfdetermination must also include the indigenous right to reject government policies that coercively subjects them to birth control programmes from this perspective autonomous governance is not only instrumental but also necessary for indigenous peoples to control the development of their distinctive culture this includes the use of land natural resources and reproductive health against undue interference from disingenuous powerful economic interests or governments as recognised in the 1994 programme for action 112 and the framework of actions adopted by the 2014 icdp 113 the right to health as a human right human rights are an increasingly important tool for the advancement of social justice they provide the guiding principles to government agencies promoting social justice and provide individuals and groups with a powerful tool to ensure that government agencies commit themselves to human rights principles 114 the right to health is also recognised in some countries as a constitutional right 115 the right to reproductive health is a subcategory of the human right to health the right to health was first articulated at the international level under the constitution of the world health organisation 1946 and subsequently established in several binding international human rights treaties 116 the right to health contains a number of elements that can be legally enforceable under national law for example the right to nondiscrimination in relation to health facilities goods and services 117 yet at the international level the right to health goes far beyond discrimination within health care provision 118 a rightsbased approach to health indicators has been proposed in order to enable progressive realisation of the right to health to be monitored and measured 119 it has been argued that a human rights approach to health could have several advantages for health care practitioners for example as the basis for equitable policies and programmes that benefit the most disadvantaged raising more funds and improving terms and conditions of those who work in the health sector 120 the un special rapporteur on the right to health pointed out in unga resolution a59422 121 that there were profound disparities between the health of indigenous peoples and that of the nonindigenous population in many countries the corollary of which is that indigenous people tend to die younger and generally live in poorer health than other population groups 122 it was further suggested that in some jurisdictions they are more likely to have chronic disorders such as diabetes high blood pressure or arthritis and are more prone to substance abuse depression and other mental disorders than are nonindigenous people suicide rates among indigenous women in certain developed countries are as high as eight times the national average hivaids and other sexually transmitted diseases are spreading rapidly in indigenous communities a trend fuelled by factors including social and economic exploitation of indigenous women as well as a lack of access to health related information 123 further evidence of health inequalities includes discrimination by some health professionals the lack of health services available in indigenous languages the lack of clean drinking water and adequate sanitation the impact of environmental contamination on the health of indigenous communities and violence including sexual violence against indigenous women and children 124 the rapporteurs 2004 report to the unga also noted the systematic inequality in access to medical services and in the quality of these services the marginalisation of traditional medicine of indigenous peoples high rates of diseases such as diabetes and high suicide rates particularly among young indigenous 117 men maternal and child mortality rates can be twice as high as the national average in indigenous communities 125 concerns over the state of indigenous peoples health were reiterated in the third session of the permanent forum on indigenous issues 126 which also highlighted the need to address the right to health of indigenous women including sexual and reproductive rights furthermore the world health organisation has published a number of reports specifically addressing health issues facing indigenous peoples 127 urging states to protect the right of indigenous people to the enjoyment of the highest standard of health 128 the who commission has stated that every government should be assessed for its impacts on health and health equity to make health and health equity a marker for government and economic performance 129 importantly the who has emphasised the importance of data disaggregation in order for policymakers to effectively monitor the health of indigenous peoples 130 it is also significant that the ilo no 169 convention 131the only international treaty specifically aimed to protect indigenous peoples rights recognises the right to health for indigenous peoples and that they may enjoy the highest attainable standard of physical and mental health 132 yet it should be noted that with 22 ratifications at present the ilo n169 convention is not a widely ratified international treaty 133 the adoption of the 2007 un declaration on the rights of indigenous peoples in particular the healthrelated articles 22 24 and 31 thereof could further add support to indigenous peoples claim for selfdetermination over their health wellbeing and development even though as discussed above the declaration is not legally binding it could reflect states opinio juris and practice and thus provide the basis for of its status as customary international law 134 133 the ilo 169 convention was adopted on 17 june 1989 and entered into force on 5 september 1991 it is notable that many latin american states with large indigenous populations have ratified the convention 134 see claire charters indigenous peoples and international law and policy 18 public law review 1 135 see for example the decision of the new zealand court of appeal in ngai tahu maori trust board v directorgeneral of conservation 1995 3 nzlr 553 see also ibid given that most estimates suggest that the mdgs 2015 global health targets are likely to be missed 136 governments are now focusing on post2015 health targets this paper contends that the right to reproductive autonomy and health need to be further developed in the post2015 agenda calls have been made for the indicators set to measure progress in the post2015 framework to be broken down by ethnic and cultural groups 137 moreover the protection of the natural environment and land belonging to indigenous peoples should be seen as an integral aspect of protecting their right to health as indigenous peoples wellbeing is traditionally linked to the conservation of the ecosystem and community wellbeing the indigenous right to land and to natural resources are firmly recognised in both the ilo n169 convention and the undrip 138 and have been upheld in decisions of international treaty monitoring bodies and regional courts 139 the need to improve indigenous peoples access to health services is often constrained by financial geographic and cultural barriers 140 access to culturally appropriate health services is necessary for indigenous peoples to gain full health rights 141 142 in some countries including australia new zealand canada and colombia a further step has been made towards appropriate services where indigenouscontrolled services exist with indigenous medicine practiced alongside mainstream medicine 143 on the other hand the recognition of indigenous traditional customs traditions and healing practices under national health care programmes could pose a number of challenges this can be illustrated in the case of south africa which has recently taken steps to formalise the role of traditional healers in birth attendants and herbalists 144 while one benefit of traditional healers is that they are often more likely to be contacted than doctors applying mainstream therapies there are disadvantages for example 42 deaths and hundreds of injuries to xhosa boys from botched circumcisions were reported in the first six months of 2012 145 this has led to calls for stronger regulations applicable to traditional healers in south africa the regulation of traditional healing practices on the other hand could be in direct conflict with the need for universal access of health services that recognises the needs and priorities of indigenous peoples it is thus paramount that those two oftenconflicting interests are carefully balanced under national health care laws and policies the right to reproductive health family planning programmes are imperative public policy mechanisms for tackling reproductive and sexual health problems given that they are preventive in nature even though not all sexual and reproductive illhealth represents a violation of the right to health or other human rights it could constitute a violation of those rights when it arises in whole or in part from the failure of a state to respect protect or fulfil a human rights obligation 146 under international law the concept of family planning has been recognised as a basic human right in relatively recent times specifically the term was used in the 1965 un commission resolution on the status of women which states that married couples should have access to all relevant educational information concerning family planning 147 yet as ericsson points out the term was not applied in the context of human rights until the 1968 un conference on human rights it was held then that parents have a basic human right to determine freely and responsibly the number and spacing of their children 148 although neither the ilo no 169 convention nor the undrip contain legal provisions recognising a specific right to reproductive health to indigenous peoples the right is recognised in other international human rights instruments in this regard the commission on human rights confirmed in resolution 200328 that sexual and reproductive health are integral elements of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health 149 in a similar fashion principle 8 of the 1994 icpd programme of action states that everyone has the right to the enjoyment of the highest attainable standard of health which includes the states obligation to provide access to health care services related to reproductive health care which includes family planning and sexual health 150 the 1994 icpd programme of action further affirmed the basic right of all couples and individuals to decide freely and responsibly the number spacing and timing of their children and to have the information and means to do so and the right to attain the highest standard of sexual and reproductive health 151 in 1995 the platform for action of the beijing world conference on women adopted similar provisions on reproductive health 152 the main difference between the two instruments is that the beijing declaration confirms the right of women to control their sexuality 153 this obligation of states to protect womens reproductive rights was generally restated in the 2014 framework of actions of the second cairo conference it declares that states should guarantee indigenous peoples right to health including their sexual and reproductive health and rights as well as their rights to both the highest standard of care and the respectful accommodation of their own traditional medicines and health practices especially as regards reducing maternal and child mortality considering their socioterritorial and cultural specificities as well as the structural factors that hinder the exercise of these rights 154 yet the report has criticised states implementation of this obligation noting that a considerable number have not addressed the issue of providing culturally appropriate sexual and reproductive health care including hiv prevention services for indigenous peoples 155 it is also a cause for concern that some states in the americas and asia despite having emphasised the right to health as a priority for indigenous peoples have simultaneously excluded sexual and reproductive health when listing areas that they prioritise concerning indigenous peoples 156 the most important reference to family planning as a human right is however in the convention on elimination of all forms of discrimination against women cedaw proclaims that women and men have equal right to decide freely and responsibly on the number and spacing of their children and to have means to enable them to exercise this right 157 the reference in cedaw to family planning is particularly significant since unlike the aforementioned unga resolutions and the icdp action programmes cedaw is a legally binding international treaty cedaw is widely 150 1994 icpd programme of action principle 8 151 ratified including australia and peru although notably the us is not a party 158 the cedaw committee 159 has raised the prospects of family planning being elevated to the status of an international human right in 1993 the committees recommendation stated that women have the right to the number and spacing of their children 160 in general however the committee avoids the term family planning which suggests that it may have become outmoded and the need for it to be replaced by the more comprehensive term reproductive health 161 in support of the right of reproductive autonomy for women the committee held in general recommendation no 19 that c ompulsory sterilization … adversely affects womens physical and mental health and infringes the right of women to decide on the number and spacing of their children 162 the programme of action of the icpd conference defines under chapter vii par 72 reproductive health as as state of complete physical mental and social wellbeing and not merely the absence of disease or infirmity in all matters relating to the reproductive system and to its functions and processes further affirming that the definition implies that people must have the capability to reproduce and the freedom to decide if when and how often to do so 163 it calls on governments and other important institutions to recognise the distinct perspective of indigenous people in relation to population and development all human rights violations and discrimination especially all forms of coercion must be eliminated 164 moreover the programme of action of the 1994 icpd 165 declares noncoercion to be fundamental to population and reproductive health programmes and that coercion in any form is unacceptable 166 yet the more recent 2014 icdp framework of actions has noted the slow progress of some states in adopting implementing and enforcement measures to ensure full enjoyment of reproductive health rights 167 the right to reproductive health which includes the right to family planning thus includes both a positive and negative state obligation the positive obligation involves the requirement for states to provide all the essential health care facilities and services while the negative obligation revolves around the states need to abstain from interfering 158 the committee on the elimination of all forms of discrimination against women has been transferred on 1 january 2008 to the office of the high commissioner on human rights in geneva see eriksson 183 159 on the powers of the cedaw committee see further section 521 below 160 recommendation no 21 see also ericsson who argues that the resolution is the only authoritative interpretation of the right to family planning 184 161 ibid at 185 in its fiftysecond session on 25 february 7 march 2008 the csw has adopted resolutions on ending female genital mutilation ecn62008l2rev1 and on women the girl child and hivaids ecn62008l5rev1 162 cedaw committee general recommendation no 19 see further section 521 which discusses communications brought before the committee 163 see 2014 icpd framework of action 164 programme of action of the 1994 icpd para 625 165 acone 17113 166 babor 118 167 in the area of sexual and reproductive health and reproductive rights less than two thirds of countries have promulgated and enforced a law protecting the right to the highest attainable standard of physical and mental health including sexual and reproductive health see 2014 icpd framework of action with ones individual reproductive choices through coercive population control programmes the 1994 and 2014 icpd programmes of action and beijing declaration and platform for action are alongside the cedaw the most influential and authoritative international documents on the right to reproductive and sexual health 168 furthermore even though the subsequent mdgs do not expressly refer to sexual and reproductive health at least three of the eight goalson maternal health child health and hivaidsare relevant to sexual and reproductive health 169 other international initiatives recognising reproductive health rights for indigenous peoples include the outcome document of the 2014 world conference on indigenous peoples 170 and the conclusions of the world conference on indigenous women in lima peru in 2013 171 the 59th session of the commission on the status of women that took place in new york from 9 to 20 march 2015 focused on the current challenges that affect the implementation of the 1995 beijing declaration and platform for action 172 in addition a number of regional treaties have been adopted affirming expressly or indirectly womens reproductive health rights particularly important is the interamerican convention on the prevention punishment and eradication of violence against women 173 which affirms that violence against women constitutes a violation of their human rights and fundamental freedoms and establishes the state duty to protect woman against violence 174 although womens reproductive rights are not listed in article 4 of the convention that provision is not supposed to be exhaustive as such the convention can be interpreted to also protect womens reproductive rights in its provisions concerning the protection of women against violence 175 within the council of europe framework the convention on human rights and biomedicine requires that an intervention in the health field cannot be carried out without the free and informed consent of the person concerned this must be done on the basis of objective information provided without any pressure regarding the nature and consequences of the medical intervention and its alternatives 176 perhaps the most significant regional treaty concerning the right to reproductive health is the protocol to the african charter on human and peoples rights on the rights of women in africa 177 this protocol entered into force on 25 november 2005 and has so far been ratified by 36 african union states 178 the protocol recognises health and reproductive rights for women in africa including the right to control fertility and the number of children and spacing of children 179 it seems clear from the foregoing that there is a relatively welldeveloped body of international norms and instruments recognising the right to reproductive health as a human right although the majority of these instruments are nonbinding cedaw is one of the few exceptions as an international treaty recognising the right to reproductive health and autonomy of women however one of its key weaknesses is that from the broader perspective of population policies cedaw has a more limited scope as it aims to affirm womens rights and hence forced male sterilisation and forced child removals are not expressly outlawed under cedaw to conclude the rights to selfdetermination to health and to reproductive health provide the essential substantive basis for the affirmation of indigenous peoples reproductive autonomy the next section assesses the extent to which there are mechanisms under international law for these rights to be adjudicated and protected procedural rights for assertion of indigenous peoples right to reproductive autonomy the substantive norms discussed in the previous sections could be easily disregarded by states if there were no effective legal and extrajudicial mechanisms for enforcement and settlement of disputes this section examines the procedural rights that exist internationally regionally and nationally for the assertion of indigenous peoples reproductive rights and for reprehension of government population policies that infringe those rights the right to prior and informed consent and to participation in decisionmaking under international law international law recognises the principle that indigenous peoples should be consulted in decisions made by national authorities and others that could affect them 180 the right to consultation and to prior and informed consent should serve as a basis for indigenous peoples to reject policies that subject them to birth control programmes indeed the right to free prior and informed consent is at heart of cases regarding reparations for victims of involuntary sterilisation programmes 181 the right to consultation is enshrined in ilo convention 169 182 which employs different standards ranging from consultation to participation and informed consent 183 according to the convention consultation must be undertaken in good faith and in a form appropriate to the circumstances with the objective of achieving agreement or consent 184 indigenous peoples participation in the broadest level of governance must not supplant local participation in connection with specific issues or projects that impact on their wellbeing 185 this right is further recognised in the undrip which defines the right of indigenous peoples to participate in decisionmaking in matters that could impact on their rightsthrough representatives chosen by them in accordance with their own proceduresas well as the right to maintain and develop their own indigenous decisionmaking institutions 186 before adopting and implementing legislative or administrative measures that may affect them 187 states must consult and cooperate in good faith with the indigenous peoples concerned through their own representative institutions in order to obtain their free prior and informed consent in particular the free prior and informed consent of indigenous peoples needs to be defined in accordance with their customary laws and practices 188 both the ilo convention 169 and the undrip thus recognise that consultation is an obligation when indigenous peoples fundamental rights are concerned 189 those developments have led anaya to argue that widespread acceptance of the norm of consultation demonstrates that it has become part of customary international law 190 the extent of this duty to consult has been intensely debated in particular it is contended that the right of indigenous peoples to participate in decisionmaking should include the right to veto decisions affecting them 191 aside from the circumstances that would involve relocation 192 the ilo convention 169 generally falls short of requiring the consent of indigenous peoples and instead establishes the principle of consultation and that they have the right to participate in decisionmaking 193 the convention also incorporates indigenous peoples right to participate in decisionmaking in matters that would affect their rights 194 before the adoption and implementation of such legislative or administrative measures 195 the international jurisprudence and state practices advancing the right to prior and informed consent for indigenous peoples has been developed particularly in the context of relocation and the right to participate in the context of extractive industry projects this right must also be recognised in the context of other coercive policies impacting on indigenous peoples wellbeing including sterilisation and birth control programmes indigenous peoples participatory rights regarding state health and population policies are expressly recognised in the 1994 programme of action to the icpd which called for governments to incorporate the perspectives and needs of indigenous communities into the design implementation monitoring and evaluation of the population development and environment programmes that affect them 196 beyond those international initiatives there are specific regional instruments recognising the principle that a medical intervention in to ones health cannot be carried out without the free and informed consent of the person concerned 197 there remain many barriers to implementation of the right to prior and informed consent in national legislation which include inadequacy of laws and regulations lack of articulated community procedures and the lack of will to facilitate access by some local communities 198 the requirement that consent be free suggests that it should be obtained without coercion intimidation or manipulation secondly prior suggests that the consent is sought sufficiently in advance of any authorisation or commencement of activities and respect time requirements of indigenous consultationconsensus processes finally informed requires that there be sufficient information regarding the nature size pace and scope of any proposed project or activity 199 the need to obtain a patients prior and informed consent has been paramount to the development of international jurisprudence concerning forced sterilisations for example in vc v slovakia the european court of human rights held that where sterilisation was carried out without the informed consent of a mentally competent adult it was incompatible with the requirement of respect for human freedom and dignity therefore it was in breach of article 3 echr on the prohibition on torture and inhuman or degrading treatment and article 8 echr on the right to private and family life 200 moreover as discussed above the lack of free prior and informed consent were paramount to the findings by the peruvian human rights ombudsman office that the peruvian sterilisation programme violated indigenous womens reproductive rights 201 the procedures for obtaining indigenous peoples consent should be culturally appropriate in line with the international initiatives concerning the right to health 202 in this regard language is often a barrier in the context of access to sexual and reproductive health services 203 for example it has been suggested that in some languages there is no term for fistula making open discussion difficult and perpetuating stigma and discrimination and restricting access to services 204 it is thus recommended that mutual forms of communication be implemented between service providers and users taking into account local languages and customs the right to access to justice the judicial and extrajudicial avenues for assertion of indigenous peoples reproductive health rights the right of individuals and communities to bring effective mechanisms for justice and redress is a fundamental aspect of the evolution of international human rights law international courts generally fail to establish a right of standing to individuals groups of individuals or corporations to bring legal proceedings for defence of individual or collective rights in particular the international court of justice only has jurisdiction over disputes between states 205 despite this this section discusses a number of other international regional and national forums for indigenous peoples to bring claims for violations of their reproductive health rights this section examines in particular their rights to access to justice before international human rights treaties monitoring bodies the ilo convention 169 compliance committee two regional human rights systems international and national criminal courts as well as alternative mechanisms to litigation such as truth and conciliation commissions un human rights treaties supervisory bodies the supervisory or monitoring bodies established under specific human rights treaties offer a level of protection against violations of indigenous peoples reproductive rights one example is the cedaw committee which may be called upon in cases involving violations of reproductive health and indigenous womens rights in addition to recommendations to state reports optional protocol to cedaw 206 introduces a system whereby communications detailing violations of the convention may be submitted to the committee both australia and peru are parties to this optional protocol the cedaw committee has focused on problems faced by indigenous women in its observations to state reports which have included recommendations regarding sexual violence against indigenous women 207 the disrespect for indigenous womens human rights and violence against them are part of a general pattern of gender injustice and neglect by governments while the international indigenous rights movement itself often turns a blind eye to the issue 208 on august 2006 the cedaw committee found for the first time that restrictions on womens reproductive freedom constituted a human right violation and decided that hungary had violated the convention by not ensuring that a roma woman who was sterilised in january 2001 had given her fully informed consent 209 the committee considered that she has a right protected by article 10 cedaw to specific information on sterilisation and alternative procedures for family planning in order to guard against such an intervention being carried out without her having made a fully informed choice 210 the committee found that a failure by the state through the hospital personnel to provide appropriate information and advice on family planning constituted a violation of the complainants right under article 10 cedaw 211 the committee further recommended that hungary introduce legislation on informed consent 212 as peru only ratified the optional protocol in 2001 communications could not be submitted to the committee 213 however in its observations on perus report the committee explicitly condemned the sterilisation practices in august 2002 expressing its concern over the numerous cases of sterilisation of women without prior informed consent using psychological violence or the promise of financial incentives thus affecting womens right to decide the number and spacing of their children and its regret that those responsible have not been punished 214 in a more recent case that demonstrates cedaws scope in dealing with reproductive health rights of minorities or ethnically discriminated groups the committee held that the lack of access to quality medical care during pregnancy was a systematic problem in brazil it found that an afrobrazilian woman who died due to the lack of adequate emergency obstetric care had been discriminated against because of her ethnic status 215 in february 2014 the brazilian government reached a settlement with the victims family in the case agreeing to pay compensation 216 another example is the work of the human rights committee against torture in its 2006 report on peru expressed concerns at reports of women undergoing forced sterilisation and considered that the state failed to take steps to prevent acts that put womens physical and mental health at grave risk and that constitute cruel and inhuman treatment 217 while not dealing explicitly with indigenous peoples reproductive rights the human rights committee has continued to favour an interpretation of article 27 iccpr that includes strong indigenous land cultural and language rights 218 the hrc has heard a number of cases regarding reproductive health although not specifically concerning the rights of indigenous women for example in k l v peru the hrc asserted that it is the state responsibility to ensure access to legal abortion services 219 an important development concerning indigenous womens reproductive rights was the hrcs 2009 call on the australian government to adopt a comprehensive national mechanism to ensure that adequate reparation including compensation is provided to the victims of the stolen generations policies 220 the un committee on economic social and cultural rights has defined the minimum standards for delivering the right to health in goods facilities and services including the underlying determinants of health care in particular their availability accessibility acceptability and quality 221 the escr committee also emphasised the participation of indigenous peoples in decisions relating to the right to health 222 in a decision of 28 november 2014 the committee called on the romanian government to revise its laws and policies to ensure access to reproductive health care for women and adolescents and recommended the implementation of a national strategy on sexual and reproductive health 223 also significant has been the role played by the committee on the elimination of racial discrimination cerd has intensified its monitoring of indigenous issues and encouraged many states to review their policies concerning indigenous peoples in this vein cerd has used the urgent action procedure in order to address the discriminatory policies of some states 224 ilo convention compliance committee state parties to the ilo convention no 169 are required to report on measures taken to ensure the implementation of ratified ilo conventions and any problems encountered to the committee of experts on the application of conventions and recommendations this committee may take specific action against noncompliance including the power to submit observations and make direct requests 225 yet the committees powers to impose sanctions are more limited 226 the ilo compliance committee has contributed to indigenous peoples rights jurisprudence including by recognising that consultations must be held when indigenous peoples interests are involved 227 although the committee has not decided a case involving perus sterilisation programme 228 in guerrero and oaxaca it has received complaints and reports of investigations observations and recommendations regarding alleged violations of indigenous peoples reproductive rights it was alleged that members of public health institutions have performed vasectomies on indigenous men and fitted indigenous women with intrauterine devices as a method of birth control without their free informed consent in two mexican states 229 moreover a local study alleged that the health system for indigenous communities was precarious and referred to the inhumane and discriminatory treatment of indigenous persons in healthcare centres and to the practice of forced sterilisation of women by tying their fallopian tubes 230 in response the mexican government indicated that its health institutions have no record of judicial or administrative complaints concerning alleged violations of sexual and reproductive rights of the indigenous population and that their freedom of choice had been fully respected the committee did not find this response entirely persuasive as such the committee requested mexico to supply information on the steps taken to guarantee that the decision to take permanent contraceptive measures is indeed a free choice and to ensure that the persons concerned are fully aware of the permanent nature of the sterilisation measures moreover the committee requested mexico to supply information on the extent to which indigenous peoples participate and are consulted regarding reproductive health and family planning 231 in a the report delivered to the committee in september 2013 the mexican government indicated that the procedure implemented by the opportunities programme of the mexican social security institute is of informed and shared consent 232 the government further noted that in 2012 the gender equity action programme with the indigenous population consolidated its initiatives in relation to the indigenous womens forum and developed projects for indigenous womens organisations addressing violence and sexual and reproductive health 233 the committee invited mexico to continue providing information on the manner in which informed consent concerning sexual and reproductive rights has been included in programmes intended for indigenous communities 234 despite the fact that as yet no overwhelming evidence was presented to the committee showing that the mexican sterilisation programme failed to respect womens right to free and informed consent the guerrero and oaxaca case is particularly significant the significance of this case relates to the fact that it shows the potential for international human rights law to condemn and ultimately revert an existing population policy programme that violates indigenous peoples reproductive rights regional human rights systems a state party may declare that it recognises as binding the jurisdiction of the interamerican court of human rights on all matters relating to the interpretation or application of the achr 235 twentyone member states of the organization of american states have accepted the courts jurisdiction 236 it is wellestablished in the iacthrs jurisprudence that a states omission to provide effective protection against threats to indigenous populations including those to their health can lead to the liability of the state itself for example in sawhoyamaxa indigenous community v paraguay 237 the court ruled that paraguayan legislation failed to provide an effective judicial remedy aimed at protecting legitimate land claims made by indigenous communities which constituted a per se violation of the achr moreover the court has stated that the displacement and expropriation of indigenous lands amounted to a violation of the right to life 238 hence the iacthr takes the view that states have both positive and negative obligations in respecting the right to life i n order for this positive obligation to arise it must be determined that at the time of the occurrence of the events the authorities knew or should have known about the existence of a situation posing an immediate and certain risk to the life of an individual or of a group of individuals and that the necessary measures were not adopted within the scope of their authority which could be reasonably expected to prevent or avoid such a risk 239 as there was no effective remedy or system through which individuals could claim redress for violations of their human rights under peruvian law during the fujimori government the interamerican commission was expected to play an important role in the redress of the indigenous and rural communities that were impacted by perus sterilisation programme 240 however one significant limitation of the commission is that it can issue recommendations but not binding decisions 241 it should be noted however that after consideration by the commission the presumed victims may request that their case be submitted to the court 242 in the mamerita mestanza chavez case the iacommhr found peru responsible for the forceful sterilisation and death of the victim as a result of the operation 243 following this decision a friendly settlement was signed in august 2003 by peru and the victims family in this agreement the government acknowledged international legal responsibility and agreed for the first time to compensate victims of the programme and agreed to modify and implement recommendations made by perus human rights ombudsman however the agreement does not foresee compensation for other victims this friendly settlement helps to explain why the agreement has not reached the interamerican court 244 although peru withdrew its acceptance of the courts jurisdiction in 1999 it was renewed in 2003 245 despite the fact that the iacommhr has taken up the cases of over 200 women sterilised under the fujimoriera program and recommended their compensation 246 at present mestanza is the only case that has led to compensation to a victim although other deaths have been reported 247 these are however only some of the most damaging consequences of the peruvian sterilisation programme and compensatory remedies must also to be available to other victims moreover the iacthr has upheld the principle of prior free and informed consent in other cases involving allegations of forced sterilisation 248 it should also be noted that the mamerita mestanza chavez case is an exceptional one in which the right to health was the central issue in a complaint brought before the iacommhr for violation of indigenous rights without there being a closer link with the indigenous right to land and property one explanation for this is connected to the fact that the achr does not explicitly protect the right to health although this right could be regarded as integral to the promotion and fulfillment of the civil and political rights enshrined in the convention 249 indeed the court applied this reasoning when it drew connections between a reproductive health right and the rights to privacy and family life in the artavia murillo et al v costa rica case concerning the ban by costa rica on invitro fertilization 250 the court found costa rica in breach of the achr ruling that the states ban on ivf violated the rights to privacy to liberty to personal integrity and the right to form a family in conjunction with the right to be free from discrimination 251 the court concluded that there were less restrictive ways to accomplish the states objective and to reconcile the interests at stake 252 the court finally held that the outright ban on the practice of ivf constituted an arbitrary interference and a restriction incompatible with the ahcr on the exercise of the right to a private and family life in article 11 253 in xakmok kasek community 254 the courts reasoning was not limited to a consideration of allegations of violations of indigenous peoples property rights indeed the court examined whether paraguay had violated the provision of basic services including health services with respect to the states obligation to protect the right to life the court held that there was a violation of the right to medical care as the state had not guaranteed physical or geographical access to health care establishments for the community 255 within the african human rights system the african court on human rights 256 is yet to decide on a case involving indigenous peoples rights 257 moreover the african commission on human and peoples rights has dealt with only a few cases regarding indigenous peoples rights 258 but none of these have dealt specifically with reproductive health rights the right to indigenous peoples health more broadly was addressed in the social and economic rights action center and the center for economic and social rights v nigeria 259 in this case nigeria was found to have violated several articles of the african charter for violating the health rights and livelihood of the ogoni people 260 this case concerned the negative health and environmental impacts of oil exploration in ogoniland and the contamination of water with lead and mercury affecting community health particularly that of the children the commission called for compensation to victims of human rights violationsincluding relief and resettlement assistance to victims of government raidsand comprehensive cleanup of lands and rivers damaged by oil operators 261 the african unions legal framework could more specifically protect indigenous peoples reproductive health rights in particular since the adoption of the protocol to the african charter on human and peoples rights on the rights of women in africa 262 the protocol recognises health and reproductive rights for women in africa including the right to control fertility and the number of children and spacing of children 263 in this regard the african commission has expressed concerns over states failure to implement their obligations under the protocol in particular it has condemned the practice of forced female circumcisions in many states and expressed concerns about the problems relating to reproductive health care and the quality of services available to women in africa 264 international and national criminal courts the more serious and abusive violations of indigenous peoples fundamental reproductive rights could also potentially be established as international crimes as such there is potential to engage the criminal liability of state officials and others acting on behalf of the state before the international criminal court the iccs jurisdiction established by the rome statute 265 arises automatically over international crimes committed in a state party or by a national of a state party sterilisation programmes that target one specific group could amount to acts of genocide and to a violation of article 2 of the un 1948 genocide convention and article 6 of the rome statute thus potentially attracting the iccs jurisdiction the genocide convention prohibits measures intended to prevent births within a group with intent to destroy in whole or in part a national ethnical racial or religious group 266 australias removal of aboriginal children from their families violates article 2 of the genocide convention as well as article 6 rome statute which prohibits forcefully transferring children from one group to another group 267 however the crime of genocide requires evidence of specific intent to destroy a group which has proved difficult to establish in specific cases 268 although they appear to meet the actus reus element of the crime it would be challenging for the icc prosecutor to establish that these coercive assimilationist policies intended to destroy a group unless the law evolved to recognise and criminalise more broadly acts of cultural genocide it must be noted that although australia is a party to the icc the rome statute only applies to crimes occurring after its entry into force in 2002 in relation to the peruvian family planning programme criminal investigations into it were terminated by the peruvian chief prosecution services in 2009 the public prosecutor in charge of the investigations decided that the over 2000 registered cases of forced sterilisation did not constitute a severe violation of human rights and thus the statute of limitations prevented criminal investigations 269 however formal criminal investigations were reopened by the attorney general in 2011 in which it is suggested that the violations amounted to crimes against humanity and therefore that the alleged offences are not covered by the statute of limitations in an apparent misinterpretation of the rules of international criminal law in january 2014 the prosecutors closed the case as it was argued that crimes against humanity only fit the situation of mamerita mestanza chavez at the time of writing no criminal prosecutions have been brought against state officials or the health practitioners involved in the peruvian programme 270 this decision by the public prosecutor is in direct violation of the friendly settlement reached in the mamerita mestanza chavez case in which the peruvian government undertook to investigate and punish those responsible for the reproductive health violations 271 reparations reconciliation and redress under national law beyond the liability of the state and individuals for human rights violations as recognised by international and regional courts the role of national court systems cannot be understated in this context in a landmark ruling in 2007 south australias supreme court awarded compensation for the first time to a stolen generation victim 272 this decision opened the way for a number of other legal actions claiming reparations for the stolen generation before australian courts 273 another notable development is the legislative proposal for a south australia stolen generation bill 2014 274 the bill foresees the reparation of indigenous aboriginal and torres strait islander peoples removed from their family as children including the payment of compensation to individual aboriginal and torres strait islander persons removed from their families as children under previous government policies to of a lump sum of up to aus 50000 276 the focus on monetary compensation under this bill sets it in contrast with the earlier 2010 stolen generations reparations bill which recognised a broader range of reparation measures that earlier bill foresaw reparation measures such as funding for healing centres community education projects community genealogy projects and funding for access to counselling services health services language and culture training 277 moreover the current draft of the 2014 bill foresees the monetary compensation of descendants of an aboriginal removed from his or her family but not for other family members and parents who have suffered harm as a consequence of the removal 278 this would have recognised the fact that the governmentsponsored child removal policies were particularly traumatic to the families it would also be in line with the bringing them home report recommendations 279 the bill is currently being debated by the australian parliament if adopted south australia will be the second australian state to set up a tribunal to compensate the stolen generation victims 280 reconciliation can play an important role in healing wounds from past crimes as applied in the case of truth and reconciliation commissions 281 even though peru has set up a truth and reconciliation commission with the purpose of clarifying the process facts and responsibilities of the terrorist violence and human rights violations produced from may 1980 to november 2000 the commission has been criticised for failing to address the statesponsored sterilisation programme that took place between the mid to late 1990s 282 in contrast australia has not set up a such a commission a significant development happened in 2008 when kevin rudd then australian prime minister apologised for the tragedies suffered by aboriginal families of the stolen generation breaking with his predecessors disregard for this issue 283 the apology is not only symbolically significant as the more concrete measures for reparation of indigenous peoples have been proposed subsequently in the south australian stolen generations reparations tribunal bill and the south australian stolen generation bill 284 another positive development came in april 2009 when rudds government endorsed the undrip despite australias vote against it in the general assembly under the former howard government 285 it has been recognised that the apology was only a first step by acknowledging the past and laying claim to a future that embraces all australians 286 and as jenny macklin who was then the minister for families housing community services and indigenous affairs has reportedly put it we have serious inequalities between indigenous and nonindigenous australians the apology is symbolic but theres a lot of hard work to be done to reverse those inequalities 287 indeed indications that considerable work lies ahead are the suggestions that aboriginal child removals still currently happen under australian welfare legislation 288 and that maternal and infant mortality rates for indigenous women and children in australia are still much higher than the national average 289 in this regard julia gillard former prime minister apologised on 21 march 2013 for another government policy from the 1950s to 1970s that led to thousands of unmarried young mothers who were coerced or deceived into giving up their babies to adoption by married couples 290 it will be interesting to follow how the governments subsequent response to the apology for these past policies which were applicable to australian women irrespective of ethnicity will compare to the reaction that followed the governments apology to the stolen generation this review of the jurisprudence of international courts and un treatymonitoring bodies as well as of two regional human rights systems suggests that under international law states have an obligation to ensure the protection of indigenous peoples reproductive rights and that states can be held liable for their failure to protect these rights moreover international regional and national courts and procedures have played important roles in recognising the right to reparation schemes and a measure of redress from past government policies violating indigenous peoples reproductive rights the guerrero and oaxaca case before the ilo compliance committee is particularly significant the significance of this case stems from the fact that it illustrates the role that international human rights law can play not only in addressing the reparation of victims and their relatives but also to condemn and potentially end an existing national policy of population control that violates indigenous peoples reproductive rights conclusion the oppressiveness of postcolonial state systems has confronted indigenous peoples with the terrifying prospect of inter alia genocide birth control and sterilisation programmes as such what type of governmental system is necessary to accommodate indigenous claims for some degree of independence in order to rule their own communities and enable them to control their fertility the right to reproductive freedom is a fundamental tool for indigenous peoples to decide their own reproductive strategies there are grounds for concern that rapid population growth in some continents and forced migration arising from environmental factors could lead to the reassertion of coercive national population policies and that these policies could impact disadvantageously on indigenous peoples this is so not only because population policies tend to be topdown and disregard the rights of minorities but also because the institutionalisation of these policies may have a racist or discriminatory intent international and national human rights law play a central role in giving effect to the right of reparation to indigenous peoples that have suffered violations of their reproductive autonomy from past governmentsponsored policies recent history and events have shown that forceful birth control programmes can pose a significant threat to indigenous peoples the longterm survival and generational continuity of distinctive ethnic and cultural groups requires that there is effective protection of their reproductive health rights in particular in countries such as peru and australia where there has been welldocument evidence of violations of indigenous peoples reproductive rights these rights must also be recognised and made effective under international human rights law while securing reproductive autonomy may pose an even bigger challenge for coming generations of indigenous peoples in light of future challenges including dislocation and climate change the main threat to indigenous peoples survival arise from national policies that disregard their right to health more broadly including policies that are complacent or condone the invasion and expropriation of their lands certainly the dispossession of indigenous lands and the impact that this has on their health pose a major threat to their survival in many parts of the world therefore the right to life and to health of indigenous peoples need to be effectively protected and must be made enforceable under international human rights law this is recognised under the 1994 plan for action programme emphasising that population policies impacting indigenous peoples need to be considered within the broader context of indigenous peoples fundamental rights including the right to health to land and to natural resources 291 although states have renewed their commitment to improving womens reproductive health and to strengthening indigenous peoples rights in the 2014 icdp it is notable that a number of states did not declare the protection of reproductive health rights for indigenous women to be a current priority yet it is the indigenous identify and the survival of distinctive indigenous cultures that may be the biggest longterm threat for indigenous peoples in particular government policies that aim to assimilate them some of these assimilationist policies may in fact be part of a family planning programme as in the case of the aboriginal child removal policies in australia therefore it is crucial that indigenous traditional cultures and languages that have evolved over centuries are also effectively protected under international law 292 the perception of indigeneity by broader society and indigenous peoples themselves defines the contours of the relationship between cultural identity population politics and human rights this paper concludes that the right to reproductive health must be seen as an integral part of the right to selfdetermination and to health under international law which delineates the degree of autonomy of indigenous peoples to selfgovernment 291 1994 plan for action programme 621 292 see siegfried wiessner the cultural rights of indigenous peoples achievements and continuing challenges 22 european journal international law 1 on the other hand it is rightly suggested that it is not for human rights law to advocate that indigenous cultures are kept frozen in time but to allow indigenous peoples to develop in their own way and protect their right to enjoy their own traditional culture see also pereira and gough including reproductive strategies moreover the right to indigenous peoples reproductive autonomy must be given effect by procedures for prior and informed consent and to consultation in the context of family planning programmes these rights must be recognised in the post2015 millennium development goals framework the right to selfdetermination to health and to prior and informed consent provide the essential legal basis that must be made enforceable under international law in order for indigenous peoples to triumph over assimilationist and other neocolonial practicesof which forceful child removal policies and birth control programmes are just some of the unfortunate examples

p e r ei r a ric a r d o 2 0 1 5 gov e r n m e n ts p o n s o r e d p o p ul a tio n p olici e s a n d in di g e n o u s p e o pl e s c h all e n g e s fo r in t e r n a tio n al h u m a n ri g h t s law n e t h e rl a n d s q u a r t e rly of h u m a n ri g h t s 3 3 4 p p 4 3 74

introduction concepts of cybernetics systems complexity chaos catastrophe and oscillation have long been part of discourse in the behavioral social and biological sciences without the ready availability of mathematical models for the social and biological sciences a nonmathematical approach to systems theory was prominent in early biofeedback work and was well articulated by schwartz and colleagues however a mathematical approach for aircraft communication and control systems had been articulated by wiener as early as the 1940s this model served as a heuristic for describing behavioral economic biological and astronomical systems among others in recent years mathematical versions of systems theory have been applied in biology and behavioral science as described below because wieners theory had limited predictive power it was soon combined and supplanted by theoretical systems with greater complexity such as shannons information theory which incorporates concepts of channel capacity noise and entropy as well as chaos theory which emphasizes deterministic nonrandom but complex nonlinear relationships among a large number of cooccurring processes for which statistical prediction is possible applications of both information theory and chaos theory have been made to the biological and behavioral sciences and the present article draws upon insights from this work for the purposes of this article we define a system as a variety of elements that interact with one another to form a whole entity a systems distinct parts are not isolated from each other thus the characteristics of the whole entity cannot generally be deduced from each of its components a stable system retains important characteristics even in the face of perturbations that disturb the behavior of specific elements dynamical systems show changing patterns of action over time but retain characteristics of an integrated whole cybernetics is the study of such regulatory processes including system characteristics like stability feedback adaptation information and the relationships among them dynamical systems have been described as organized or disorganized and of greater or lesser complexity simpler organized systems can often be described and modeled in linear terms although nonlinear approaches usually are more appropriate for more complex systems a control system is defined as a stable system in which system elements interact to preserve system stability both for internal control and in response to perturbations caused by external influences systems can be modeled as closedloop or openloop an openloop system involves only a system response to an outside event it does not provide an internal mechanism for monitoring system performance or preserving system stability for example openloop models have been used to biomimetically describe the flying patterns of drosophila melanogaster after stimulation behavioral and chemical interventions designed to change system behavior are examples of open loop control processes such as when we teach a person to lower muscle tension or blood pressure directly rather than by using natural feedback mechanisms a closedloop model includes internal regulation whereby system responses to outside stimulation are processed through internal feedback loops that monitor and adjust the response of the system itself as a discipline biofeedback is particularly concerned with closedloop internal regulatory systems and tries to maximize their effectiveness a good example of a closed loop system is the baroreflex as will be described in more detail later in this article however when biofeedback or relaxation is used as a strategic intervention to control acute symptomatology the resultant process can be described as an openloop system a common control mechanism leading to system stability in closed loop systems is the negative feedback loop negative feedback loops preserve stability by activating opposing processes that act to modulate change though importantly stable systems tend to contain both positive and negative feedback loops as will be described below negative feedback systems usually have inherent delays caused by the time needed for opposing system elements to effect change in each other negative feedback loops with delays cause oscillations at particular frequencies cinquin demongeot 2002 a very simple negative feedback system is the thermostat which responds to changes in ambient temperature by switching a heating or air conditioning system on and off here the delay is dependent on such factors as outside air temperature insulation and volume of inside air thus room temperature oscillates around the thermostatic setting but is rarely constant the negative feedback loop in the baroreflex system also contains delays as will be described below oscillatory properties have been observed in systems as small as the cell and as large as societies for example at a cellular level oscillations have been used to map various negative feedback loops in protein concentrations and circadian gene expressions in bacteria in social systems oscillations describe patterns of voting marital relationships and mood the baroreflex system is a good example of a stabilizing oscillatory process it produces periodic fluctuations in blood pressure heart rate and vascular tone that reflect modulatory control external influences on blood pressure induce blood pressure changes that without a control mechanism could burst blood vessels or cause circulatory insufficiency depending on the direction of blood pressure change the baroreflex responds to blood pressure increases by slowing heart rate and causing vasodilatation which in turn produces a decrease in blood pressure each time blood pressure decreases the same mechanism produces vasoconstriction and heart rate acceleration which causes blood pressure to rise again changes in blood pressure are delayed by a number of factors including inertia in blood flow and blood vessel plasticity the delay in blood pressure changes following heart rate change averages about five seconds thus yielding the ubiquitous heart rate oscillation of about 10 seconds ie five seconds for the baroreflex to cause an increase in blood pressure when the baroreflex responds to a decrease in blood pressure and five seconds to cause a decrease in blood pressure following a baroreflex response to a blood pressure increase in actuality however the baroreflex system is composed of two closed linear systems with negative feedback loops it also contains a slower vascular tone loop with a rhythm of approximately 002003 hz which has a slower response time than the heart rate loop it should be noted that a full description of baroreflex control would not be restricted to purely mechanical properties of the reflex the baroreflex system shows characteristics of neuroplasticity dworkin demonstrated that the baroreflex can adapt to changing environments through classical conditioning consistent with dworkins findings lehrer and colleagues demonstrated that regular stimulation of the baroreflex through biofeedback can increase baseline baroreflex gain suggesting an improvement in regulatory capacity over blood pressure changes complex control of systems most psychological and biological systems are much more complex than thermostats with multiple control mechanisms and multiple overlapping oscillations the quantitative characteristics of which depend on the frequency and phase of each component oscillator as well as the interactions among them changes to one system component affect others so the individual control mechanisms are interdependent thus promoting biological vitality and complexity additionally it should be noted that closed loop systems with negative feedback loops often require simultaneous open loop processes in order to function properly to provide sufficient stimulation to stimulate negative feedback loop activity this adds to the complexity simple control such as control of room temperature can typically be described with linear mathematical models but when multiple controllers operate each with a characteristic frequency attendant mathematical computations become more complex existence of multiple overlapping control systems assures system stability in the face of various perturbations by providing multiple backups a high degree of entropy reflecting a high degree of nonlinearity andor a need for multiple linear formulas to describe the system is often related to health and biological system stability conversely simple periodicity or random variability often underlies pathology in disordered systems reflecting respectively either the presence of only a single control oscillator or absence of any regulatory activity oscillatory patterns with greater complexity such as those that occur when a number of oscillatory patterns overlap are described as chaotic chaos reflects the simultaneous operation of numerous control processes although the healthy cardiovascular system can be effectively modeled using linear statistics it also has chaotic properties which diminish when cardiac function is impaired or an individual is in danger of dying from physiological decompensation similarly healthy adjustment is characterized by chaotic rhythms in appetite and mood among other biobehavioral dimensions also negative feedback loops often work in concert with open loops as described above and with positive feedback loops and resonance characteristics as described below to maintain optimal functionality oscillation control and health many oscillatory systems in the body such as neural cardiovascular and circadian tend to degrade with age reflecting a decrease in adaptive capacity in addition there are also pronounced agerelated decreases in baroreflex gain while blood pressure oscillations tend to increase with age perhaps reflecting degrading of control over this otherwise tightly regulated function generally speaking oscillatory patterns in a variety of biological control systems tend to be a characteristic of youth fitness and health oscillatory properties do not only represent activation of specific control reflexes they provide information as well periodic stimulation is required for system control in feedback networks this principle has been proposed for cellular behavior as well as macro biological and behavioral systems as in discussions of open loop processes described above and both resonance and stochastic processes described below external stimulation perturbs a control system causing it to oscillate without such oscillations and hence without noise systems may fail to get the information they need to function properly the tendency for noise to stimulate system oscillation is called stochastic resonance there is evidence that interoceptive and exteroceptive noise enhances the sensitivity of a variety of control processes from micro to macro levels studies of stochastic resonance show that noise can facilitate control functions as in optimization of monosynaptic afferent reflexes in the motor system of the cat by noisy stretching of a synergistic muscle in humans extreme absence of system perturbation as in sensory deprivation can cause regulation go awry resulting in psychoticlike sensory and emotional symptoms one could therefore speculate that psychological stress may have some beneficial effects by introducing noise into neural regulatory processes just as exercise helps maintain many physiological processes since in biological systems oscillations tend to reflect the operation of reflex systems involved in modulation and selfcontrol presumably a complete lack of stimulation would deny exercise to these reflexes causing them to atrophy under normal circumstances however the environment provides sufficient perturbations in biological and behavioral systems to preserve their normal function in psychophysiological theories of stress effects this formulation overlaps with the more recent concept of allostasis and allostatic overload allostasis refers to stability achieved through variability and is analogous to the activity of oscillating control processes stimulated by stochastic noise or general unorganized environmental stimulation a well functioning personality or biological system responds well to moderate environmental stressors and in fact may be energized by them as in yerkes and dodsons model of stress and performance wherein moderate stress enhances performance in moderately difficult tasks while very low or very high levels of stress can be detrimental allostatic overload occurs when environmental stresses are either too great or too prolonged or when various control reflexes become exhausted resonance a source of stimulation and simplicity in system oscillation in addition to oscillation another characteristic of negative feedback systems with a delay is resonance when outside stimulation causes a system oscillation at a particular frequency and no other forces are at work to dampen the oscillations negative feedback loops can themselves destabilize the system by causing increasingly large resonance frequency oscillations to the point where information from other frequencies no longer gets processed a common example of a runaway negative feedback loop resonance effect is the larsen effect that occurs when a microphone is placed near a speaker causing a highpitched squeal at a single frequency in such a case a single highamplitude oscillation triggered either by noise or by pulsatile stimulation close to the resonance frequency can obscure the effect of otherwise meaningful perturbations in the human body resonance effects in the postural control loop have been implicated in postural impairment in parkinsons disease resonance has been similarly implicated in agerelated impairment in gait control in terms of psychophysiology it is conceivable that resonance effects might inhibit the fightorflight reflex because a single homeostatic process may overwhelm reflexes needed to confront an environmental stressor one could speculate that resonance effects stochastic and otherwise might deprive the system of information from various internal control mechanisms as when resonancefrequency oscillations are at such a high amplitude that they obliterate information from reflexes operating at different frequencies thus it is possible that resonant oscillations in the heart rate baroreflex system at 6minute could weaken the effects of other control reflexes by greatly diminishing their relative size and depriving the system of information this is a hypothesis for future research to prevent a runaway resonance process systems must be dampened dampening effects on heart rate amplitude during heart rate variability biofeedback probably stem from inherent limitations in the ability of the heart to respond at extreme levels the literature on heart rate variability biofeedback however shows that not all resonance effects are detrimental resonance in the cardiovascular system produced by a rhythm in the baroreflex is the basis of the beneficial effects of heart rate variability biofeedback the baroreflex provides a negative feedback loop for controlling blood pressure such that heart rate falls when blood pressure rises and viceversa when blood pressure falls thus modulating blood pressure fluctuations the resonance frequency of this system appears to be related to the individuals blood volume with a lower resonance frequency among people with a larger blood supply the resonance frequency appears to be determined by changes in hemodynamic inertia resulting from fluctuating heart rate when this resonance system is activated by a respiration rate close to the resonance frequency oscillations in heart rate become very large this highamplitude stimulation of the baroreflexes appears to strengthen them and is perhaps the cause of the various salutary effects of heart rate variability biofeedback heart rate variability biofeedback has been shown to restore autonomic control that has been acutely repressed by experimental exposure to inflammatory cytokines and appears to ameliorate a number of disorders characterized by autonomic andor emotional dysregulation including hypertension asthma anxietystress depression and chronic pain while improving athletic performance we might however theorize that the effects of constant breathing at resonance frequency would not be advantageous chronic resonance frequency breathing could theoretically weaken or obstruct reflexes dependent on oscillations at other frequencies thus individuals practicing heart rate variability biofeedback are instructed to practice for a relatively brief period of time daily and to use the technique strategically when symptomatic positive feedback loops the body also contains multiple positive feedback loops whereby change in a particular direction facilitates greater change in that direction although positive feedback can provide a stimulating effect in an open loop system it also plays a role in closed loop systems in psychophysiology positive feedback loops often are involved in maladaptive processes a prime example is anxiety and depressions propensity to amplify their inherent symptomology by triggering greater sensitivity to anxious or depressive thoughts thus creating a vicious cycle on the cellular level positive feedback loops may be necessary to stimulate modulatory negative feedback loops however positive feedback loops can also play an important role in enhancing emotional control the psychological augmenting effects of positive feedback may add to oscillation amplitude during hrv biofeedback or the sympatholytic effect of muscle relaxation this may result from a spiraling relaxation effect just as anxiety begets more anxiety by sensitizing anxiogenic brain circuits heart rate variability biofeedback or muscle relaxation therapy may compound relaxation effects positive feedback loops can also play a role in creating system complexity which may increase stability by creating a multiplicity of stable states as well as by maintaining oscillation amplitude during frequency adjustment positive feedback loops have been shown to promote load compensation in control of movement and to be necessary to prevent dampening of oscillations in cellular function positive feedback loops also are important for the maintenance of the ovulatory cycle and for propagating dopaminergic signaling without some form of regular perturbations oscillations will gradually decline in amplitude and disappear positive feedback loops can provide these perturbations simplicity complexity and randomness the dimensions of simplicity and complexity are important for understanding psychobiological control and can be usefully incorporated into theories of applied psychophysiology simplicity in a biological or behavioral control system can have multiple sources in addition to reflecting the effects of resonance simplicity may result from system fatigue due to allostatic overload or from biological damage to system components such as when heart failure leads to diminished entropy in heart rate simplicity in heart rhythms as a sign of cardiac pathology was discussed earlier emotional rigidity or simplicity is well described in dsmiv as a sign of psychopathology which is characterized by a tendency to respond to a wide variety of situations with a stereotyped response sadness anxiety suspiciousness anger etc however just as simplicity is a sign of poor adaptation so is random variation suggesting lack of modulatory control pathological examples of random fluctuations include manic or depressive episodes in bipolar disorder as well as certain cardiac arrhythmias such as preventricular or preatrial contractions asthma exacerbations and so on work in the tradition of chaos and information theories has provided mathematical tools for describing organized complexity of temporal patterns in terms of entropy as described in information theory including shannons spectral entropy calculations pincus approximate entropy lempel and zivs method for evaluating randomness these measures represent various approaches to calculating relative unpredictability of fluctuation patterns in a time series or the number of dimensions or fractals necessary to describe a data set mathematically autonomic regulation healthy regulation is often characterized as sympathetic and parasympathetic activity converging in a limit cycle around a critical value such as is the case of cortisolvasopressin or acetylcholineepinephrine reactions where each process induces a compensatory reaction in the other thus sympathetic activity may simultaneously suppress parasympathetic activity but increase parasympathetic reactivity thereby producing an oscillation during extremely stressful stimulation an individual may show wild oscillations in various autonomic functions both sympathetic and parasympathetic although these oscillations are sometimes paradoxically suppressed in severe emotional reactions heart rate changes in response to stimulation appear to be important modulators of systemic response reduced cardiac variability in response to stimulation is related to a variety of pathophysiological states while increased heart rate variability and vagal influence on the heart are positively correlated with recovery after physical exercise stress thus flexibility in cardiac response to stimulation and higher vagal influence on the heart are related to better adaptation to interoceptive and exteroceptive demands this is another example of ways in which complexity and oscillatory function are related to health and adaptability thermoregulation thermoregulation is another system in which several systems converge around a critical value until the mid 20 th century stability and circadian variability in core body temperature were considered homeostatic responses to environmental triggers such as light intensity or daily routine in fact core body temperature is partially regulated by an endogenous clock in a central control mechanism which integrates multiple systems including thermoreception of ambient temperature systems for conserving or dissipating heat as well as those for generating heat and endogenous circadian regulators as with heart rate variability circadian thermal variability decreases with age a relationship between circadian thermal oscillation amplitude and general homeostasis can be hypothesized but further evidence is needed to confirm its existence oscillation complexity and disease heart rate variability complexity is indicative of cardiac and neurocardiac flexibility and adaptability and may be diminished significantly by pathology a healthy heart can respond to various momenttomoment physical and emotional demands while the diseased heart does not exhibit such flexibility although oscillations may persist in the diseased heart aging and disease cause increasingly more regular oscillatory patterns reflecting a decrease in mechanisms of cardiac control such noncomplex patterns of variability ultimately predict death in the critically ill similarly a disturbance of complementary oscillatory patterns in pancreatic islet beta cells is associated with impaired glucose tolerance and diabetes mellitus under normal conditions oscillations in nervous output from pancreatic ganglia cause pancreatic islet beta cells to secrete insulin in a coordinated pulsatile manner at two distinct periodicities 1 in small amplitude oscillations with a periodicity of 515 minutes and 2 in larger amplitude ultradian oscillations ranging from 80 to 150 minutes particularly in response to the ingestion of food or intravenous glucose perfusion this oscillatory rhythm operates through an insulinglucose negative feedback loop with a delay between plasma insulin and hepatic glucose production compared with steadystate infusion this oscillation promotes more efficient glucose utilization when these oscillatory rhythms are disturbed such as in diabetes mellitus type ii decreased oscillatory complexity is associated with system decompensation mental illness mood and behavior appear to be governed by many of the same concepts used to describe oscillatory behavior in physiological processes as with physiological systems organized complexity is the hallmark of healthy psychological behavior both hyper and hypostabilities may characterize a breakdown in normal mental functioning and leave a person psychologically vulnerable to the deleterious effects of stress bauer and whybrow found that while participants with bipolar disorder showed some brief periods of fairly well defined cycling in mood their overall pattern of mood changes were less complex than controls paulus et al compared patients with schizophrenia to healthy individuals in a binary choice study and found that participants with schizophrenia showed a simpler and more predictable pattern of response apparently reflecting decreased adaptability in cognitive processing a study of laterality in electrodermal activity found decreased activity and complexity in the left hand compared with the right among depressed patients and decreased activity and complexity in the right hand compared with the left among patients with schizophrenia while there were no laterality differences among healthy individuals these results are consistent with theories of right hemisphere dysfunction in depression and left hemisphere dysfunction in schizophrenia however even some psychopathological states appear to possess chaotic organization tschacher et al recorded occurrence of psychotic symptoms among 14 patients with schizophrenia over time and found a complex nonlinear time course in eight of them others showed more random psychotic behavior suggesting that the patients were responding to environmental cues not modulated by control processes eeg oscillations reflect system functions systems theory also applies to neurons activity in the brain whose functioning has been shown to be interdependent with other nearby neurons and even neurons in different brain regions the complexity and chaotic characteristics of brain function particularly as studied by electroencephalogram has been thoroughly reviewed elsewhere briefly eeg reflects summations of excitatory postsynaptic potentials that neurons emit as discrete events when neurons fire synchronously relatively highamplitude slow waves occur in a relatively simple pattern when they fire desynchronously the numerous potentials can both augment and cancel each other out generally resulting in loweramplitude more complex signals at higher frequencies fastfiring cells in the cortex may contribute to these effects as does the interaction between excitatory and inhibitory processes faster lowamplitude oscillations tend to predominate during states of arousal attention and cognitive processing and in general during periods of greater cortical activity oscillations in eeg signal reflect the interplay of various brain processes involved in cortical integration such that specific kinds of mental activity may be reflected in definable patterns of activity at specific frequencies and at specific electrode locations slower waves from the cortex reflect decreased arousal at the measured eeg sites low levels of alpha and beta activity andor increased waking slowwave activity are associated with a lack of inhibitory control over behavior similarly a greater frontal theta beta ratio is related to decreased emotional response inhibition greater delta and theta activity and lower alpha activity have been found in the eegs of children with fetal alcohol syndrome this pattern is also found in attention deficit disorder lower cognitive abilities impaired motor control hypoglycemia and antisocial behaviors it is even found during deep relaxation and sleep while exposed to hypoxia fasting and in sexual arousal and orgasm conversely delta theta and lowerfrequency alpha activity are inhibited when people are awake and cognitively active a recent study found that during tasks with increased cognitive demand increases occurred in the eeg frequency with the greatest activity across electrode sites but a decrease in eeg entropy oscillations are not smoothly distributed across the frequency spectrum resonance structures have been identified at frequencies of 4 10 20 and 40 hz with the largest body of research on the 10 hz rhythm the center of the alpha frequency band resonance properties can be determined by a variety of methods for instance one can stimulate the system at specific frequencies with photic stimulation and determine the frequencies at which highamplitude oscillations are obtained one may also use computer simulations based on known frequency characteristics of particular nerve cells or from evoked potentials alternatively one can stimulate an individual with audible noise and measure the obtained frequency peaks resonances at these frequencies suggest the existence of specific positive feedback reflex arcs at each resonance frequency related to particular neural processes contributing to each resonance frequency thalamocortical processes have been studied and modeled and rhythm bands containing each of these frequencies have been described in a large literature it has been theorized that delta oscillations reflect activity of motivational systems while theta oscillations reflect emotional regulation and alpha oscillations reflect inhibitory processes some theorists have related specific resonance frequencies to the period length of experimentally evoked action potentials eventrelated potentials synchronies or asynchronies patterns of theta and alphafrequency resonances triggered by memory consolidation processes have been identified it is also known that memory consolidation occurs during sleep which is characterized by highamplitude slow eeg waves primarily stemming from the brain stem with cortical modulation of lower centers perhaps from a single oscillator phase relationships in eeg activity among various brain areas have also been studied appearing to vary systematically for example occipital phase synchrony in the alpha rhythm tends to be greatest during relaxation with eyes closed and decreases with greater arousal experience of pure consciousness in transcendental meditation appears to be characterized by alpha phase synchrony from the frontal and central areas although phase synchrony may reflect tight coordination among brain sites more complex forms of coordination have also been modeled often involving varying frequencies varying orderly phase relationships and nonlinear relationships where frequent changes in phase relationships among brain areas reflect complexity of cognitive processing measures of chaos and complexity applied to eeg data suggest a simpler pattern of brain organization with fewer control processes among patients with schizophrenia and depression pezard et al found that eeg patterns became more complex among depressed patients whose depression improved becoming indistinguishable from those among healthy individuals while the pattern of decreased complexity persisted among individuals whose depression did not improve other studies have found risk for autistic spectrum disorder and the presence of attention deficit hyperactivity disorder to be related to decreased average eeg complexity social systems humans live as couples in families and in neighborhoods or larger social and economic networks systems theory has been applied to social systems and indeed oscillatory patterns of social system behavior can reflect negative feedback loops which could contribute to stability stability in a social system generally represents a stable pattern of interaction implying the action of mechanisms that resist change oscillatory patterns of openness and closedness to new ideas have been described in societies as have variations in societal norms about expression of emotion although presumably extremes in either of these characteristics trigger a consequent tendency in the opposite direction voter patterns appear to have oscillatory characteristics which in the united states have been quantified as thirtyyear oscillatory patterns in party alignment the cause for this oscillation period may reflect generational change perhaps people see the problems caused by results of their parents voting patterns and react to this by changing course although delays chaos and resonance characteristics in social feedback loops have not been measured the existence of specific frequency patterns in some of them suggest that these characteristics may be present dyadic systems may also have oscillatory qualities gottman and his colleagues have taken a mathematical approach to assessing marital systems they have applied concepts of nonlinear dynamics and catastrophe theory which posit complete periodic restructuring of systems when perturbed by certain forces they propose that marriages have one or more set points for nature and style of interaction some of which may be favorable to marital satisfaction and stability and others unfavorable from this perspective they have developed formulas that predict marital stability and divorce they record verbatim transcripts of marital interactions where they note the number of times that individuals respond to each others content with specific affect including such variables as threshold for negativity and frequency of positive and negative interactions in marriages characterized by reciprocal negativity and paucity of positivity in interactions couples can be trained to modify their individual behavior thus based on positive feedback loops marital systems wherein negativity begets negativity may be altered so that positivity begets positivity the overarching goal is to move the interaction system from a negative steady state to one that is more positive repair and dampening functions have been calculated which can modify the positive or negative influence of one partner on another in various steady state conditions the investigators report conflicting data about whether rigidity in behavior predicts poor marriage outcome but show how intervention can affect the system of interaction and ultimately marital satisfaction their model includes the interaction of perception of wellbeing in the relationship the flux over of negative and positive behaviors and physiological responses systems theory has also been applied in analysis of corporate structures but concepts of oscillation delay and influences of positive and negative feedback loops have not been studied corporations are systems just as those defined above they are constantly bombarded by changes in market conditions competition etc and need to maximize the adaptiveness with which they respond to changing conditions while still maintaining their structure information and communication both from outside of and within the organization has been proposed as a medium for achieving these ends utilization of feedback from information allows an organization to monitor both external events and internal processes for example if an organizations norms do not allow for transmission of bad news to its ceo then poor uninformed decisions are likely to be made various feedback mechanisms can prevent change from happening although we have found little research using time series analysis to discover patterns of oscillations in negative feedback loops comprising organizational structures examples of feedback loops in organizational behavior have been described presumably oscillations occur in organizational communication as well as in other control systems and might be quantifiable on a number of dimensions such as commands to change operational procedures to adapt to external pressures oscillating with instructions to follow internal protocols pressured work versus relaxation and supportive versus critical communications from superiors implications for research in psychophysiology linear models are frequently employed to predict one variable from another however because physiological systems are so complex such prediction does not truly characterize physiological states time series models have become available that can be used to better model these systems the complexity of biological and behavioral systems and the fact that complex systems can be mathematically modeled present a challenge to psychobehavioral research this paper proposes that we reexamine the systems approach in light of methodologies recently proposed cybernetic systems approaches in biology and psychology present practical challenges such as in the assessment and measurement of multiple systems and large quantities of time series data nevertheless quantification of complex systems involved in personality illness marital or social harmony and stress reactivity may give us greater insight into ways of promoting health and managing disease and are thus amply justified hypotheses generated by this review this review would lead us to posit certain hypotheses these include 1 any stable system can be modeled using time series analysis 2 internal control mechanisms can be modeled as closed negative feedback loop systems with oscillatory properties decreases in oscillatory properties will be associated with less adaptability to perturbations and greater vulnerability to system failure 3 stable systems are complex indicating a multiplicity of control mechanisms however they are not random 4 adaptability of a system can be modeled from the effect of perturbations on its various closedloop systems of internal control changes in any elements due to system perturbations will return toward a pattern of stable equilibrium 5 a stable system does not necessarily have a single level of stability this may change depending on demands placed on the system 6 disease injury stress and older age all reduce adaptability and will be reflected in decreases in oscillations of control systems complexity of oscillations and ability to return to equilibrium after perturbation they may also be characterized by greater periods of randomness 7 this model can be applied to all systems biological behavioral cognitive emotional social organizational etc elements of systems could be quite varied and include such diverse phenomena as behaviors communications and biochemical or physiological functions particular implications for applied psychophysiology and biofeedback the present analysis indicates that further investigation of patterns of oscillation in various psychobiological systems is warranted better identification of oscillatory systems may lead to the elucidation of homeostatic or allostatic control mechanisms in such systems and may ultimately lead to the development of ways to exercise and strengthen reflexes that strengthen allostatic capacity ideally these exercises could render an individual more resilient to effects of environmental stressors improve performance and strengthen resistance to psychological and physical disease systematic use of various quantitative approaches to assessing oscillation and complexity could contribute to advances in this field work in this direction has already begun in studies of heart rate variability and eeg biofeedback heart rate variability biofeedback is based on the explicit mechanism involving stimulation and exercise of modulatory reflexes by stimulating resonance characteristics of an oscillating system for this method the theory proposed in this paper predicts that only periodic practice of the technique would be beneficial while constant practice of the technique might actually be iatrogenic since the resonance frequency oscillations would prevent chaotic variability in heart rate and possibly decrease adaptability if they were continuously present however strengthening of homeostatic reflexes with a consequent increase in chaotic variability appears to be beneficial periodic stimulation of a reflex seems to improve its efficiency we have found this to be the case with the baroreflex as yet no studies have reported changes in chaotic variability in the resting state after a course of heart rate variability biofeedback although other measures of variability do appear to increase it is possible that biofeedback used to increase other sources of periodic variability in the cardiovascular system might also be explored one such possibility is biofeedback targeting the vascular tone baroreflex following research by vaschillo and colleagues neurofeedback is another biofeedback modality that explicitly addresses oscillations by stimulating and exercising modulatory reflexes in the central nervous system alpha rhythm and theta beta rhythm biofeedback have been used to enhance relaxation memory consolidation and attention and appear helpful for such disorders as attention deficit hyperactivity disorder and anxiety disorders as well as intellectual performance enhancement this feedback may strengthen reflexes involved in conscious attention and memory consolidation depending on the particular frequencies and brain regions that are trained pulsatile stimulation by electricity and light flicker have also been used chaotic and oscillatory properties of various psychophysiological measures suggest that there may be many more potential control reflexes that can be trained perhaps one on each fractal plane this raises a host of other possibilities for future biofeedback research future research may bear fruit by examining various sources of oscillation in the body and in behavior to determine whether periodic stimulation of these oscillations may similarly exercise modulatory reflexes and improve health in particular resonance and positive feedback loops could be considered such as in heart rate variability biofeedback wherein positive feedback can promote complexity and maintain oscillatory activity caused by negative feedback helping individuals adapt to environmental demands applications of systems theories to social and organizational structures other than for gottmans approach to marital interactions have tended to be nonmathematical focusing primarily on norms beliefs and behaviors that preserve a particular pattern of social interaction time series analysis of these interaction patterns may yield important information that could be used as instruments for increasing social stability or social change

systems theory has long been applied in psychology biology and sociology this paper applies newer methods of control systems modeling to the assessment of system stability in health and disease control systems can be characterized as open or closed systems with feedback loops feedback produces oscillatory activity and the complexity of naturally occurring oscillatory patterns reflects the multiplicity of feedback mechanisms such that many mechanisms operate simultaneously to control the system unstable systems often associated with poor health are characterized by absence of oscillation random noise or a very simple pattern of oscillation this modeling approach can be applied to a diverse range of phenomena including cardiovascular and brain activity mood and thermal regulation and social system stability external system stressors such as disease psychological stress injury or interpersonal conflict may perturb a system yet simultaneously stimulate oscillatory processes and exercise control mechanisms resonance can occur in systems with negative feedback loops causing highamplitude oscillations at a single frequency resonance effects can be used to strengthen modulatory oscillations but may obscure other information and control mechanisms and weaken system stability positive as well as negative feedback loops are important for system function and stability examples are presented of oscillatory processes in heart rate variability and regulation of autonomic thermal pancreatic and central nervous system processes as well as in socialorganizational systems such as marriages and business organizations resonance in negative feedback loops can help stimulate oscillations and exercise control reflexes but also can deprive the system of important information empirical hypotheses derived from this approach are presented including that moderate stress may enhance health and functioning

introduction covid19 is the third known animal coronavirus after severe acute respiratory syndrome and middle east respiratory syndrome 1 although covid19 can be transmitted through droplets close contact aerosols and possibly oralfecal transmission patients can also transfer the virus to other people in the incubation period 23 it is associated with sars and mers but shows some specific pathogenic epidemiological and clinical features that are not fully understood to date 3 there have been 26 468 031 confirmed cases of covid19 globally including 871 166 deaths in the world and 382 772 confirmed cases of covid19 with 22 044 deaths in iran based on the report of the world health organization on 5 september 2020 4 patients with mild symptoms of covid19 without chronic conditions that are aware of the disease can be cared and treated at home by compliance with all precautions family caregivers should apply the principles of home care to these patients despite the existence of numerous epidemiological studies on the outbreak of disease there is little information for supporting family caregivers of patients with covid19 5 the effects of covid19 may have impacted caregiving intensity which is defined as the amount and type of care provided by informal caregivers 6 it also may have affected caregivers caregiver burden which is defined as the impacts on physical and mental health and healthrelated quality of life may also have changed due to the pandemic 7 one study found that informal caregivers are likely at greater risk of adverse effects on their health due to the pandemic as they have been found to have particularly more stress and suffer from more depression and physical problems 8 the different nature of covid19 and the need to maintain public safety will limit the physical presence with patients and therefore caregiving in this situation will be unique for everyone involved the importance of maintaining social distance to control the covid19 pandemic probably increased isolation loneliness psychological stress and other adverse health problems 9 social and family relationships are disrupted not only for patients but also for their caregivers 10 mirzaei et al indicated that caregivers of patients with covid19 face greater challenges compared to other caregivers because of limited training and resources at hand and their lack of knowledge about this emergent disease and the way to care for the patients 11 the results of a review showed that sleep disorders fatigue and inadequate selfcare were recognized as common physical health problems in family caregivers 12 other qualitative and quantitative studies show that family caregivers may also grapple with anxiety depression apathy disappointment loneliness and isolation because of reduced social interactions and social exclusion while providing that care 1314 covid19 conditions have overwhelmed family caregivers as well as others in the community with new economic stressors such as job loss by the household head and high medical expenses many family caregivers have other roles in addition to the caregiving role such as managing their job housekeeping child care and additional responsibilities and concerns about their childrens education due to school closures from covid19 they also must strive to protect themselves and other family members from virus transmission and all of this is more difficult to manage than caring for other diseases or in other situations 15 abendroth et al also argued that the anxiety about caring for a patient at home could be reduced by seeking information in caregivers as an adaptive strategy 16 given the importance of home care followup and selfcare education to patients and families counseling centers and home care services are obliged to provide the necessary training to families to provide care services for patients at home according to the guidelines of the ministry of health and medical education 17 under who guidelines any patient with a severe acute respiratory infection should be triaged and admitted to the hospital however people who have mild diseases do not require hospitalization and to continue the treatment and care in the home can be referred to health centers 18 the acceptable criteria of who for home care of patients with covid19 are as follows patients who do not tend to stay in the hospital patients with mild symptoms and those who do not have systemic diseases such as immune deficiency cardiovascular disease or the risk of developing complications the patient and family should comply with the treatment including isolation at home hand washing respiratory hygiene cleaning the environment and observe safetyrelated issues 19 evidence shows homebased caregiving effects on caregivers quality of life and life satisfaction due to the combination of social distancing recommendations stayathome orders limitations on gatherings and the disproportionate impact of covid19 itself on mortality and morbidity among older adults there is a critical and immediate need to understand the specific challenges and changes experienced in family caregivers 7 considering the peak of covid19 in iran and the lack of human resources physical space protective and therapeutic equipment in the hospitalization of patients many covid19 patients with mild to moderate symptoms are obliged to receive home care services since most of the studies have focused on the experiences of patients or health care staff and few studies have been conducted on family caregiving experiences in iran and at the global level so the consideration of caregivers experience and their problems is necessary to plan services and support them therefore a better understanding of how the pandemic has impacted home caregivers can inform future interventions to address stress and health problems stemming from caregiving through the pandemic along with the everyday issues normally encountered this study was conducted to explain the lived experiences of home caregivers in the families of patients with covid19 methods study design and setting a phenomenological approach was developed by taylor and bogdan in 1975 to the social sciences 20 but diekelmann et al applied hermeneutic phenomenological approach in health and nursing education 21 so this qualitative study was carried out using dickelmans method this study is used when the researcher needs the revelation of the littleknown or unknown phenomenon through an indepth examination of the lived experiences of people involved in that phenomenon 22 the present study was conducted in the center of covid19 control at the khoy university of medical sciences iran study participants the study participants consisted of 23 family caregivers who provided care for patients with covid19 at home and willingness to participate in research participants were selected using purposeful sampling method inclusion criteria are participants who have patients with covid19 at home based on laboratory tests and home caregivers who have cared for a patient with covid19 for at least 14 days and have not been affected by covid19 during the care of a patient exclusion criteria included participants who showed clinical signs of covid19 home caregivers who cannot take care of the patient incapable of verbal communication and any psychological disorder that causes a lack of transfer the individual experiences sampling continued until data saturation was achieved when the researchers perceived that no new themes were emerging saturation in qualitative studies constitutes the completion of code levels and new conceptual information requiring new code or expansion of the existing code is not obtained 23 data collection the semistructured interviews were used for data collection after explaining the goals and importance of research to the participants the informed consent was obtained to participate and record the interviews participants were assured that the obtained information would be used only for the research and would remain confidential the interview was planned and implemented concerning the qualitative questions of research and focusing on the experiences of home caregivers of patients with covid19 interviews were conducted individually with 23 participants at the private rooms of covid19 control headquarters where there is no or minimal employees commuting to the place having proper ventilation and a window to the outside of the building while maintaining a social distancing of at least 2 m with the participant and using gloves and masks each participant was interviewed only once the total number of interviews was 23 and there was no conflicting data the interviews lasted between 45 and 60 minutes and then interviews were transcribed by putting analysis phenomenological philosophy is based on believs of taylor and bogdan have dominated in the social sciences 20 but in the health and medical sciences especially in nursing used dickelmans hermeneutic approach for interpreting data 21 this approach used when the research purpose is understanding the human lived experience in this way the researcher categorizes the data by interpreting the discourse of participants 21 so in this study the interviews were analyzed using the principles of hermeneutics phenomenology as developed by diekelmann this qualitative approach was selected because it gives a high level of access to participants lived experience 21 the analysis was done by a sixmember interpretive team and involves dickelmans sevenstep analysis trustworthiness credibility confirmability transferability and dependability by lincoln and guba were employed to achieve the trustworthiness and validity of the study 24 credibility means that the findings of the study are real and that the findings reflect the research objective and social reality of the participants to ensure the credibility of the findings there was a prolonged engagement with the participants and data the findings were shared with some of the participants for this purpose the transcribed interview and the extracted primery codes were presented to the participants and they commented on its accuracy and in case of any discrepancies they were considered to ensure the confirmability of the findings the interviews and all procedures taken to conduct the study were recorded and complementary comments of research team were applied in data analysis to check the dependability of the findings an external reviewer who was familiar with both the clinical setting and qualitative research was asked to review and confirm the results the transferability of data was achieved by maximum variation of the samples such as different levels of age education occupation and family relationship with the patient results participants demographic details and their relationship to the patient are presented in table 3 the themes emerged from first reading and rereading descriptions transcription was read as a whole to gain an overall understanding and impression of the narrative then the narrative was reread line by line second writing interpretive summaries and coding for emerging themes short interpretive summaries were written and the common themes with exemplar quotations from the narrative were identified to support the interpretation clusters of themes were merged and these classifications were named third analyzing selected transcripts as a group to identify themes collaborative analysis was performed to do these meetings were held biweekly to discuss interpretations for similarities differences or contradictions fourth returning to the text or to the participants to clarify disagreements in interpretation and writing a composite analysis for each text if conflict occurred or further interpretation was needed the group returned to the original text and reread all texts to identify hidden meaning and link themes or consulted the original interviewers for clarification fifth comparing and contrasting texts to identify and describe shared practices and common meanings the researcher compared and interpreted the relational themes to uncover the constitutive patterns existing within the relational the constitutive pattern expressed the relationship of all the previously identified themes sixth validation of the interpretations draft themes and constructive patterns were observed by the researchers supervisor all responses and suggestions received were integrated into the final draft the individual texts and audiotapes were also reviewed many times to allow the researcher to become further immersed in the hermeneutic circle gain an indepth understanding of each participants experiences and further validated the interpretations seventh eliciting responses and suggestions on a final draft excerpts from the participants own words that reflected the strong meaningful transactions were included in the final written report quotes of family caregivers the codes extracted from the interviews led to the emergence of 13 primary concepts 9 subthemes and 3 main themes irrational fear of disease fear of getting infected because of the permanent intellectual engagement about the transmission of the covid19 to the caregiver and family members frequent washing and disinfection of hands and home appliances was done as some caregivers were suffering from respiratory allergies but due to obsessive thoughts and fear about getting infected with the virus could not emancipate themselves from these behaviors indulging in strength of immune system some caregivers had too much sensitivity to strengthen the immune system through which they could reduce the risk of affliction with the disease they tried to consume diverse herbal teas the properties of some of which have not been approved to strengthen the immune system increasing the burden of care in caregivers lack of support many patients and caregivers expressed that the government and medical team were unaware of their care problems at home in most cases patients are cared for in a shared room at home with other family members and there was no separate room or suitable place in the house to care for them besides necessary training about patient care was not given to the caregivers moreover lack of financial resources high cost of treatment and job interruptions caused financial burden in families and caregivers caregivers family challenges patient care by the family caregivers provides a context for the neglect and inattention of other family members this issue is a predisposing factor for damage to family members therefore many caregivers assumed that the pressure and stress they endure are more than patients that is because the caregiver must not only meet the patients needs but also be responsible for a lot of family problems and issues selfreinforcement highlighting positive features putting the caregivers under the challenging conditions of care provision caused the revelation of positive human characteristics such as patience strength and resilience in the face of hardships calming down increasing a sense of altruism and helping people in need turning to spirituality given the exposure of caregivers to stressful events such as caring for a patient with covid19 spiritual growth emerged in them and made them more resistant to the hardships caused by the care there were things like a change of attitude in life deepening the relationship with god appreciation for blessings being thankful for gods blessings and hoping in god in the direct quotes of these participants discussion the themes obtained from the interview with the participants were an attempt to achieve the main purpose of the study that was to explore the experience of home caregivers of patients with covid19 statement of principal findings the results of this study showed that longterm care performing tasks related to patients daily activities and patients psychological problems along with the physical fatigue of caregivers had caused mental disorders such as burden obsessive behaviors and fear of disease transmission in caregivers of course in addition the participants had positive experiences such as tending or serving to strengthen itself therefore it can be said that the disease had positive and negative consequences on caregivers the development of obsessive behaviors increasing the burden of care in caregivers and high human achievements are important themes of the present study interpretation within the context of the wider literature the irrational fear of disease was one of the main themes participants stated that the thoughts of fear of transmitting infection and disease automatically enter their minds due to these obsessivecompulsive behaviors the duration and frequency of hand washing and sterilization of equipment were dramatically enhanced caregivers said they were too sensitive to boost the immune system to help the patient to overcome the virus and prevent other family members from becoming infected in this respect the study of brooks et al demonstrated that the fear of disease transmission and concern of getting infected with the covid19 increases dramatically in critical situations and epidemics this concern in families with small children or pregnant women is much more than in other families 25 perhaps many people are not familiar with the nature of covid19 and infection is stigmatized as the patient not respecting their health and not following proper hygiene practices therefore developing obsessive behaviors et al also revealed that some factors could influence increasing the care burden some of these factors are concerns associated with the risk of afflicting disease ambiguity in the status of career prospects lack of incomegenerating resources lack of adequate facilities at home in the period of home care and the lack of sufficient support of the medical and governmental system of patients after discharge 28 asgari et al identified several challenges in family caregivers of patients with covid19 the main themes of the study were captured in a whirlpool of time and feeling helpless and loneliness a part of these experiences was due to careers to protect other family members and friends against getting the virus isolating themselves due to a fear of others becoming infected 29 thus providing relevant information on symptoms medical and protective care support in preventing disease complications and identifying the factors that cause the burden of care on the caregiver is essential 30 many participants had economic concerns the families of patients who are cared for at home and can not go to work suffer from great economic pressure 10 the research performed by brooks et al indicated that financial concerns are among the adverse psychological outcomes of closure because of home quarantine governments and policymakers should make the necessary mutual trust to people in the community and offer financial compensation for their losses 25 furthermore the findings of the study conducted by hertzpalmor et al indicated that the most significant psychological problem that arose after the recovery of sars in china was the reduction of financial resources and household incomes so that it was regarded as the highest predictor of reducing mental health 31 one of the most prominent positive consequences caused by caring for family caregivers was selfreinforcement the caregivers felt that they had become human beings who were more insightful and mature in the care process they expressed that caring has led to a deeper relationship with god appreciation of blessings gratitude for gods blessings better acceptance of situation and a positive direction in life investigations have also indicated that those who use positive strategies to cope with stress decrease adverse outcomes and increase positive results 32 religious behaviors and beliefs have a positive impact on the meaningfulness of life behaviors such as trust in god worship and pilgrimage can bring inner peace to individuals through creating hope and encouraging positive attitudes and they can incur less damage in the exposure of stressful life events 33 besides divine fate has been taken into consideration from two perspectives some people consider it as a god bless others believe that these events awake people and are opportunities for people to be prepared for the present situation 29 strengths and limitations one of the limitations in this study was the personal characteristics and mental concerns of the participants affecting their response therefore by explaining to the participants before the interviews and conducting indepth interviews the researcher tried to minimize this limitation in the case of lacking preparedness of participants another time was considered for the interview one of the strengths of the present study is variation in sampling in order to consider all influential factors in the occurrence of the phenomenon sampling of caregivers in different age gender cultural social and economic areas was performed implications for policy practice and research health care providers are required to consider the role of family members in providing care for patients and their home care challenges also it is recommended that interventions such as education to the patient and hisher caregiver counseling family therapy and referral to financial support groups to reduce the pressures of caring should be considered this can both promote the quality of patient care and guarantee the physical and mental health of caregivers as unknown patients it is recommended for the health staff to check the health of these people regularly via telephone and if possible provide inperson visits daily besides sharing positive experiences of family caregivers allows the researchers to design interventions to decline negative consequences conclusion this study implies that much attention should be paid to psychosocial physical mental and family relationships health of caregiver to provide highquality care to the patient we can conclude that the level of care pressure in caregivers of covid19 patients is high it is possible that these pressures reduce the level of patient care and also jeopardize the physical and mental health of caregivers it can also turn the families of these patients into vulnerable families who require intervention counseling and followup over time the optionality of participating in the study the confidentiality of the information obtained and the possibility of withdrawal from the study at any stage were provided to the participants data availability statement the data that support the findings of this study are available from the corresponding author upon reasonable request quotation primary concepts every day i have to disinfect the washbasin the bathroom the room surface the door handles and the dishes several times on the other hand i cant wash my spouses clothes in the washing machine and i have to wash them into the basin and pour disinfectant liquid on them doing all these things really takes a lot of my time and i get tired however if i dont do these things the children or i will get infected my health has changed a lot since my husband took the corona i use masks and gels regularly and wash my hands frequently with soap and water whatever i touch i wash my hands for example i disinfect the door handle regularly im really afraid that the disease will be transmitted to me we washed our hands a lot with soap and alcohol we became obsessed when we go out on the street if we do not shake hands we will go home again after washing and wash our hands well one is afraid frequent washing of hands because of the constant washing of hands and disinfection of furniture and kitchen utensils with javel water before each use i am suffering from lung problems even my child has an obsession and washes hisher hands constantly because my husband has a heart disease both he and i were very upset about corona i even disinfect the inside and outside of the car and then i get in the car i disinfect the phones several times a day all of the things that i buy from the outside first take out the bags and then if they are washable i wash all of them or disinfect their surface previously if i washed the fruit once now i put the fruits in a pan disinfect them with vinegar and salt leave them for half an hour and then wash them again continuous disinfection of surfaces permanently i give my daughter strengthening foods and a variety of effervescent tablets at home to eat them and recover sooner because it is believed that vitamin c and d are excellent the doctor said that i should give fruits that contain high vitamin c to my son at home because it strengthens the immune system i also buy oranges tangerines lemons grapefruits oranges and kiwis wherever i saw and then i would take the juice and let it eat excessive use of vitamins my wife and me drink ginger and lemon herbal tea every day so that our bodies to be strong i became highly sensitive to the immune system of myself and my family i knew that they get corona should drink plenty of warm fluids so i went to a store of medicinal herbs and bought mint thyme chamomile and a few other herbs in combination and gave them to my parents to drink every day in a form of herbal tea consumption of herbal teas since my husband got afflicted with covid19 he does not go to work for about two months and i think someone else was replaced to work in the factory i dont know what to do we have a lot of loans and installments that we must pay for them on the other hand we have to think about the monthly rent of the home and the cost of our needs corona has caused part of the cost of living to be spent on prevention supplies but now my husband cannot go to work due to illness i also spent all the money we had saved during this time and i do not know what will happen next we were really suffered financially economic concerns there are strict rules in the hospital that do not let you see a doctor directly additionally they are always busy they do not matter at all what my problems are concerning the care of my mother and how do i deal with the problems in addition to her illness my mother is also depressed she does not talk to anyone these do not care for the medical staff well in terms of the potential of finding out understanding or effective use of health information everyone is different some have enough information and skills and others do not i went to search for it and obtained the information no one taught me but many people especially the elderly do not have the condition and cannot do it lack of responsiveness of the medical team after discharge during this period i have taken after my father and done his work since i am the only son in the family however because of quarantine i do not have access to my wife and child and i cannot go to them this has caused problems in my family i take care of my husband who took the corona in our house and sent the children to their grandmothers house i was worried that would get a corona and that my children would be without a mother it has been about two months since i did not huge my children fed them or slept with them i was worried about my mother having diabetes and heart disease i had nightmares that my mother had taken a corona i am very dependent on my mother and i am always worried about losing her isolation of the caregiver the patients caregiver is more engaged in the situation and is under pressure than the patient himself because the caregiver follows up all the patients work and needs on the one hand he is looking for drugs on the other hand looking for the cost of living moreover he has to do all the sick work at home now judge for yourself during this time i went to work and took care of the patient at home i felt i had no strength left most of the relatives would call to ask for help but i did not even have enough time talk to them quotation primary concepts we did not tell any of our relatives or neighbors about my fathers disease for we knew that if they found out they were bothering us would constantly ask how he was afflicted with the disease why he did not respect and they look at us completely differently as if we have a leprosy patient at home community perception of covid19 is not just a disease and is not limited to a person with the disease but is identified as a person who most likely did not have health behaviors and as a result of these unhealthy and careless behaviors they have get corona so we did not want anyone to know about the disease hiding the disease from relatives and others during this period i became stronger and more patient i think i can tolerate difficult situations more easily difficult situations can be in terms of finance loneliness and problems that can happen to humans my husband is a touchy and irritable person he has made a thousand excuses since he got sick and i take care of him at home but i think god has increased my patience and strength so that i can take care of my husband and children now i am facing the problems of life alone well this disease which is not permanent we have to increase our patience and endurance patience in difficult conditions now i have become more discerning i have realized and understood my mothers love for myself more i have found that if i am at this position at present it is because of my mothers forgiveness and sacrifice nothing makes me feel better and happier than seeing my wife calm and well thank god i am by her side and i can help her opportunity for love now many things have changed a lot i appreciate life more i appreciate what god has bestowed me and i appreciate my health so much more than before maybe i was a little unaware of it i thank god for all this in general caring has given me knowledge the knowledge of the path i am going to take where i have made mistakes in life and where i have used the blessings of god correctly it has made me aware that i am always grateful for the health that god has given me in a word i want to say that i became another human being appreciation for blessings this disease influenced me a lot i got closer to god the opening out of a heart for god makes me very calm and it is the reassurance of my heart i am less ungrateful and i always think he knows the best of everything it is true that i did not leave anything for my son at home but i was also worried about his condition every time i prayed and recited the quran and i even vowed that god would cure my son of this disease god has helped me everywhere and i am sure that he will never leave me alone due to the fear of jeopardizing the familys health participants were trying to strengthen their immune systems in this regard caleo et al indicated that individuals in critical conditions are incredibly concerned with their family situation and are continuously seeking extreme care for them 26 moreover louca et al study showed that a number of micronutrients have been shown to play key roles in supporting immune function and in reducing the risk of respiratory infection also they observed modest but significant association between the use of dietary supplements and lower risk of testing positive for sarscov2 however the results were significant only in women but not significant in men 27 considering that it is reasonable to hypothesize that vitamin supplementations may enhance host immune responses against covid19 nearness and recourse to god the problems of patients lack of support for the patient and family are the basis of many stresses that targeted the participants souls hence one of the themes derived from this study was the increased burden of care in caregivers wang contributorship all authors participated in the process of the initial drafting of the article review presentation of the initial idea and design collection of the data analysis and interpretation of the data and all of them take responsibility for the accuracy of the material contained in the study ethics and other permissions this paper is part of the results of a research project approved by khoy university of medical sciences iran which has been approved by the ethics committee of that university participants were given enough information and each person signed an informed consent form to participate in the research and audio recording during the interview moreover the necessary explanations about

background following the spread of covid19 many patients received home care services for recovery the family is one of the informal caregivers who provide daily physical and psychological support to the patient and they have the most contributions in the care of patients objective this study explains the experiences of home caregivers in the families of patients with covid19 methods this is a qualitative study with a hermeneutic phenomenological approach purposeful sampling was applied and semistructured interviews in the center of covid19 control in khoy iran were used to collect the information twentythree family caregivers who had already provided care for patients with covid19 at home participated in the study the themes emerged from interviews the interviews were recorded and transcripted and then analyzed using dickelmans interpretive phenomenological approach results thirteen primary concepts six subthemes and three main themes were extracted from the data analysis including irrational fear of disease with subthemes fear of getting infected and indulging in strength of immune system increasing the burden of care in caregivers with subthemes lack of support and caregivers family challenges and selfreinforcement with subthemes highlighting positive features and turning to spirituality conclusion understanding the complexities experiences and beliefs of family caregivers about living with a covid19 patient provides a comprehensive perception of the psychological and physical consequences of care executive decisionmakers health care personnel and mental health professionals can also take the necessary strategies to support and manage home caregivers and interdisciplinary cooperation

introduction is economics a science or a social science arguments have been made for both orientations ie that economics is a social science a science and even a moral science in terms of sciences it has been linked with physics with many physicists doubling as or transforming into economists and a subpart of physics econophysics specifically evolving which deals with economics there are also links with biology frey argues economics is a social science as it is part of those sciences which deal with actual problems of society ie it is the subject matter which makes it a social science however he also points out that in practice economists tend to fill the journals with axioms lemmas and proofs ie they adopt what they perceive as a scientific and particularly a mathematical methodology mayer argues that economists act as though economics is a hard science and this is reflected by their sophisticated use of mathematics however he then goes on to argue that econometrics is not sufficiently advanced to enable us to test theories as a hard scientist would with respect to this argument it is worth noting that econometrics has moved a long way since 1980 when mayer wrote his paper and perhaps that objection is not as valid today as it was then in any case part of the reason for this disagreement as to the nature of economics may be because the subject matter of economics deals with people whether as agents in firms or consumers either as individuals or aggregates this will tend to place it as a social science but in terms of methodology it has arguably closer links with the sciences it is essentially a quantitative discipline theoretical models are built to replicate and simplify some real world situation empirical work is focused on econometrics and many of the techniques used and developed by economists are also used outside the discipline and often in the sciences such as biological sciences economics has of course evolved over the years fourcade et al argues that for much of the period since 1945 a theoretical approach based on rigorous mathematical modelling was the main path to establishing scientific purity in economics however in the 1990s and 2000s there occurred a shift in emphasis from theory to empirical work einav and levin potentially link this shift to a substantial increase in data availability they argue that this may change the emphasis on setting up and testing hypotheses to one of searching for the best possible explanation it may also further move economics away from the emphasis on theory all of which may in turn impact on how economists perceive themselves and the relationship of economics with other disciplines the quantitative nature of most economics research is in contrast to the qualitative methods that characterize the work of many other social scientists mankiw epitomises this perception when he admitted he thought of himself as and sought to project the image of a scientist he admitted that this might amuse physics academics but he would remind them that economists formulate theories with mathematical precision collect huge data sets1 on individual and aggregate behaviour and exploit the most sophisticated statistical techniques to reach empirical judgments that are potentially at least free of bias and ideology however he also thought that economists could be likened to engineers having been put on earth not to propose and test elegant theories but to solve practical problems this perception that economics is different from the social sciences may also have contributed to the insularity of the discipline as reflected for example in the relative dislike of economists for interdisciplinary work when contrasted with other social scientists as well as a reluctance to cite work from these other disciplines there have been a number of attempts to map academic disciplines on the basis of citation or similar data it is often done for specific disciplines rather than science as a whole thus mccain analyses cocitation data 2 using cluster analysis and multidimensional scaling to produce maps of highly cited and cocited documents in clusters representing interrelated research activities the focus is on mapping economics journals and is able to identify several major groups comprising the core of economics a west european set of journals formal journals basically key theory and econometrics journals public finance journals and economics journals 3 a number of studies do attempt to map the full range of disciplines rafols et al using a matrix of similarity measures based on correlations of different pieces of information items conclude that science is a fragmentary structure composed of both solid clusters and empty spaces this gives support to the concept of independent but potentially linked disciplines rather than a continuum of study with somewhat artificial boundaries the analysis is based on citing similarities among isi subject data there is an important biomedical research cluster and a major physical sciences cluster comprising engineering physics and material sciences there is a rather diffuse social sciences cluster which rafols et al argue is due to relatively low citation rates economics is part of this cluster but with some links to mathematics and computer science bollen et al use click stream data to construct a journal network that outlines the relationships among various scientific domains economics is on the periphery of the social sciences cluster but it is also one side of a bridge connecting the social sciences to physics and engineering via production and manufacturing hence these mappings tend to loosely tie economics to the social sciences but often with some linkage to parts of the sciences however most of these analyses are based on citations or similar measures rather than the similarities in the structure of academic work we have already emphasised that economics analyses social science issues but that it is the methodology or the style of working which differentiates it from the social sciences and links it to the sciences it is almost inevitable that economics citations will be greater in social sciences than the sciences but this tells us relatively little about the similarities between styles of working there is little hard evidence on subject linkages based on different styles and in order to provide the beginnings of a perspective on this we compare the journal title characteristics of the different disciplines the characteristics we will focus on include title length average word length the proportion of papers containing a colon the proportion containing a question mark the average publication date and the number of authors in particular we will extract the economics footprint as reflected in these title characteristics we will then compare this footprint with those of other disciplines we will argue that each discipline tends to adopt a certain style in terms of these characteristics lewison and hartley argue for example that there are substantial differences in title length use of colons and question marks etc between disciplines nagano also emphasises different disciplinary conventions with respect to the title distinguishing between the hard and soft sciences different disciplines also tend to differ in the number of authors and the extent to which journal papers are important compared to for example books if disciplines have their own style then it seems reasonable to assume that there are also similarities between contiguous disciplines for example we would expect as suggested in the literature the characteristics of a social science discipline to be more closely aligned with other social science disciplines than ones in the sciences following on from this we will then use cluster analysis to place the different disciplines within groups to see how well they fit into the social science science and art and humanities categories in the process we will also identify the group and subjects to which economics most closely belongs in doing this analysis we make use of a unique data base obtained from the research excellence framework4 of 2014 this is the latest in a series of exercises seeking to evaluate the quality of research done in uk universities across a range of subject areastermed units of assessment in this ref there were 36 such uoas as listed in table 1 including one for economics and econometrics 5 table 1 also gives the number of papers on which our analysis is based in economics there were 2600 individual pieces of work submitted not all were journal papers and a proportion were submitted more than one once to the economics panel ie by definition they were jointly authored papers this left 2246 separate papers to analyse each entry to a uoa was scrutinised by a subpanel working within the framework of 4 main panelsad economics was in panel c along with the other social sciences the main scrutiny was on the quality of academic research contributions primarily journal articles and books which were individually looked at and assessed by panel members each participant in the ref could submit up to four research outputs each submission was also accompanied by a research environment statement and a number of case studies which highlighted the impact of the universitys research on society or the economy widely defined the evaluation thus comprised three components the quality of the four research outputs submitted by individuals the research environment statement and the impact of the research on society or the economy our focus is on the publications hence and this is an important prerequisite for the study the definition of the discipline of the sciences and social sciences is based on the refs subjectclassification system in the next section we present the summary data on title characteristics we then use cluster analysis to group the different disciplines together and finally conclude the paper the differing characteristics of disciplines in terms of journal titles table 1 shows the characteristics of the titles ie median title length median word length proportion of papers containing a colon or a question mark the average date of submitted papers etc these calculations are done for the main subject groupings the data relate to journal titles only and these form the basis for the cluster analysis 6 focusing on journal papers the penultimate two columns show that in economics 805 of papers were also submitted in other disciplines whilst 638 of papers were submitted at least twice within the economics uoa in the latter case they would most likely have been submitted by coauthors in different institutions multiple submissions of the same paper across disciplines were particularly common in the health and engineering uoas they were much less common in the arts and humanities multiple submissions within a discipline were relatively common in the sciences particularly physics and also business but less common in engineering uoas apart from the data on multiple submissions the other columns are calculated on papers rather than submissions hence if a paper was submitted more than once to the economics panel it would still only be counted once in calculating the statistics columns median character length of title median author numbers average publication date using a colon using question mark of submissions which are journal papers median word length of multiple publications in same uoa of multiple publications in other uoas number of journal papers in uoa which form the sample for our analysis source calculated from data on journal papers in the ref for these columns the number of papers this left for analysis is shown in the final column of the table the median number of authors in journal articles for economics was 2 this is on the low side with a median across all disciplines of 3 the average was much higher at 11 being pushed up by the very high average number in physics 924 but in general across the sciences and health disciplines the number of authors tends to be high the average can be heavily influenced by one or two outliers in physics for example the most number of authors is 3269 for a paper on the higgs boson in the ref this paper was submitted 13 times this is why in this current analysis for the number of authors and also title length average word length and the number of citations we work with the median that is we calculate for example the median title length of all the titles in the sample and use that instead of the mean title length the average date of submission also shows systematic variations across the disciplines it tends to be earliest for the sciences and engineering and latest for the arts economics is quite late this may reflect the ease of writing a new paper in the different disciplines in the sciences a grant is often needed and also the team of people tends to be larger than in the nonsciences thus in the nonsciences it may be easier to write a new paper if current ref output is considered unsatisfactory however in order for the ease of writing new papers to explain the timing of submissions we also need the starting date for research to be influenced by the ref cycle the other columns provide us with information on the way economists work in comparison with other disciplines firstly the proportion of submissions which are journal papers was quite high at 9179 this reflects the importance economists place on journal papers other submissions include books and also working papers however the proportion of journal papers is still higher across much of the sciences and engineering but it does tend to fall substantially for other disciplines such as law history and languages thus in classics less than a third of submissions are journal papers there is also information which helps us compare economics with other disciplines in the structure of the title economists tend to be parsimonious in title length relative to other disciplines with a median number of characters of 64 only philosophy having a shorter median title length 7 the longest titles tend to be in the health disciplines and sports sciences which is linked to health economists are however less parsimonious in their use of colons the heaviest users of colons tend to be the arts and social sciences in sociology over 66 of submissions feature a colon and in business it was almost 53 colons were least common in mathematics and electrical engineering the same is true with respect to question marks finally economists tend to use shorter words than the science and health disciplines and longer ones than the arts and social sciences 8hence we can see that different disciplines have different styles and practices with respect to journal titles together with the number of authors the sciences including the health sciences tend to be characterised for example by a large number of authors and be parsimonious in using question marks and colons even though their titles tend to be relatively lengthy this raises the possibility of categorising economics with respect to other disciplines at least with extent to title characteristics the number of authors and the submission dates for the ref by the use of cluster analysis the basic assumption is that people in contiguous disciplines work in a certain style which tends to characterise those disciplines two disciplines which are close will tend to have similar characteristics in terms of numbers of authors and the characteristics of the title apart from providing information on different title characteristics across disciplines it is also worth noting that characteristics such as title length use of colons and question marks have been found to impact on citations grouping disciplines we use cluster analysis to group disciplines based on title length number of authors date of submission use of colons and question marks word length of journal titles and proportion of submissions in the form of journal papers the basic idea of cluster analysis is to group first the two disciplines that are closest using a euclidean distance criterion in some techniques the squared euclidean distance is used the euclidean distance is formed by finding the difference in the values of the first variable between two disciplines and squaring the result repeating for each variable adding the all the squared differences together and taking the square root of this out of all the disciplines in the study the pair that are closest join first and lowest in the dendrogram when groups are being joined together some measure of the collection of values of a variable is needed and various possibilities are discussed later we consider only journal articles and not other publications such as books which may in themselves follow a different format in their title than do journal papers the percentages of joint papers shown in the penultimate two columns of table 1 were not included in the cluster analysis as they will tend to reflect the number of authors and hence this would be to an extent double counting this characteristic in addition the number submitted outside the discipline partly depend upon how the boundaries are drawn by the ref itself rather than inherent characteristics of the discipline we standardised the data by transforming each variable into a z variable this is frequently done when the different variables are substantially different this was done in stata and the algorithms used to calculate the different clusters using different assumptions were also those which are given in stata figure 1 shows the dendrogram calculated using the method of average linkage as its name suggests this uses the average over all papers in a cluster for each variable as the measure of cluster location the average linkage method tends to work well in many situations and is reasonably robust the diagram shows the euclidean distance two subject matter areas that have highly similar characteristics join low in the diagram hence aeronautical and general engineering are highly similar at higher values of the vertical axis clustered pairs are joined by a third area or group of areas with largely similar characteristics to the pair other areas that have somewhat similar characteristics are also paired moving up the diagram the number of clusters reduces and each contains more heterogeneous although somewhat similar areas economics is initially grouped with philosophy although quite late in the clustering process hence the linkage is not that strong at the same approximate level of dissimilarity is a second group involving architecture geography sports science business social work education sociology anthropology area studies law and politics these correspond closely to the social science disciplines and ref panel c this group is subsequently linked to a second grouping comprising modern languages media studies history theology english language music the arts and classics which largely correspond to the arts and humanities and ref panel d it is these two combined groups that economics and philosophy eventually are linked there is then one further large grouping this is made up of sub groupings of allied health agriculture biological sciences psychology and earth systems which largely come from panel a the health sciences and the four engineering disciplines which come from panel b the sciences these two sub groups merge and are then joined by chemistry physics a sub group of maths and computer science and finally clinical medicine and public health to a large extent the clusterings are intuitively plausible but there are some surprises for example the clustering of sports science with architecture and geography however this does take place quite late which suggests that the linkage with sports sciences and the other two disciplines is not that strong even so there are plausible connections with geography forming a bridge between the other two the full title of sports science is sport and exercise sciences leisure and tourism and the latter two areas make the linkage with geography plausible similarly with geography and the last two elements of architecture built environment and planning but the linking of psychology psychiatry and neuroscience with earth systems and environmental sciences is more difficult to rationalise however the subsequent linking of this subgroup with allied health biological sciences and agriculture veterinary and food science is easier to rationalise eg the link of earth systems with agriculture and biological sciences hence we can see that groupings based on journal paper characteristics categorise the different disciplines into the sciences social sciences and the arts in a manner which largely supports the conventional groupings as can be seen from table 2 where these clusters are listed we choose seven clusters9 as this allows the main clusters to emerge given that some uoas such as clinical medicine will tend to be on their own not linking to other uoas in this case both the social sciences and the arts and humanities are well identified most of the sciences in both panels a and b form a single cluster with the exceptions being clinical medicine public health chemistry and physics mathematics and cluster a fitted by average linkage b wards linkage c single linkage d complete linkage e is fitted by average linkage excluding the number of authors computer science also form their own subgroup economics does not fit in well with the other social sciences nor indeed does it fit in with the sciences it fits best with philosophy although the fit is not that strong and if we move to nine clusters it is on its own not linked with philosophy if we use other methods 10 to identify the clusters the results viz a viz economics change relatively little as can also be seen from table 2 for example when using wards method there is a clearer split identifying panels a and b and the social sciences form two clusterswhich join together again when we reduce the number of clusters to 6 the dendrograms give more insight than the simple identification of clusters but what this table also reveals is that while the contents of a cluster might be identical or almost identical under different linkage assumptions the ordering of clusters depends on the algorithm and other assumptions the final column shows the clusters using average linkage when we omit the number of authors the results are similar to before although social sciences now has two sub clusters and in panel b chemistry and physics are now part of the other sciences but with maths and computing excluded but still the clusters are based around the different ref panels and hence these results are not being driven by large differences in the number of authors between disciplines the same is true if we omit the proportion of papers which are journal papers fig 2 dendrogram based on average linkage with subgroups for economics 10 wards method is based on increasing the overall withincluster variance to the smallest possible degree single linkage is based on the minimum distance and complete linkage is based on the maximum distance 11 if we repeat the analysis but using the raw data not the standardised one then there are some changes the clusters still identify the different panels well but now economics is weakly linked with mathematics and computer science again there is no evidence of a linkage with either the rest of the sciences or the social sciences splitting up economics in this section we divide the economics papers into three groups those published in theory journals those published in econometrics journals and all the remaining papers we used the same categorisation principle as hudson ie a journal was counted as a theory journal if some version of the word theory appeared in the title and similarly for econometrics with respect to variations on econometrics for this exercise the journal econometric theory was counted as an econometrics journal table 1 shows the summary data on these three sub groups of economics there are substantial differences with titles of both theory and econometrics journals having significantly at the 1 level lower proportions of papers with both colons and question marks the titles of papers in theory journals are exceptionally parsimonious whilst their average word length is high relative to other disciplines although not as high as papers in theory journals word length in econometrics journals also tends to be high relative to other disciplines the penultimate column shows that a submission which spans disciplines is relatively uncommon for papers in theory and econometrics journals but slightly more common in the rest of economics redoing the cluster analysis in a manner consistent with that shown in fig 1 results in the dendrogram shown in fig 212 papers published in econometrics journals are linked in with maths and computing as subsequently are papers published in theory journals they thence join with the sciences although at a high level of dissimilarity the rest of economics now links with business and thence to the social sciences this result does not change if we use the other methods for clustering the clustering algorithm is a hierarchical one and expanding the disciplines has had only limited repercussions on the structure of the other clusters and this involves mainly business and philosophy the close tie of econometrics to mathematics is not that surprising although that with computer science a little more so perhaps the most surprising conclusion is that other economics ties with business and follows a completely different path up the dendrogram to that of theory and econometrics it is this second part which is linked with the social sciences these differences suggest that economics is a broad discipline compared with some others although it is also a discipline with a degree of heterogeneity it is also not surprising that these clusters are different to those that we get using citation analysis the latter will relate primarily to subject matter rather than to academic style of working the ref data provides more information on the linkages between economics and other subjects via the submission to other uoas of papers also submitted to the economics uoa the proportion of joint submissions shown in the penultimate column of table 1 for the theory and econometrics journals combined is significantly lower at the 1 level than for the rest of economics 13 ignoring business uoa partners for theory and econometrics seven out of twelve partners were in mathematics or computer science for the rest of economics the spread was wider out of 71 nonbusiness uoa partners nine were in the mathematics or computing uoas with the other largest groupings being public health history social work and social policy and education these linkages will partially reflect closeness of subject matter as in citations but also possibly closeness in working styles 14 the results albeit with small samples again suggest that the more quantitative part of economics is closely linked with mathematics and computing but that the rest of the discipline is spread more widely across parts of the sciences the social sciences and also the arts conclusions this paper represents one of the first attempts to identify using quantitative analysis the linkages between different disciplines based on the stylistic characteristics of journal papers we are able to identify subjects as defined in the ref into clusters which closely resemble those which form the four main ref panels and also more generally what are thought of as the sciences the social sciences and the arts and humanities this indicates both that contiguous disciplines have similar style characteristics evident in the title of the journal papers in those disciplines and that using these we are able to link the different disciplines together in a manner which broadly is reflective of the social sciences sciences and arts and humanities as they are generally understood thus linking cluster 3 to panels a and b cluster 5 to panel c and cluster 6 to panel d as in column a of table 2 correctly identifies 29 of the 36 disciplines the disciplines of physics and public health however are difficult to categorise and maths and computer science form a separate group from the rest of the sciences economics as a whole is linked with philosophy although not strongly so only area studies is allocated to a wrong panel the fact that we have been able to successfully allocate disciplines to clusters which so closely resemble the ref panel groupings suggests that our methodology is sound on the basis of our analysis it seems possible that most of economics does not closely link with any of the other disciplines economics tends to have relatively few authors but more than the arts and humanities tends to be parsimonious in title length and to an extent particularly when compared with the other social sciences and the arts and humanities in the use of colons when we look at subdisciplines within economics we find that econometrics first links with maths and these are then joined by economic theory and computer science business and the rest of economics link together and thence with the rest of the social sciences although at a relatively high level of dissimilarity and hence the linkage is not that strong however there is little evidence of a link with the sciences per se this is not unexpected large grants involving several labs have become increasingly important in the sciences at least as represented by the leading papers this may have tended to increase author numbers and this too will leave a footprint on title styles of course grants are important in economics too but not to the same extent as in big science with respect to the question posed in the title of this paper our view in part informed by these results is that the subject matter of economics places it clearly as a social science but many in the discipline act as if it were a science economics has gradually developed into an interdisciplinary subject that uses scientific methods for example setting out and formally testing hypotheses and particularly a mathematical approach to solve social science problems this dual aspect may explain why it fails to fit neatly with either as in fact it combines elements of both it is a social science pursued with more quantitative rigour than much of the rest of the social sciences this emphasis on technique then pushes economics and economists away from the other social sciences and in some subdisciplines towards maths placing economics as a science emphasises technique above subject matter but there is then a danger that technique becomes an end in its own right rather than a means to an end ie a vehicle which allows a more refined analysis of economic issues which have wider relevance often for example when developing a new econometric technique which subsequently becomes widely used this is justified but sometimes this is not the case which helps explain the relative isolation of the discipline as noted earlier this does not mean that economists should abandon their quantitative focus but that they should always strive to ensure that their work contributes directly or indirectly to an understanding of a real world issue this is consistent with freys observation that economics is part of those sciences which deal with actual problems of society but that most economists attempt to imitate the sciences and that economics can be regarded as a branch of applied mathematics it is also consistent with the view that that economics particularly neoclassical economics is the most mathematical of the social sciences there are two further implications of this both of which might be explored in further work firstly modern universities have mainly organised their structure along the tree of knowledge type model according to which knowledge is split into branches then into major disciplines and thence into subdisciplines and specialties this has tended to result in economics being linked with the social sciences or business schools seldom are they linked with any of the sciences this may lead to problems in being involved with administrators and academics who do not really understand the way economists work nor their values secondly the ethos economists perceive themselves as being part of tends to set the confines within which successful economists must work if economists perceive themselves as mathematicians then this sets out the theoretical style we see in many journals if they see themselves as scientists then the emphasis moves to hypothesis testing if on the other hand they see themselves as social scientists this will focus attention more on policy outcomes and a greater readiness to use the results of the other social science disciplines the analysis has focused on papers submitted to the ref whilst this provides a large number of papers to analyse they are biased towards the better higher quality papers further analysis could extend the data set to cover a more random set of papers across a range of journals in each discipline in order to determine whether the writing characteristics of these high quality papers translate to the discipline as a whole in addition further work could estimate clusters based on other aspects of papers such as length and the typical structure of a paper abstracts too differ between disciplines in many journals it is a single paragraph of between 100 and 250 words but in some of the science disciplines the abstract too is divided into sections other possible characteristics include the numbers of equations footnotes or endnotes quotations and use of explanatory diagrams or flow charts use of regression analysis and the ratio of the length of the concluding section to the rest of the paper 15 finally we have divided the subject along into theory econometric and other areas this could have been taken further dividing by subject subfields such as health economics labour economics and macroeconomics and then studying these subfields attribution by means of semantic similarity defining the subfields could be done eg by looking at title papers in journals recognised as representing the different disciplines

different academic disciplines exhibit different styles including styles in journal titles using data from the 2014 research excellence framework ref in the uk we are able to identify the stylistic trends of different disciplines using 155552 journal titles across all disciplines cluster analysis is then used to group the different disciplines together the resulting identification fits the social sciences the sciences and the arts and humanities reasonably well economics overall fits best with philosophy but the linkage is weak when we divided economics into papers published in theory econometrics and the remaining journals the first two link with mathematics and computer science particularly econometrics and thence the sciences the rest of economics then links with business and thence the social sciences

introduction one of the major avenues through which the advancement of artificial intelligence is affecting society and its people is by redistributing economic opportunities and earning prospects such redistribution can be equitable and inclusive or biased in favor of certain groups that get to benefit from economic power concentrating in their hands 9 up until recently many technologists believed that technological progress always lifts all boats and automatically leads to shared prosperity once the economy has gone through an adjustment period this has left many to ignore the consequences of their inventions for economic inequality however since the 1980s technological progress has been accompanied by a significant increase in inequality for example 4 surveys a significant body of economic literature that finds that automation in the us has led to a polarization of the labor market whereby middleincome jobs that used to perform routine tasks were replaced by lowerincome jobs while those at the top of the income distribution experienced significant gains leading to an increase in economic inequality 14 document a similar phenomenon across the oecd a club encompassing the richest countries of the world over the past two decades that median wages the compensation of a typical worker grew at a slower pace than overall productivity and that the gap between the two has been increasing in recent years it has fortunately become common to see demands that ai should be humancentered with transparency and accountability as paramount features however those are often immediately and unfortunately followed by statements like overwhelmingly ai will disrupt labor markets and the economy around the world which are taken as immutable facts there seems to be a big difference in attitude towards ai violating notions of fairness accountability and transparency versus the prospect of ai disrupting the economic order increasing inequality and endangering the livelihood of millions of workers the former is justifiably seen as unacceptable while the latter is often taken as a given and treated as an unavoidable consequence of ai advancement the difference in attitude seems in part driven by the ethical foundations used to evaluate advances in ai under traditional deontological foundations developing an ai system that operates and performs all its actions while complying with all of societys traditional ethical rules is considered fair game even if the system has the side effect of triggering general equilibrium effects in the economy that lead to the displacement of millions of jobs by contrast under more consequentialist foundations it is more natural that such massive job displacement would be considered a violation of ethical norms the distinction between the two approaches also has significant implications for how society is expected to respond to job disruption if it is considered fair game for the developers and deployers of ai to disrupt labor markets and impose losses on millions of workers then the burden of adjustment is on workers it is their duty to face their losses and they must continuously upskill in order to remain relevant in the labor market that is being reshaped by ai advancement the implication for governments is that they are welladvised to strengthen social safety nets expand training programs and prepare for benefits like a universal basic income all financed by taxpayers not the perpetrators of the disruptions in other words it is society and its people not the ai developers who are expected to bear the burden of ensuring that ai advancement does not cut people off their sources of income by contrast if it is considered unethical for the developers and deployers of ai to disrupt labor markets then the burden is on the ai industry to consider the impact of the technologies they are shaping on labor markets and employment opportunities and it would be incumbent upon the ai industry to guide its decisions around the development of ai to avoid massive elimination of jobs and make the adjustments to a new technological and economic reality less burdensome and costly for workers and taxpayers this paper builds on the recent economic literature discussing the impact of automation technology on labor demand and lays out a framework for systematically evaluating and predicting the impact of new aibased technologies on labor income we propose a stepbystep procedure that can be used by interested stakeholders in the ai industry and research community without prior knowledge of economics to evaluate which ai applications are likely to lift all boats and support shared prosperity and which ones are likely to contribute to greater inequality evaluating this question throughout the ai development process is a critical step towards assuring that ai advancement is ethical and creates a fair and inclusive economic future for humanity 7 we hope that such an evaluation will inform the choices of researchers developers innovators investors and consumers in the field of ai and that it will help to practically execute the idea of steering the direction of ai progress to benefit the workers instead of displacing them 310 a decrease in labor demand can manifest itself as reduction in wages employment or both hence gauging the change in labor demand allows to understand the direction and magnitude of impact on workers incomes and financial wellbeing we should note that assessing ais impact on labor demand does not necessarily capture the impacts that technology has on other aspects of wellbeing and overall job quality like safety level of physical strain schedule predictability freedom from surveillance etc however job quality is frequently correlated with wages levels as higher labor demand also gives workers more bargaining power to ask for better job conditions the rest of this paper is structured as follows section 2 discusses why the current trajectory of ai advancement risks exacerbating economic inequality section 3 presents ways to practically incorporate the consideration of economic inequality into the ai research and development process and proposes a highlevel framework for directing ai progress for shared prosperity section 4 makes a case for ai researchers and developers to recognize the responsibility of ensuring that their creations support economic inclusion section 5 outlines the frameworks limitations and open questions for future work section 6 concludes advances in ai and employment traditional economic theory views capital and labor as the main factors of production in the economy capital includes machines equipment etc the factor labor can be distinguished by geography or by levels of education eg into lowerskilled mediumskilled and higherskilled labor depending on the application it may also be useful to distinguish workers along specific occupations that may be differentially affected by an innovation technological change may boost the returns on some or all of these factor owners but some types of technological change lead to starkly diverging impacts on different factor owners 9 for example they may increase the returns on capital but not labor or of higherskilled workers but not lowerskilled workers or to offer a very specific example of ai engineers but not radiologists by implication they may shake up who in society has access to gainful employment opportunities and for whom those opportunities become harder to obtain as a consequence of falling demand for their skills ai may change workers access to economic opportunity even more starkly than the redistributions generated by past waves of technological progress let us provide a clear example of the type of redistributions that ai may generate an ecommerce business that scales up might displace a large number of local momandpop stores resulting in a concentration of gains from selling goods to consumers to provide another example a shift towards consuming news through social media may disrupt traditional patterns of news consumption and may cause local newspapers to lose advertising revenues leading to large job losses at local newspapers and again resulting in a concentration of gains in the hands of a few large companies ai may also generate significant redistributions across countries 11 in the following let us discuss three common types of technological change that are frequently discussed and that may have large effects on workers earnings opportunities automation skillbiased technological change and human augmentation automation automation displaces human labor with machines frequently higherskilled workers are employed to design systems that automate away the jobs of lowerskilled workers a cursory look might suggest that automating a job always has negative effects on workers while creating jobs always has positive effects on workers but it is more complicated than that automation of human labor is not in itself undesirable the history of progress since the industrial revolution is a story of relentless automation that has contributed to rising living standards moreover there are many examples when automation allowed us to make work less dangerous and less physically taxing if the automation of human tasks is accompanied by the creation of new tasks for humans then the adverse effects on labor demand are offset 2 empirical evidence from the us suggests that while tasks automated and reinstated by technological change used to balance out during the four decades following wwii the past three decades have seen task displacement significantly outpacing reinstatement ai is expected to continue this trend and may even accelerate it 3 moreover if the new tasks that ai advancement creates require a much higher level of skills or educational attainment compared to the tasks being displaced these new tasks will bring little to no economic relief to the workers whose jobs get automated even if the new jobs match or exceed the displaced jobs in volume skillbiased technological change a type of technological change that disproportionately benefits those with comparatively high levels of educational attainment is referred to as skillbiased skillbiased technological change is poised to exacerbate societys structural inequalities especially in countries with low economic mobility technological change does not have to be skillbiased in fact the first wave of the industrial revolution is generally viewed as having been biased in favor of unskilled workers who suddenly had much greater earning opportunities likewise there is nothing inherent about ai that makes its applications necessarily be skillbiased or laborsaving ai can be used to complement lowerskilled workers making their labor valued more highly it could also be used to expand the economic possibilities of people who previously had limited access to training and education or for whom education was prohibitively costly in other words ai advancement could be economically inclusive but making it so requires deliberate action human augmentation it is commonly suggested that developing ai systems that augment human workers instead of displacing them would be a good recipe to ensure that advances in ai benefit workers some ai firms have even started to use this language when describing their products in promotional materials and sales pitches while humanaugmenting ai as a generic goal seems more desirable than measuring the progress of ai by how well it automates away humans it is important to note that humanor laboraugmenting ai can still result in the displacement of workers and reductions in wages because laboraugmenting ai may still be laborsaving it all depends on whether the firm will cut its prices and how much demand will respond to the price cut for a simple example suppose that a firm employs workers to produce a product that is sold to consumers suppose further that the firm develops and deploys laboraugmenting ai technology that allows each worker to increase their output per hour by 10 with this technology 10 fewer workers are needed to produce the same amount of output if the firm cannot increase its production volume or the number of units it can sell per year it may have to make redundant those 10 of its workers by contrast if the firm lowers the price of its product as a result of its reduced labor costs and if consumers are willing to buy a lot more of the product at the lower price then the firm might keep or even grow the size of its original workforce to satisfy the increase in the demand for its product whether this happens or not depends on how responsive consumer demand for the product is to the changes in its price in a competitive market the firm is indeed likely to lower its price when its costs decline and even in a monopolistic market the firm might lower its price for example if it aims to keep its markup constant this stylized example illustrates that developing ai that is augmenting humans is not enough to ensure that employment and wages are not reduced because laboraugmenting technology allows firms to employ fewer workers to produce the same amount of goods something needs to compensate for the reduction in labor demand that such technology will create in order to avoid job losses these three examples illustrate that the effects of new technologies on labor markets are not always straightforward to assess and that a systematic economic framework is needed to sort through the different effects in the following section we propose the outlines of such a framework allowing researchers companies and policymakers to evaluate the overall impact of a new technology on labor markets as we discuss the effects of technology on wages and inequality we do not take a stance on what particular social welfare function to embrace but our results on what redistributions a technological innovation will give rise to are relevant for any inequalityaverse social welfare function framework for evaluating ais impact on labor demand this section describes a set of questions that represent a heuristic to systematically evaluate the overall or general equilibrium impact of an ai application on labor demand and consequently on employment and wages we will use customer service chatbots and autonomous grocery delivery vehicles as illustrative examples when describing the logic of the framework customer service chatbots are applications frequently powered by natural language processing machine learning models that simulate the behavior of human customer support agents for the purposes of this discussion we will refer to applications that respond textually or vocally to textual or vocal customer service requests as chatbots in todays world human customers frequently encounter such chatbots for example when texting or calling customer support number responding to a how can i help you today automatic popup prompts on commercial websites and in other contexts autonomous delivery vehicles are driverless vehicles with a space to transport goods but not people at the time of writing autonomous delivery is not widely commercially available but a few startup companies are piloting them in a limited set of locations 1 for the purposes of this discussion we will examine autonomous grocery delivery while noting that autonomous delivery vehicles could be used to deliver other types of goods as well the framework that we propose in the following does not provide precise quantitative estimates of the magnitude of effects often mapping relative magnitudes and the directions of effects is in itself already very instructive and permits to understand the direction of the overall impact on labor demand however we hope that the proposed framework will inspire followup work on how to flesh out the described effects in more detail and at a more quantitative level 12 depending on the particular ai application we also note that some steps may be skipped if the magnitude of the described effects is not deemed significant enough to merit a deep investigation direct effects the direct effects reflect the workers who are directly hired or displaced because of the introduction of a new ai application in a company while holding everything else fixed we capture these direct effects via the following two questions which types of workers will be displaced by the introduction of a new ai system and in which geographies are they located it is important to capture the skill level and geographic location of those workers in order to understand if any of the compensatory effects below will be of relevance to them for example if an ai application displaces workers without a college degree in one set of locations and creates an equal number of jobs requiring advanced degrees in another location the displaced workers will not be able to compete for the newly created jobs in the chatbots example the workers directly displaced are customer service associates located around the world with major centers in the united states india and the philippines those are predominantly formal sector jobs with predictable schedules and earnings skill requirements vary the workers directly displaced by autonomous grocery delivery vehicles are delivery associates often employed as independent contractors also referred to as gig workers their jobs are frequently precarious and lacking earnings predictability and benefits but the work can be physically demanding and prone to injury there usually are no degree requirements associated with delivery jobs notably autonomous delivery vehicles would also displace unpaid work by households who shop for and bring their groceries home by themselves without calling a delivery person for what types of workers will new demand be created by the introduction of the ai application and in which locations the introduction of chatbots will create demand for software engineers customizing and maintaining the bots chatbot platform sales and customer success people product and marketing managers most of those jobs will require a college or advanced degree and will likely be geographically concentrated they will also likely be fewer in number compared to the number of displaced customer 1 see for example and service associates identified in step 1 because one chatbot development company can service many corporate clients introduction of autonomous grocery delivery vehicles will create jobs similar to the above at companies producing those vehicles but in addition would create a need for workers assembling grocery orders and loading them onto the autonomous delivery vehicles those jobs will be similar in quality and skill requirements to the jobs of displaced delivery gig workers but might be safer and higher in volume if a significant number of households switch from shopping for and delivering their own groceries to using an autonomous delivery vehiclepowered service demand effects will the innovation increase demand for the companys products because it will lower its prices or increases the quality of its products will the increase in product demand translate into higher demand for workers for what categories of workers and in which geographies a company that cuts its costs by replacing some or all of its human customer support agents with an automated chatbot might lower the costs of its main product because of the lower expenses on customer support moreover it might offer more customer support services and choose to provide it in contexts where it was not used before this might not have much impact on how many human customer support agents it employs but it may somewhat raise labor demand for all types of workers across the company if grocery deliveries are made easier and less costly by the introduction of autonomous delivery households will demand more grocery deliveries increasing the revenue and associated employment of pickers at grocery stores however there are likely few effects on the overall volume of groceries purchased since grocery consumption is quite inelastic and quickly reaches a point of saturation vertical effects how does additional product demand affect labor demand along the supply chain of the innovating company in the chatbot example the innovating company will need fewer workstations for customer support less office space and fewer office services resulting in lower labor demand among those suppliers however if the company can expand the demand for its products because of lower prices or better marketing then it will also raise the demand for its intermediate inputs which may add labor demand to the economy for the grocery delivery vehicles we do not anticipate significant vertical effects since total demand for groceries will not change significantly horizontal effects the horizontal effects capture how companies that produce goods and services that are substitutes or complements to the innovating company will be affected economists refer to goods or services as substitutes if they can easily be used for the same purpose eg taxi rides or uber rides goods or services are complements when an increase in the consumption of one makes it more desirable to consume the other eg coffee and cream how will competing companies producing substitute productsservices be affected will they need to downsize their workforces in which geographies and for which categories of workers for the company introducing chatbots lower prices may undercut its competitors and lead to cuts in their workforce in the case of autonomous grocery delivery services associated with getting to and from the grocery store might be impacted resulting in a decrease in car sales and in the use of public transportation impacting the associated employment the customer service chatbots are not anticipated to lead to significant effects on complementary goods if a significant number of households switch from buying their own groceries to using delivery services as a result of the introduction of autonomous delivery vehicles it might affect the volumes of purchases of services that rely on the physical presence of customers at grocery stores for example small vendors in front of the store the effects are not likely to be major factor reallocation how will wages adjust to reflect the new balance of labor demand and supply resulting from these changes our final question considers how equilibrium in the labor market is affected the workers displaced by technological progress will after an adjustment period be redeployed in different companies or sectors increasing overall output and wealth in the economy however when workers need to compete for new jobs they will push down wages in their sector and conversely for workers who are in higher demand wages will rise this implies income redistributions that have the potential to exacerbate or to mitigate inequality depending on the specifics of the situation in our example of chatbots the layoffs of customer service representatives will put downward pressure on the wages of unskilled workers whereas the hiring of additional ai engineers will put upward pressure on their wages moreover capital owners will benefit from the greater returns that the company earns ultimately the described effects are likely to increase inequality for the grocery delivery vehicles the results will be similar leading to a redistribution of income from unskilled workers to ai engineers although the losses of unskilled workers are likely mitigated by the fact that many of the displaced drivers can be redeployed as pickers in grocery stores it is important that the field of ai introduces a practice of systematically evaluating these effects to gauge the impact of their inventions on the income prospects of different groups of workers and to ensure a fair distribution of the gains from progress we view it of particular importance for ai developers to pay attention not to disadvantage those groups of society who already are marginalized and who have limited access to retraining opportunities responsibility of the ai community progress in ai is unlikely to bring about an inclusive economic future if the direction of ai development is determined solely by market forces which tend to favor efficiency but do not ensure that the gains from progress are distributed equitably for example in recent decades the labor share of income in the us has decreased and the wages of noncollege educated workers have stagnated and have not shared in the productivity gains generated by technological progress 5 market prices do not always reflect the true social costs and benefits generated by a business activity and therefore may provide misguided incentives for example in a free market prices do not reflect the costs of environmental damage produced by a carbonemitting enterprise as a result the costs are not borne by the polluter but instead by society as a whole to make the polluting enterprise internalize the full costs of its operations economic theory suggests taxing activities that produce externalities but even in absence of carbon taxes companies still have a moral responsibility to take on voluntary commitments to cut their emissions and minimize the uninternalized cost to society from their operations likewise market prices do not reflect distributive concerns when companies produce technologies that induce undesirable shifts in labor demand and consequently reduce the labor share of national income there is a cost to society in the form of a more unequal income distribution disrupted livelihoods distressed families and communities and sometimes even deaths of despair 6 these are costs that companies do not internalize akin to environmental externalities in absence of a regulatory framework to internalize the cost of jobdisplacing innovation it is up to developers to behave responsibly in how they handle the redistributive power of ai however aside from voluntary action on the part of ai developers to consider the economic interests of workers in the ai development process government can also take steps to ensure that the regulatory environment does not provide incentives for excessive automation and ever greater concentration of earning opportunities for example the incentives for innovators are affected by tax policies current tax regimes that favor capital over labor 1 and policies that limit labor mobility 13 create strong incentives to develop ai applications that focus disproprotionately on laborsaving use cases if these policies remain in place ai advancement might bring about levels of automation well above what is socially optimal to the disproportionate detriment of the economically vulnerable workers with limited access to retraining opportunities the risk of excessive automation is increasingly recognized by scholars on the future of work but unfortunately the current discourse places too much of the burden of adjustment to the changing technological landscape on workers and governments including developing country governments questions around the role and responsibility of the ai industry and the ai research community remain relatively neglected limitations and call for future work the set of heuristics described in section 3 is an early attempt at defining the questions that the ai industry and research community ought to be asking in order to evaluate the likely impact of their choices on inequality and availability of gainful employment opportunities for workers especially the more economically vulnerable workers with lower levels of educational attainment and limited access to retraining opportunities this attempt has both gaps and limitations a nonexhaustive list of those is below first the economic framework we outlined is only the beginning of a research agenda to develop models of the impact of advances in ai on earning opportunities many different approaches are possible and we hope that many will be considered further developed and refined by both the ai ethics and the economics community second there is often a considerable amount of uncertainty when it comes to estimating the magnitude of the likely impacts of ai advancement on labor demand especially so for the secondand thirdround economic effects such as effects that propagate internationally through trade global supply chains or other mechanisms ai developers and scientists working on basic research which can subsequently be used to enable many different kinds of applications face an additional layer of uncertainty the heuristics described above could be improved by introducing weights that reflect the associated levels of uncertainty about each of the effects being considered but even when the level of uncertainty seems overwhelmingly high we want to caution against the ai industry and research community excusing themselves from the responsibility to think about the likely impact of their actions and choices on economic inclusion to return to our analogy to environmental effects just because climate science does not yet allow us to precisely attribute climate effects to the energy management and waste management choices does not mean that our choices should be reckless the same holds for the effects of ai on inequality it is incumbent upon members of the ai community to think about the economic future that they are so powerfully contributing to for societies around the world third the framework presented above focused on labor demand and market wages as a measure of shared prosperity and ignored other aspects of job quality on the one hand this position is justified because for the majority of the human population labor is the main asset that allows them to earn income ai applications that reduce the demand for human labor undermine the value of what is the main and for much of the worlds population the only asset which people have on the other hand quality of labor demand not only its volume matters to human wellbeing if an aiinduced change to production processes replaces 1 million good jobs with 35 million jobs of equal pay but starkly lower job quality it would be difficult to argue that this was overall beneficial to workers and advanced shared prosperity lastly even though paid labor is currently the main source of income for the majority of humans we do not want to rule out the possibility that far greater shared prosperity and human flourishing may be possible in the future of humanity if all labor is replaced by sufficiently intelligent ai systems and machines 1516 this would entail a transformative change in our society and would bring about a stark set of novel challenges including challenges in the way in which income is distributed 8 we believe that in the short and medium run while paid labor is the main source of income for the majority our proposed framework to develop ai for shared prosperity offers one of the most promising ways of distributing the gains from technological progress if we did approach a situation in which novel ai systems turn all human labor into a redundant technology we believe in the same spiritthat it would be incumbent upon the developers of these systems to develop new ways of sharing the economic gains generated by their inventions that do not rely on compensating labor in order to avoid mass immiseration and advance shared prosperity globally across human society conclusion advances in ai have the potential to produce farreaching impacts on workers and carry the risk of exacerbating longstanding inequalities within as well as between countries ai developers have a moral responsibility to think about the economic impact of their creations whom they might benefit and whom they might harm we argue that the responsible ai community needs to make an effort to develop frameworks and heuristics for thinking rigorously about these impacts and to steer ai development choices away from applications that deepen economic inequality and instead into directions that fulfill the potential of ai to generate shared prosperity

future advances in ai that automate away human labor may have stark implications for labor markets and inequality this paper proposes a framework to analyze the effects of specific types of ai systems on the labor market based on how much labor demand they will create versus displace while taking into account that productivity gains also make society wealthier and thereby contribute to additional labor demand this analysis enables ethicallyminded companies creating or deploying ai systems as well as researchers and policymakers to take into account the effects of their actions on labor markets and inequality and therefore to steer progress in ai in a direction that advances shared prosperity and an inclusive economic future for all of humanity• social and professional topics → employment issues automation economic impact codes of ethics sociotechnical systems

mexicanborn persons account for the majority of deportations from the united states in 2009 mexican nationals accounted for 86 of the 613003 persons apprehended in the united states and 72 of the 393289 persons removed from the country deportees comprise a diverse population which includes persons apprehended while crossing the border during workplace raids or during prosecution for other criminal charges including drug offenses in 2010 11 of mexicans who were deported to mexico from the united states were women mexican migrants and return migrants including deportees with drugrelated criminal records might experience increased risk for hiv transmission from continuing drug use and related risk behaviors such as syringe sharing lifetime drug use is highest among mexicans who have ever migrated to the united states possibly because of increased exposure to drugs through social networks in border communities and in the united states specific subgroups of mexican migrants in the united states including injection drug users experience a documented risk for hiv although women who migrate exhibit lower rates of drug use than men women experience additional vulnerabilities to hiv including sexual exploitation among persons who inject drugs in tijuana mexico male deportees had four times the risk of hiv infection this elevated hiv risk was not found among women in contrast another study found that mexican women who injected drugs also reported frequently trading sex for money or drugs significant gaps in the literature prevent a thorough understanding of how involuntary migration including deportation can shape hiv risk among vulnerable groups including drugusing women little is known about the relationships between deportation social and economic vulnerability drug abuse and engagement in hiv risk behaviors among women who inject drugs thus we conducted an exploratory qualitative study of deportation experiences among women who inject drugs in tijuana many mexican deportees are returned or travel to border cities such as tijuana baja california which is adjacent to san diego california together both cities form the busiest land border crossing in the world in 2010 40 of mexicans deported from the united states arrived to ports of entry in baja california with tijuana receiving the largest share of deportations at 126000 persons tijuana is the largest and fastestgrowing city on mexicos northern border with the united states with an estimated 14 million people in 2005 the city lies on drugtrafficking routes for heroin cocaine and methamphetamine destined for the united states tijuana supports a large population of injection and noninjection drug users increasing hiv prevalence particularly among highrisk populations of idus female sex workers migrants and deportees is a significant concern for health officials in tijuana hiv among substanceusing migrants is also concerning because of the potential for bridging otherwise unconnected populations via their sexual and drug use practices which may occur in diverse geographic regions among women in a cohort of idus in tijuana the adjusted hiv prevalence was recently estimated at 31 notably in the larger cohort the majority of idus diagnosed as hiv positive were unaware that they were hiv positive persons who are unaware of their hiv serostatus are at high risk of transmitting hiv implying that the sexual and substanceusing networks of undiagnosed binational populations such as deportees might experience heightened risk for infection given this setting and the lack of research on deported women who inject drugs we drew on rhodes risk environment framework for understanding the social and structural production of hiv risk within this framework it is posited that drug users risk for hiv is shaped by exogenous physical social economic and policy risk factors at the macro meso and micro levels in addition to endogenous individual characteristics and risk behaviors such as unprotected sex and sharing of syringes using this framework in our exploratory study we aimed to describe the experiences and risk environments within which deported drugusing women in tijuana lived throughout their migration and druguse trajectories methods study population recruitment we recruited women from a prospective study examining hiv risk behaviors among idus living in tijuana mexico as previously described in april 2006 outreach workers used respondentdriven sampling to recruit participants 18 years old with evidence of recent injection drug use for our exploratory study sample we first generated a list of idus in the prospective study who reported us deportation of the 1056 prospective study participants 15 were women 36 of whom reported us deportation in october 2008 outreach workers invited all women who were not lost during the followup period to participate in our exploratory study after obtaining voluntary and informed consent we enrolled 12 women in our exploratory study we reimbursed women with us 20 for their time for undergoing qualitative interviews the human research protections program of the university of californiasan diego and the ethics board of the tijuana general hospital approved the study protocols data collection during october and november 2008 trained bilingual interviewers conducted semistructured qualitative interviews in private interview rooms in tijuanas zona norte an area of the city where drug use is widespread based on our theoretical framework we developed a semistructured interview guide to query women on their migration deportation drug and sexual experiences within various risk environments in the united states and mexico sample questions included tell me about your drug use in the united states and describe what happened the most recent time you were deported because many participants experienced multiple deportations we asked women to focus on their most recent deportation a strategy that the study team developed to increase the participants ability to recall the conditions surrounding this event interviews ranged in duration from 60 to 120 minutes and were conducted in english spanish or both languages according to womens preferences we digitally recorded and transcribed interviews but did not translate the transcriptions because we wanted to preserve participants language which was often bilingual and contained terminology specific to the economic and drug subculture of tijuana data analysis we analyzed data for concepts by identifying major categories in participants experiences we created an initial coding scheme based on the major themes and concepts in the interview guide next we read several crosssections of interviews revising the coding scheme to include emergent concepts and categories we independently applied these codes to five interviews and discussed and resolved all discrepancies between coders by refining code definitions we continued applying codes and memos to the transcripts when new codes emerged we updated the coding scheme and reread all transcripts according to the new structure we employed atlasti a qualitative data analysis computer software program to attach codes and memos to transcripts throughout the analysis we discussed emergent themes and compiled quotations illustrative of key concepts quotes presented in this article were translated from spanish to english as necessary by the first and last authors and follow the original wording of the participants statements results we identified several important themes relating to the various social and physical risk environments surrounding womens drug use before during and following us deportation we found that most womens social risk environments in the united states contributed to their initial drug use escalating drug abuse and injection drug use drugabuse experiences in the united states were intertwined with womens criminal histories and eventual deportation to mexico following us deportation women reported heightened social and physical risk environments in tijuana including lack of social networks greater financial and physical insecurity emotional distress increasing drug dependence and lack of access to drug treatment and other health services in the following sections we review these themes in greater depth and provide illustrative examples of womens experiences migration experiences the median age and educational attainment in our sample were 375 years interquartile range 3241 and 9 years respectively women were born in four states in mexico including baja california jalisco chihuahua and guerrero women arrived in the united states as children either migrating with parents or being sent by parents to live with us relatives most women completed primary and secondary education in the united states and spoke english proficiently or fluently at the time of the interview women lived in cities in southern california and suburban or rural areas and rural areas in northern and central california participants reported a median of 25 lifetime deportations with the most recent deportation occurring a median of 5 years before the interview drug use initiation in the united states women reported first consuming alcohol and marijuana during adolescence when most were already living in the united states three women who traveled to the united states during later adolescence recalled seeing family members in mexico use alcohol or drugs but initiated their use of illicit substances after migrating to the united states several women reported trying cocaine or heroin in high school in the united states and began injecting these drugs during late adolescence womens social risk environments in the united states facilitated their initial drug use women explained how family members friends and boyfriends in the united states introduced them to drugs women also attributed early experimentation with drugs to an underlying curiosity because of the high prevalence of drug use in their communities and social networks as described by a woman who migrated to california as a young child when i was sixteen i wanted to see how it felt my whole family used well not my whole family but my brothers and sisters … i used to see them get high or whatever and i wanted to know how it felt i wanted to join the club i thought it was cool … anything that they had i used … pcp acid rock heroin crystal coke some women recalled experiencing pressure to use drugs by gang members sex partners and acquaintances one woman who used cocaine and methamphetamine in the united states explained my husbands friends introduced me to drugs they were very possessive people who wanted me to use even though i didnt want to although women attributed much of their initial drug use to social relationships two women also described practical or employmentrelated reasons for starting to use drugs one woman described how methamphetamine could help her maintain sufficient energy for two factory shifts i felt enthusiasm strength … i was no longer sleepy or in pain and i worked well drug abuse in the united states for nearly all women in our sample occasional drug use during adolescence in the united states transitioned into regular daily consumption of drugs eventually contributing to physical dependence on heroin andor crack cocaine experiences with methamphetamine in the united states were limited and alcohol use was likely underreported because it was not a focus of our interviews some women discussed periods of polydrug use in the united states particularly in the context of social relationships and parties women described how friends spouses and sex partners enabled their continued drug abuse for example one woman attributed her increasing dependence on heroin to a close friend who regularly supplied her with the drug she would give me a bit more and more and several months passed by and i felt shivers my bones in my arms ached and she would tell me maybe you are addicted to that stuff heroin because i was using more and more despite increasing drug abuse and dependence five women described using drugs in the united states within an environment of relative stability and social support when asked about daily life in the united states before deportation one woman explained it was good because i was working to pay my bills help my mom … i wasnt ripping nobody off i was doing good living a normal life not so normal because i was using drugs you know what i mean but i was stable in my life while living in the united states family members provided economic and childcare support despite womens escalating social and legal problems resulting from drug abuse my husband supported me gave me money … my family saw i was crazy from drugs but they helped me with the rent helped me with my daughters and everything despite the economic stability and social support in the united states four women described negative consequences of their increasing use of heroin crack cocaine and methamphetamine losing control over ones life was a theme reported in many interviews for example one participant lost her job when caught with illicit drugs at work and another described selling and trading sex for drugs at night in a dangerous neighborhood women also described social problems resulting from their drug abuse for example one woman hid her drug use from friends and family in the united states out of fear of being ostracized or punished and two women described having to live on the streets after being kicked out of families homes injection drug use in the united states nearly all women reported injection drug use in the united states eight women injected regularly for many years and two reported injecting in the united states occasionally or just to see what it was like similar to the social risk environment influencing their initial drug use and experimentation women reported that friends boyfriends and family members in the united states taught them how to inject drugs seven women explained that they regularly shared injection equipment with friends and boyfriends because of physical dependence and withdrawal apathy or not caring about the consequences and not knowing where or how to access sterile injection equipment one woman who started injecting heroin in the united states when she was 16 years old explained that she knew sharing syringes could be dangerous but did so anyway out of necessity because i didnt care you know … because its a pretty ugly feeling when youre sick women bought syringes in the united states from drug dealers or at liquor stores and one respondent reported obtaining syringes from her mother a nurse i know it broke her heart supplying me with syringes if youre going to be using that shit at least promise me that youre going to use clean needles and if you run out please dont use nobody elses needle it was something that i was raised with i mean raised no thats not the word i got used to you know clean needles two women reported rarely sharing syringes because they typically injected alone hiding their drug use from their social networks or avoiding other idus for safety concerns deportation and criminal justice system experiences for all participants in our sample womens most recent deportations were preceded by lengthy criminal histories that often included serving hard time in us federal and state correctional facilities several women served lengthy prison sentences reasons for womens most recent deportations included being arrested violating parole and having a record of unauthorized entries into the united states criminal charges ranged from minor drug possession charges to armed robbery auto theft and assault some women experienced feelings of defeat and hopelessness with regard to us criminal justice and immigration systems particularly when contesting their immigration charges became more difficult because of past drug offences one woman explained that she was prohibited from ever returning to the united states because of her accumulated drug and immigration charges immigration is hard on drug trafficking which is why i got so much prison several women recalled being informed by immigration officials that they were prohibited from reentering the united states for periods of 10 to 20 years or that they were banned for life another respondent remarked that she was assumed to be mexican and perhaps was singled out for being mexican despite having little connection to or knowledge of the country immigration started looking for mexicans … they interviewed me and they told me that because of my drug history i couldnt be in the united states i had to get deported you know they asked me are you afraid that somebodys going to hurt you in your country or something and i told them no because i consider the united states as my country you know not anywhere else … i dont know anybody in mexico women described waiving their rights and agreeing to voluntarily return to mexico in exchange for an expedited removal process without additional prison time women described different levels of drug accessibility in prison and detention facilities with 9 women using drugs in prison and only 1 woman using drugs in an immigration detention center women described obtaining drugs and injection equipment from visitors or other inmates while in prison and 1 woman sold drugs many women described intense physical withdrawal symptoms and getting clean in prison and detention facilities followed by relapse or bingeing upon release one woman who served consecutive federal sentences for drug charges and unauthorized reentry into the united states an immigration offense noted two or three years before i got out of prison i stopped using drugs completely i wanted to get clean you know but i didnt last very long after i got out postdeportation milieu following their most recent deportations women were released into tijuana or migrated to tijuana from other mexican ports of entry in search of economic opportunities drugs or the local party scene or existing social networks in the city women experienced heightened physical risk environments immediately following deportation including difficulty communicating with family and friends in the united states and mexico finding shelter and safety and securing employment some women shared the cost of temporary housing with other deportees in the zona norte women lacking social networks in tijuana described feelings of fear isolation and disorientation with the neighborhoods or street culture of tijuana and other border cities into which they were released some women were deported and released into mexico very late in the evening and experienced increased physical vulnerability immediately following deportation including lacking money and shelter although some women shared the cost of hotel rooms with other deported women one woman described immediately engaging in sex work because she needed money for food and shelter and her deportee acquaintances showed her the ropes another woman met a man in the zona norte who initially offered help but actually abducted her for several months the man injected her with heroin which she had never injected regularly and forced her to sell sex she eventually escaped but remained dependent on heroin and continued sex work at the time of the interview half of our sample reported that sex work was their primary source of income others were underemployed in the informal sector four women reported an average monthly income of less than us 250 indicating high levels of financial need another immediate postdeportation concern was reentering the united states several women expressed an interest in returning to the united states for family reunification and improved financial stability but women who were banned from returning to the united states worried about additional criminal charges and incarceration none of the women had attempted to return to the united states following their most recent deportation because they lacked the resources to hire a coyote or were afraid one woman explained a lot of people die when they cross into the united states and it makes me scared and i no longer want to return postdeportation drug abuse locating drugs was a major concern for many women immediately following deportation two women described meeting men who were willing to provide them with shelter or drugs at least temporarily in exchange for sex one woman explained how this quickly led her back into a life of working the streets to support her drug use when i was sent here i was unfamiliar with tijuana well i knew tijuana but not this drug scene so i arrived with a little money it ran out and i had to convince a man here and it was simple to trade sex to get high … and i fell lower and lower many women relapsed into old drug habits some immediately began using the same drug they had used in the united states and others experimented with new or rarely used drugs methamphetamine a new drug for many women postdeportation was injected in combination with heroin or by itself two women tried to abstain from drugs because they had been clean in prison or detention before their deportation they reported that they were unsuccessful in abstaining from drugs because of the ubiquitous presence of drugs in the zona norte women described increasing drug dependence in tijuana following deportation which several women attributed to the lack of control over their lives postdeportation injection drug use several important themes emerged regarding injection drug use in womens postdeportation risk environments first the 4 women who rarely or never injected drugs in the united states began injecting regularly following deportation women described beginning to inject because of drug dependence lack of selfcontrol and the influence of their social networks and neighborhoods in which drug abuse was pervasive second women reported frequently sharing syringes in tijuana particularly with people from whom they sought help injecting including boyfriends and hit doctors although many women described efforts to avoid sharing injection equipment because of fear of acquiring hivaids or developing abscesses sharing injection equipment was common with sex partners two women described their need to be high on drugs when its business or to make sex with clients easier a final emergent theme relating to injection was the fear of being apprehended or harassed by police for carrying syringes being a known user or lacking proof of identification even though carrying syringes and having track marks are legal in mexico some women reported never carrying syringes because they were afraid of or had experienced police harassment or detention instead women reported injecting in the same locations where they bought drugs hoping that sterile syringes would be available one woman described how she tried unsuccessfully to hide her track marks from the police which she showed the interviewer i used to inject my arms and everywhere my legs were all fucked up you know see all those black spots i used to burn myself so there wouldnt be anything no tracks or whatever and the cops wouldnt see it but im still track looking because theyve got holes see i burned myself they hurt a little bit but i didnt care at the time respondents bought sterile syringes from pharmacies and liquor stores obtained free syringes from a local organization or borrowed used syringes from other drug users in picaderos postdeportation drug treatment seven women in our sample had experience with drug treatment programs in the united states or mexico at the time of the interview nearly all women wanted to get clean and several described strategies to reduce their drug consumption or frequency of injecting however only 5 women had attended drug treatment programs in tijuana which they described as unsanitary strict involuntary and overly religious four women felt fearful or skeptical of existing programs in mexico because of their poor reputations financial access was a major barrier to drug treatment six women who were interested in starting drug treatment did not know how to afford entrance fees four women had knowledge of a methadone clinic in the zona norte that charged a prohibitive daily fee of these 2 women ultimately found longterm methadone treatment to be unaffordable one woman described purchasing methadone once a week or less depending on how much money she could save postdeportation emotions nine women described feeling lonely and sad following their most recent deportation often because they were separated from children and other family members in the united states and elsewhere in mexico several women discussed losing everything as exemplified by a woman who was deported 10 years prior to the interview and was unable to return to the united states i felt alone i felt abandoned … before my deportation i did use drugs but not like right now … i had my house my children my children were young i still have my children but they are older now married … well the deportation affected me a lot since in the past i did not use drugs on the street i feel humiliated women also believed that they had been rejected by family members in the united states and reported feeling ashamed about their current lives and struggles with drug dependence i mean right now i havent seen my family in about a year already because my habit is getting too much you know and i dont want them to see me like this because i dont want them to lose the little respect they still have for me you know and thats why i dont want to bring them here they want to come and live with me but no no no no i tell them no im not ready for you guys yet women described wanting to discontinue sex work although supporting themselves was perceived to be much more difficult in tijuana than in the united states one participant characterized life in mexico as a daily struggle to earn enough money for food and drugs two respondents mentioned their desire for a stable routine although they did not believe they could achieve such stability without help one woman described her hope to find a good man who could help her get a job get clean and live in a house discussion our exploratory study which was guided by a riskenvironment framework provides an important characterization of the range of migration and drug use experiences physical and social vulnerabilities and hiv risk factors among women who are deported from the united states to mexico we identified several key themes relating to the social and physical environments that influence womens drug abuse and engagement in other risk behaviors for hiv transmission overall women described that social networks influenced their initial drug use in the united states which was followed by escalating drug abuse incarceration and eventual deportation to mexico key themes supported the notion of heightened risk environments following deportation including greater financial and physical insecurity increasing drug dependence emotional distress and lack of access to drug treatment and other physical and mental health services overall we found that deported drugusing women in tijuana reported extensive experiences with us migration drug use incarceration immigration detention and deportation previous studies have found drug use among mexican american adolescents and young adults to be associated with the americanization process particularly among young women with high levels of acculturation most women in our study immigrated involuntarily to the united states as minors and thus had little or no exposure to drugs in mexico mimicking druginitiation trends among adolescents born in the united states women began experimenting with drugs with friends and family members during their middleand high school years in our sample all women became heavy drug users by early adulthood while living in the united states in addition to exposure to us culture the social and physical risk environments of womens lives in the united states facilitated their drug initiation and continued use our study findings support arguments by valdez and coauthors that culturally relevant theories of social networks and drug use must consider the influence of family members in addition to that of peers and sexual partners within social networks our study supports previous findings that characteristics such as familismo and collectivismo can influence behaviors within druginvolved mexican american families women in our study also described supplementing their familys financial support by engaging in criminal activities in the united states including drug selling theft and occasional sex work womens us social networks might have encouraged or accepted these criminal activities however exchanging sex for drugs could simultaneously increase autonomy from families and traditional gender roles suggesting complex relationships between social and economic influences on womens drug abuse in the united states womens legal problems relating to drug abuse were often described as the primary causes of their deportations women developed extensive criminal records in the united states often starting in adolescence and resulting in lengthy periods of incarceration and detention drug use continued during incarceration but injection behaviors were rare and some women described getting clean during these periods of their lives following deportation women described struggling with drug dependence and quickly relapsing into drug abuse and other risky behaviors these findings are consistent with research on the economic social and drugrelated challenges that incarcerated drugusing women face when released into communities where they lack social support and financial opportunities the experiences of women in our sample support arguments that the us criminal justice system needs evidencebased drug treatment services for minority women including drug treatment and other health and social programs for parolees reentering communities our findings suggest that women could have benefitted from sustained drug treatment services in us prisonsdetention centers and following their deportations however none of our respondents had accessed drug treatment or other reentry services in the united states or mexico the womens stories highlight the need for programs to recognize the multiple risk environments that deportees experience and identify ways to integrate or reintegrate deported women into mexican communities it is unsurprising that women described postdeportation life in tijuana as being more difficult uncertain and dangerous than in the united states because many of the respondents were unfamiliar with tijuana or mexico before deportation despite the lack of programs for return migrants and deportees globally in addition to drug treatment we learned from the women that they could benefit from services to help them cope with their emotional distress and physical and financial insecurity following deportation participants in a qualitative study of traumatized refugees in switzerland held positive views of medical treatment and expected that they would benefit from services to help them cope with distress women in our sample also lacked formal economic opportunities and social connections following deportation highlighting a need for social reentry programs for return migrants for example mexican migrant and deportee programs could systematically provide deported women with assistance in locating affordable housing and obtaining identification cards necessary for securing formal employment access to legal employment opportunities might be particularly useful for deported drugusing women because migrants in tijuana and other regions of mexico have reported substantial migrationand drugrelated stigma and exclusion from communities into which they enter finally programs for deported drugusing women could also include spanishlanguage education assistance navigating financial and legal institutions in mexico and the development of positive social networks our data illustrate multiple overlapping social and structural vulnerabilities to hiv and other physical and mental health concerns experienced by deported women overall we found that women in our sample experienced heightened vulnerability to hiv in their postdeportation risk environments because of their disadvantaged status as parolees involuntary return migrants idus with significant drug dependence and women who trade sex for money or drugs an additional source of hiv vulnerability might result from the release of deportees in an international border region which rhodes and coauthors described as including increased population movement drug trade and transport social disruption created by language and economic difficulties exploitation fear of authority and mixing of economically and socially disadvantaged populations for women being released late in the evening in a dynamic border region might result in physical and sexual violence that further contributes to their vulnerable status and marginalization over the long term furthermore although women in our sample did not specifically remark on the recent drug violence in mexico more than 34000 people have died as a result of mexicos drug conflict since december 2006 suggesting important impacts of violence on mexican communities the social and structural factors of the postdeportation risk environment warrant additional research so that public health resources can be efficiently directed toward services that serve vulnerable deportees and other return migrants our exploratory study findings must be interpreted in light of the following limitations first our data on migration deportation and drug use were based on selfreport and could have been affected by recall bias we asked participants to focus on their most recent deportation because many women had lengthy migration histories second we selected participants based on selfreported deportation and cannot confirm actual us removal events third the shame and fear regarding certain experiences could cause social desirability bias or a reluctance to report certain events fourth we did not specifically inquire about alcohol use and believe that additional research is needed finally the small number of women in the prospective study who reported deportation and could be located limited our sample size to 12 women although theoretically data saturation can be achieved within 12 interviews the objective of our exploratory study was to describe the range of experiences of a highly vulnerable and understudied population we believe that the 12 womens stories provide a powerful basis for future investigation of risk environments within migration and deportation trajectories although we give examples of potential services for return migrants in mexicous border cities additional research with a larger sample is needed to develop concrete policy and programmatic recommendations conclusion we found that deported drugusing women in tijuana mexico have complex migration and drug use trajectories special efforts are needed to help these women avoid or cope with the negative health and social consequences of involuntary return migration a multitude of factors contribute to the unique postdeportation risk environments of deported drugusing women including their injection drug use and drug dependence release from incarceration lack of social and economic resources unfamiliarity with the postdeportation society stigma and policing practices gender and engagement in sex trade our study findings indicate that binational coordination is needed to help deported women resettle in mexico especially when they emigrated involuntarily are unfamiliar with the country to which they are returning and are struggling with drug dependence and relapse women could benefit from assistance in accessing quality drug treatment services locating safe and affordable housing reestablishing citizenship and securing employment additional research is urgently needed to help understand how such programs could help reduce vulnerabilities to hiv while improving the general health of deported migrants and their sexual and drug using partners in the usmexico border region and the communities in which they reside

deportation from the united states for drug offenses is common yet the consequences of deportation for women drug users are poorly documented in 2008 in tijuana mexico we conducted an exploratory qualitative study of migration deportation and drug abuse by interviewing 12 mexican injectiondrugusing women reporting us deportation women reported heavy drug use before and after deportation but greater financial instability and physical danger following deportation than when in the united states we identified an unmet need for health and social services among deported drugusing women including hiv prevention drug treatment physical and mental health services and vocational training binational coordination is needed to help deported women resettle in mexico

introduction groups associated with the extreme right have maintained an online presence for some time 1 2 where dedicated websites have been employed for the purposes of content dissemination and member recruitment recent years have seen increased activity by these groups in social media websites given the potential to access a far wider audience than was previously possible in this paper we present exploratory analysis of the activity of a selection of these groups on twitter where the focus is upon groups of a fascist racist supremacist extreme nationalist or neonazi nature or some combination of these twitters features enable extreme right groups to disseminate hate content with relative ease while also facilitating the formation of communities of users around variants of extreme right ideology message posts by such groups to which access is usually unrestricted are often used to redirect users to content hosted on external websites for example dedicated websites managed by particular groups or content sharing websites such as youtube these posts also assist in the mobilization of participants for subsequent interactions such as offline demonstrations or other offline activities our investigation has found that communities of users associated with extreme right groups are indeed present on twitter the primary objective of this analysis is the detection of such communities within individual countries using network representations of user interactions in this context an interaction is defined as one user mentioning another within a tweet where reciprocal mentions between users can be considered as a dialogue 3 potentially indicating the presence of a stronger relationship for the purpose of this exploratory work we have retrieved twitter data including profile information and posted tweets for a selection of eight countries using a sampling method that requires the identification of sets of core users who are considered to be highly relevant a network representation is extracted for each of these country data sets from which communities of related users are detected having ranked these communities based on their stability we can describe them using the hashtags contained within tweets posted by the member users each such description can then be used in conjunction with manual analysis of the user profiles tweets and external websites to provide an interpretation of the underlying community ideology our secondary objective is the identification of international relationships between certain groups that transcend geopolitical boundaries this involves the analysis of two network representations of the interactions between the core users from the eight country sets using the follower relationships and mentions dialogues it appears that a certain amount of international awareness exists between users based on the follower relationship while mentions interactions indicate stronger relationships where linguistic and geographical proximity are highly influential in section 2 we provide a description of related work based on the online activities of extremist groups the generation of the twitter data sets using profile data and tweets for users from each country of interest is then discussed in section 3 next in section 4 we describe the detection of local extreme right communities within individual countries including the methodology used for network derivation community detection stability ranking and description generation in this exploratory analysis we focus on two case studies using the usa and germany networks where we offer an interpretation of a selection of these communities due to the sensitivity of the subject matter and in the interests of privacy individual users are not identified instead we restrict discussion to known extreme right groups and their affiliates analysis of the international relationships between extreme right groups from the eight countries is presented in section 5 finally the overall conclusions are discussed in section 6 and some suggestions for future work are made related work the online activities of different varieties of extremist groups including those associated with the extreme right have been the subject of a number of studies burris et al 2 used social network analysis to study a network based on the links between a selection of white supremacist websites they found this network to be relatively decentralized with multiple centres of influence while also appearing to be mostly undivided along doctrinal lines similar decentralization and multiple communities were found by chau and xu 4 in their study of networks built from users contributing to hate group and racist blogs they also found that some of these groups exhibited transnational characteristics the potential for online radicalization through exposure to jihadi video content on youtube was investigated by conway and mcinerney 5 a continuation of this work by bermingham et al 6 included network analysis of the associated youtube users where it was suggested that a potentially increased online leadership role may be attributed to users claiming to be women according to centrality network density and average speed of communication sureka et al 7 also studied the activity of extremist users within youtube investigating content properties along with hidden network communities in a similar approach to that of burris et al tateo 8 analyzed groups associated with the italian extreme right using networks based on links between group websites a combination of social network analysis and content analysis methods were used caiani and wagemann 9 studied similar italian groups along with those from the german extreme right they found the german network to be structurally centralized to a greater extent than that of the italian groups a related study by caiani and parenti 10 concluded that spanish extreme right groups do not exploit the internet for the purposes of communication and mobilization to the same degree as other countries the contents of websites belonging to central nodes within russian extreme right networks were analyzed by zuev 11 in their review of the conservative movement in the usa blee and creasap 12 discuss the engagement in online activity as part of an overall mobilization strategy by the more extremist groups within it mcnamee et al 13 analyzed the messages from a number of hate group websites characterizing them using four themes education participation invocation and indictment simi 14 suggested that the apparent decentralization of white supremacist groups according to among other aspects their online activity should not be confused with disorganization or irrelevance as the majority of this related work involved the study of dedicated websites managed by extreme right groups we felt that an analysis of their activity in social media would complement this by providing additional insight into the overall online presence of these groups data retrieval with user curation twitter data was collected to facilitate the analysis of contemporary activity by extreme right groups as the hypothesis was that extreme right communities within social media would tend to be relatively smaller than mainstream communities a form of snowball sampling was applied rather than using a random sampling approach one of the objectives of this analysis was the detection of extreme right communities within individual countries given this we used the curation method as proposed by greene et al 15 to generate core sets of relevant user accounts one set per country of interest this involved the initial identification of country seed user sets where the user accounts within these seed sets were chosen based on a number of criteria prior knowledge of extreme right groups informed the selection of countries of interest following the bootstrapping phase the core sets were expanded over a number of iterations based on manual analysis of the users proposed in the recommendation phases a selection of recommended users were added to the core sets using the following criteria  relevant profiles for example those containing references to known groups or employing extreme right symbols  recent tweet activity  similar youtube user account profiles  follower relationships with known relevant users  users with selfcurated lists containing relevant users  extreme right media accounts for example record labels online music stores radio stations concert organisers etc a number of recommended users were also ignored such as inactive users or those that were not deemed to be related to the extreme right these included traditional conservative users nonconformistsantiestablishment users considered to be leftwing and conspiracy theorists as the focus of the analysis was on extreme right groups higherprofile politicians or political parties were ignored for the most part with a minor number of these users included where it was felt that there was a close association with relevant users although expansion of the core sets using this criteria required a certain amount of subjectivity it is felt that this was acceptable given that the requirement was to identify a relatively small number of relevant user accounts and relevance is often immediately evident from manual profile analysis a major obstacle was the language barrier as the use of online translation tools were not always helpful in the case of ambiguous profiles in such cases where the relevance of a user profile was inconclusive the user was ignored although this leads to a disparity in core set size for example spain and germany have a relatively larger number of users core set size does not necessarily influence the size of the communities detected within the generated networks as demonstrated later in the case study sections profile data including followers friends tweets and list memberships were retrieved for each of the core users as limited by the current twitter api restrictions the bootstrap process also retrieves a selection of profile data of those users having a follower relationship with a core user in order to address possible incompleteness additional profile data was also retrieved for any users having a reciprocal follower relationship with more than one core user to produce the final data sets for analysis as the twitter follower relationship tends to exhibit lower reciprocity than other social networking sites 16 the understanding was that this action would be largely isolated to those users having a relatively stronger relationship with core users having retrieved the user data from twitter the interactions between users within the individual country sets were analyzed with the objective of detecting communities of related users at the country level an interaction is defined as one user mentioning another with the inclusion of within a tweet where reciprocal mentions between users can be considered as a dialogue 3 thus potentially indicating the presence of a stronger relationship a network is created with n nodes representing users and undirected weighted edges representing reciprocal mentions between pairs of users with weights based on the number of mentions occurrences currently all mentions occurrences are considered rather than selecting those from a specific time period any connected components of size 10 are filtered at this point we use the method of greene et al 17 which is a variant of the recent work by lancichinetti fortunato 18 to generate a set of stable consensus communities from a reciprocal mentions network where 100 runs of the oslom algorithm 19 are used to generate the consensus communities in this analysis we are primarily concerned with the detection of the most significant communities with the strongest signals in the network therefore the consensus communities are ranked based on the stability of their members with respect to the corresponding consensus matrix we employ the widelyused adjustment technique introduced by 20 to correct for chance agreement correctedstability stabilityexpectedstability 1expectedstability a value close to 1 will indicate that c is a highlystable community as higher values of the threshold parameter τ used with the consensus method result in sparser consensus networks and having tested with values of τ in the range 0 1 0 8 we selected τ 0 5 as a compromise between node retention and more stable communities finally community descriptions are generated using a tfidf vector for each community where the terms are hashtags contained within tweets posted by users within the community a description consists of the top ten hashtag terms ranked using their tfidf values case study usa a reciprocal mentions network was created for the usa core set and associated data consisting of 835 nodes and 2501 edges where 29 of the original 32 core set nodes were present the consensus communities were then generated using the methodology described earlier the consensus network generated with threshold τ 0 5 consisted of 672 nodes and 6876 edges fiftyfive communities were detected and a selection of relevant communities having high stability scores can be found in table 2 community a would appear to be national socialistwhite power in nature with the appearance of hashtags such as aryan thewhiterace wpww masterrace and nazi an analysis of the users and associated profiles finds references to the american nazi party along with other related terms such as 14 and 88 in user names there are also references to skinhead groups including a website where related media and merchandise can be found for sale users appear to be mostly from the usa although a small number of european users are also present references to the london riots of 2011 are also made within tweets where blame has been apportioned to nonwhites pipa refers to the protect ip act which appears to be a shared concern among such groups with respect to potential curbs to civil liberties some similar white power themes appear in community b whose description also includes wpww although they would appear to be more subtle than those of community a an analysis of the user profiles finds a certain number of north american white power users with some similar references as community a albeit on a smaller scale one of the core users promoting a radio station website could be considered influential here the trayvontruth and treyvon hashtags refer to the recent fatal shooting in florida of trayvon martin a 17yearold africanamerican teenager it appears that this story is being used to propagate a message of alleged persecution against whites references to tcot and gop can also be seen indicating the presence of more traditional conservative users however this does not necessarily point to any official link between these groups the appearance of the sopa hashtag is most likely analogous to that of pipa in community as description the users in community c form quite a large north american community which is primarily white power oriented as can be seen from the frequent occurrences of wpww among the description hashtags along with rahowa there are many national socialist references within the user profiles and as with community a many user names containing 14 and 88 in a similar fashion to community b an external white power radio station website seems to be influential here which correlates with some of the hashtags such as wpradio contest and wpwwgiveaway most of the users in community d appear to be connected with a number of white rabbit websites which allege the existence of white genocide here antiracist refers to the associated slogan antiracist is just a code word for antiwhite this community also contains one liberal user with a highlevel of posting activity who has interacted with a certain number of the other white power users communities e and f are interesting as neither community contains a single user from the usa core set however an analysis of the users in both communities shows that reciprocal follower relationships with usa users are common the users in community e appear to be white south africans with some profiles containing racist and national socialist references many tweets from these users relate to perceived cultural threats from black south africans that are often retweeted by international users almost all of the description hashtags are related to south africa such as anc and afrikaners community f consists mostly of users associated with the english defence league a group opposed to the alleged spread of militant islamism within the uk hashtags such as rochdale brighton luton and dewsbury are uk locations most likely indicating various edl subgroups while uaf refers to the unite against fascism group a staunch opponent of the edl although both communities e and f would appear to have a certain amount of awareness and interaction with other nationalities as indicated by the follower relationships the majority of interaction seems to be at the local level if mentions interactions are assumed to represent stronger relationships a reciprocal mentions network was created for the germany core set and associated data consisting of 247 nodes and 646 edges where 46 of the original 53 core set nodes were present the consensus communities were then generated using the methodology described earlier the consensus network generated with threshold τ 0 5 consisted of 167 nodes and 799 edges eighteen communities were detected and a selection of relevant communities having high stability scores can be found in table 3 an analysis of the users in community a finds them to be primarily associated with the town of geithain near leipzig in sachsen this can also be seen from hashtags such as geithainer geithain and gha along with the leipzigrelated hashtag lvz users belonging to various extreme right groupings are present such as freies netz and the junge nationaldemokraten references to aktionsbüros are also made the bollywood hashtag refers to a geithain business that has been subjected to repeated attacks by neonazis while unsterblichen refers to antidemocratic flashmob marches that have been occurring sporadically throughout germany these protests are linked to spreelichter an extreme right group from südbrandenburg that was recently banned by the local authorities 1 they used social media to propagate national socialistrelated material including professionalquality videos of the marches themselves case study germany 1 like community a the users in community b appear to be mostly related to a geographical location namely the federal state of thüringen where the towns of altenburg gera and saalfeld can be found most of the users are associated with freies netz with a number from other parts of germany the rfd hashtag refers to rock für deutschland a concert organised by the npd in thüringen which will take place in july 2012 other relevant hashtags include apw and 13februar a reference to the bombing of dresden which began on february 13 1945 this event is usually commemorated by extreme right groups each year also relevant is volkstod which refers to the perceived destruction of german people and traditions since world war ii often mentioned in spreelichterrelated content the binding theme of community c is related to the 130abschaffen hashtag which refers to demands for the abolition of a paragraph in the german penal code associated with the criminalization of incitement to hatred along with denial andor justification of the holocaust and national socialist rule although other relevant hashtags such as apw volkstod and spreelichter are present some of the users have been inactive for some time and it appears that these may have been replaced with new accounts other interesting hashtags are mobilisierungsvideo and unibrennt where the latter refers to a student protest movement this movement appears to be unrelated but the use of this hashtag by known extreme right users may be strategic as it could ensure the propagation of tweets to a wider audience community d is the largest of the selected consensus communities and contains a wide range of users from groups such as aktionsbürosbündnis freies netz junge nationaldemokraten and spreelichterunsterblichen these users would appear to be quite active with many apwrelated tweets along with tweets containing urls linking to content hosted on external websites such as youtube or other dedicated websites the altermedia hashtag refers to a collective of politicallyincorrectnationalistoriented news websites where the german website contains content such as spreelichter articles and a section related to the npd guben is a town in the state of brandenburg on the border between germany and poland and its many occurrences may indicate a geographical connection with brandenburg particularly as spreelichter was also based in this state it also appears that some of the users here are replacement accounts for older versions that are members of community c finally as with the usa case study a community without any core set users has been selected for analysis in this case all of the users in community e appear to be related to the npd the hashtags bamberg and ruhrgebiet refer to locations within germany and the presence of other hashtags such as flugblatt and rat along with separate analysis of the tweet content may indicate mobilization prior to elections separately the türke hashtag refers to people of turkish descent and is often used in tweets from community e users alleging the involvement of such people in criminal activity a common accusation by german extreme right groups similarly stolberg refers to the town where a german teenager was killed by nongermans in 2008 which is also the focus of an annual extreme right commemoration we also analyzed the international relationships between the various groups within the data sets based on the interactions between the core users from the eight country sets two types of undirected network were generated a followers network consisting of user nodes and unweighted edges representing follower links between users and a mentions network where edges were created for each instance of a user mentioning another with the inclusion of within a tweet as with the countrybased networks only reciprocal edges were used in order to capture stronger relationships all stored follower and mentions instances were included and connected components of size 10 were filtered international follower awareness the international followers network can be seen in fig 3 as might be expected most of the follower relationships are between users from the same country although a certain number of international relationships are identifiable it would appear that linguistic and geographical proximity is influential here for example there appears to be a close relationship between the spanish and italian users with strong connections also between the uk and usa similar behaviour with respect to social ties in twitter has been identified by takhteyev et al 21 and kulshrestha et al 22 however there appear to be some exceptions to the influence of geographical proximity most notably swedish and italian users that are not colocated with their respective country nodes in both cases the majority of tweets from these users are in english which presumably ensures a wider audience the former user is a swedish representative of a panscandinavian group espousing national socialist ideals who appears to be interacting with many international users particularly from the usa this user has been increasingly active in recent months the italian user is a national socialist whose tweets often contain urls to music or video content hosted on external websites but it is unclear if a direct association exists with any particular group from an analysis of other central nodes in the network it would seem that those involved in the dissemination of material with the use of external urls or media representatives such as extreme right news websites and radio stations are attempting to raise awareness amongst a variety of international followers this is especially the case when the english language is used international dialogue the followerbased relationship between international users could be considered as passive when compared with that of the mentionsbased networks where such interactions can represent actual dialogue between users the mentions network in fig 4 can be seen to be somewhat smaller than the corresponding followers network in fig 3 for example none of the greek core users are present apart from this the network has a similar structure to that of the followers network in that most interaction occurs within individual countrybased communities connections between these communities do exist but are fewer than in the followers network the influence of linguistic proximity appears to take precedence here with the use of english playing a major role as mentioned in the previous section for example a relatively large number of connections remain present between the uk and usa users in the case of the german community while the followers network contains a number of connections with other international users this has now been reduced to a single connection with a user acting as an englishlanguage twitter channel for a swedish nationalist group similarly the swedish user colocated with the usa community is the same user as that in the followers network who appears to be involved in many englishbased dialogues with international users it should also be emphasized at this point that this analysis does not necessarily provide extensive coverage of the international relationships between all extreme right groups that are active on twitter as it is possible that the data retrieved from twitter is incomplete the objective is to demonstrate the existence of these relationships by means of an exploratory analysis this caveat also applies to the countrybased community analysis conclusions and future work extreme right groups have become increasingly active in social media websites such as twitter in recent years we have presented an exploratory analysis of the activity of a selection of such groups using network representations based on reciprocal follower and mentions interactions the existence of stable communities of associated users within individual countries has been demonstrated and we have also identified international relationships between certain groups across geopolitical boundaries although a certain awareness exists between users based on the follower relationship it would appear that mentions interactions indicate stronger relationships where linguistic and geographical proximity are highly influential in particular the use of the english language in relation to this media user accounts such as those associated with extreme right news websites and radio stations along with external websites hosting content such as music or video are a popular mechanism for the dissemination of ideals among users from a variety of disparate groups although a certain number of the detected communities can be associated with a specific extreme right group or ideology this is more ambiguous in other cases where communities appear to contain members from a variety of known groups this may be a consequence of incompleteness in the data sets retrieved for this analysis it may also be related to variances in twitter usage patterns in different countries for example the use of twitter tends to be more prevalent in the uk and the usa than in other countries such as germany2 the laws of different countries should also be taken into consideration as an opinion that may be legally voiced in one country may not be permitted in another particularly within the context of extreme right ideals however it may also be the case that social media websites are merely used by such groups to disseminate related material to a wider audience with the majority of subsequent interaction occurring elsewhere in future work we will address the issue of incompleteness in the data sets including the current disparity in core set sizes local community analysis of countries other than the usa and germany will be performed and we will collect data beyond the eight countries used in this analysis we also plan to study the temporal properties of these networks which will provide insight into the evolution of extreme right communities over time

many extreme right groups have had an online presence for some time through the use of dedicated websites this has been accompanied by increased activity in social media websites in recent years which may enable the dissemination of extreme right content to a wider audience in this paper we present exploratory analysis of the activity of a selection of such groups on twitter using network representations based on reciprocal follower and mentions interactions we find that stable communities of related users are present within individual country networks where these communities are usually associated with variants of extreme right ideology furthermore we also identify the presence of international relationships between certain groups across geopolitical boundaries

background weight gain during pregnancy is one of the main markers of physiological and somatic changes that reflect fetal development and growth 12 however insufficient or excessive gestational weight gain can threaten maternal and child health 34 contributing to the presence of unfavorable gestational outcomes particularly in women classified as having highrisk pregnancies 5 as determinants of maternal health sociodemographic conditions such as limited access to health care 6 7 8 also play an important role during pregnancy 9 unfavorable aspects such as less education the absence of paid work and a low family income are described in the literature as social determinants associated with insufficient or excessive gwg 29 additionally the evidence supports the hypothesis that household food insecurity can be a particularly important barrier to maintaining health during pregnancy 10 studies performed to assess the effects of hfi on weight gain during pregnancy observed that hfi was related to both the possibility of insufficient weight gain 11 and metabolic adaptations that increase the risk of obesity 12 hfi is defined as the lack of secure access to sufficient amounts of safe and nutritious food for normal growth and development and an active and healthy life 13 psychometric scales contribute to the assessment of hfi which can be measured based on concerns about a lack of food to the restriction and experience of hunger in cases of more severe limitations 1415 it is important to note that women are more vulnerable to hfi the global assessment of the impact of hfi showed that women were approximately 27 more likely to be exposed to more severe hfi than men 16 in brazil data from the last family budget survey revealed a vulnerability and limited access to food in households headed by women approximately 52 of whom were affected by severe hfi 17 a similar finding was reported in the study by lignani et al which evaluated a model of hfi determinants according to the authors when the head of the family was female there was a greater probability of having occupations with lower income levels 18 the relationship between women and hfi is the result of unequal access to and control of financial resources and unstable incomes affecting the acquisition of food 19 additionally the main causes of hfi for women have been revealed by different sources such as poverty low education being out of the labor market a large family the number of children under five low food diversity and a low frequency of daily meals 16 during pregnancy hfi can contribute to nutritional problems related to deficiencies in food intake during a stage of a womans life with a higher demand for nutrients for fetal growth and development hfi is a potential factor associated with the health risks of pregnant women and can contribute to the aggravation of disorders associated with gestational risk such as anemia and gestational diabetes mellitus 1012 a systematic literature review showed that the associations between hfi and the health of pregnant women were related to poor dietary quality dietary diversity and inadequate nutrient intake moreover hfi was related to higher risks of depression and anxiety 20 although hfi is an important measure to be evaluated during pregnancy few studies have explored its effects on the adequacy of gwg in atrisk women during pregnancy the investigation of this relationship may assist in the identification of pregnant women exposed to unfavorable social health conditions and development of interventions to reduce the pregnancy risk related to insufficient gwg and excessive gwg this study aimed to verify the association of hfi and unfavorable sociodemographic characteristics with total gwg inadequacy in highrisk pregnant women methods study design this prospective cohort study was carried out with pregnant women from a maternity and prenatal unit of a public university hospital located in the metropolitan region of rio de janeiro the uh has a coverage area comprising seven municipalities in the metropolitan region of the state of rio de janeiro 21 comparing the characteristics of these municipalities it is possible to perceive different sociodemographic conditions in 2013 the evaluation of the municipal human development index for example indicated that in the municipality where the uh is located the idhm was 0837 the highest index among the seven municipalities on the other hand among the municipalities served by the uh the lowest idhm rate was 0654 the idhm is a number from 0 to 1 where 1 represents greater human development in the locality and the measure is composed of three dimensions longevity income and education in the municipality where the uh is located life expectancy at birth was 762 years the average per capita monthly income in real was r 2000 and among the population over 25 26 were illiterate and 337 had the highest level of education in contrast the municipality with the lowest idhm had a life expectancy at birth of 726 years with an average per capita income of r 440 in addition 111 of the population was illiterate and only 37 had the highest level of education 22 this information indicates the differences and inequalities among pregnant women attending uh in brazil all pregnant women are entitled to access prenatal care in the unified health system by the primary health care service at the phc pregnant women are monitored periodically and when any pregnancy risk is identified and diagnosed they are referred by the national regulation system 1 to a more complex prenatal service the classification of gestational risk is a dynamic process that identifies pregnant women who need interventions that require greater assistance and technological resources and more complex care according to their risk potential health problems or degree of suffering 6 the gestational risk factors considered for referral to highrisk prenatal care may be related to previous clinical conditions factors related to their previous reproductive history and factors related to the current pregnancy 6 the uh prenatal and maternity service specifically serves pregnant women referred and classified as having some gestational risk pregnant women are referred to a screening consultation to confirm the diagnosis of pregnancy risk nonconfirmation indicates the counterreference that is the return of these pregnant women to the primary phc whereas confirmation of gestational risk indicates continuity of care in the most complex prenatal care units in this study prenatal and maternity ambulatory care was performed at the uh all of the referred pregnant women who had a proven gestational risk and remained in the uh were approached and those who consented to participate in our study were included in the sample figure 1 shows the flow of care of these pregnant women from the identification of gestational risk in phc to the possible outcomes in prenatal care regarding the diagnosis of gestational risk until delivery at the uh maternity ward the data collection for this study was carried out between august 2017 and october 2019 for the sample selection in addition to the pregnant women presenting with some confirmed gestational risk the eligibility criteria were age ≥18 years a single pregnancy and an expected delivery through october 2019 this study complies with the declaration of helsinki 23 this study was approved by the research ethics committee of the federal university of rio de janeiro variables included in this study gestational weight gain the total gwg was calculated as the difference between the final weight and the initial weight the gwg is a measure for assessing and monitoring the health of pregnant women carried out by health professionals in several prenatal units hospitals and maternity units 6 the recommendation of the total gwg of the institute of medicine was adopted so it was necessary to calculate the initial body mass index by the weight and height ratio 624 height and weight measurements at the beginning of pregnancy were collected from the pregnant womans health booklet a document used in prenatal care for monitoring and providing health guidelines during pregnancy these were measured during the prenatal consultation at the phc of origin of the pregnant women most of the pregnant women included in this sample had these measures reported in the first gestational trimester an opportune time to check their initial weight 6 the first prenatal consultation of the uh for approximately 76 of the pregnant women occurred after the first gestational trimester a characteristic that was expected since some of the risk factors appear or are diagnosed only after the first gestational trimester 6 in this study we chose to use the weight measured in the first trimester of pregnancy and recorded in the pregnant womans health booklet as the initial weight thus even if the consultation of the pregnant woman at uh took place after the first trimester of pregnancy we considered the initial weight measurements measured at phc until the 13th week of pregnancy initial bmi during the first prenatal consultation at uh an interview was carried out to apply the data collection questionnaire at this moment the pregnant womans health booklet was requested to verify the initial anthropometric measurements of height and weight and they were considered to estimate the initial bmi 6 for pregnant women who started prenatal care at the phc after the first gestational trimester and without data about the initial weight registered in the pregnant womans health booklet selfreported initial anthropometric measurements were requested from them and considered in the analyses this assessment considers the premise that the measurement of the initial weight represents the weight measured in a period of up to two months before pregnancy and during pregnancy at the limit of 13 weeks of gestation 6 1 sisreg is a virtual management system of the ministry of health that manages from the basic and specialized outpatient network to hospital and hospitalization at the levels municipal state federal including private services of the unified health system and university students seeking greater control flow and optimization of the use of resources in order to guarantee the humanization of services to determine the final weight the medical records of the pregnant woman in the maternity ward were consulted the final weight was considered to be the weight measurement at the last prenatal consultation at uh two weeks before the date of delivery in the absence of information about this measure in the medical record the women were asked about it in the maternity ward after delivery and the selfreported final weight was considered the initial bmi was categorized as follows low weight normal weight overweight and obese the total gwg was classified into three categories of weight gain according to the ranges established for the initial bmi low weight 125180 kg of total gwg normal 1101600 kg of total gwg overweight 70115 kg of total gwg and obese 5090 kg of total gwg 17 the total gwg was adjusted according to the gestational age as a measure of the final weight household food insecurity hfi was estimated based on the brazilian household food insecurity measurement scale the ebia is a validated instrument for the brazilian population that investigates the dimensions of access to food through the perception of a family member regarding the lack of financial resources available for the purchase of food 14 this psychometric scale comprises 14 items and categorizes households according to hfi exposure ranging from concern about the lack of food at home and insufficient quality of meals due to a lack of food and hunger the hfi severity levels are measured in the ebia by the sum of affirmative responses to each item on the scale the absence of positive responses characterizes the condition of household food security which indicates that the respondent has no concern or perception of income limitations regarding food purchase and access the cutoff points classify the hfi fig 1 flowchart for selecting the sample of pregnant women at risk in a university hospital metropolitan area of rio de janeiro brazil 2019 into three levels mild hfi moderate hfi and severe hfi more details about ebia have been described in the literature 14 25 26 27 in this study the levels of moderate hfi severe hfi were considered in the same category sociodemographic and health for pregnancy variables sociodemographic and gestational characteristics were included to describe the sample and to investigate social vulnerabilities that could contribute to health inequalities and negatively affect gwg maternal age in years was investigated and categorized considering that pregnant women aged 35 years tend to have more unfavorable gestational outcomes 6 the level of education was classified into three categories 9 years 915 years and 15 years despite the lowest level of education being a risk factor for pregnant women 6 the categories established in this study considered the highest level of education of the sample of pregnant women and we classified them by using a category of less education as incomplete primary education schooling was described in association with health conditions and gwg 2829 unsafe marital relationships also compromise the health of pregnant women 6 the variable marital status considers the impact of living alone and the difficulties faced by single women and mothers in accessing material and financial resources due to gender inequality 17 in this evaluation the categories were established 28 drinking water consumption was studied as a gestational risk factor reflecting the unfavorable environmental conditions to which pregnant women are exposed 6 data on the raceethnicity variable were selfdeclared and evaluated in the categories of white or blackmixed race considering the vulnerability that racial inequality confers on the health of populations 3031 family income was investigated in relation to the minimum wage and two categories were studied the minimum wage is the minimum amount regulated by law for paid work 32 taking 2018 as a reference the annual value for the minimum wage in brazil in the current currency was r 954 which corresponds in this period to usd 2614 3334 family income is an important measure to investigate access to resources such as the purchase of food by families 35 in relation to health the following information was investigated as determinants of gwg the number of prenatal consultations was considered in categories established based on the recommendation of 8 or more consultations for the monitoring and health care of pregnant women and babies including the identification of risk factors and monitoring of gwg 6 the number of previous pregnancies was obtained as studies indicate the highest risk of excessive gwg in multiparous pregnant women 283036 gestational age at the time of delivery was also obtained initial bmi 24 was assessed in three categories the decision to sum the categories of overweight bmi and obese bmi was due to the sample size the consumption of alcoholic beverages and smoking during pregnancy were also investigated in relation to gwg 636 with the exception of the variable total number of prenatal consultations and gestational age at delivery which were investigated at the maternity hospital all of the other data were obtained at the first consultation of the pregnant woman at the uh statistical analysis we estimated the proportions and confidence intervals to describe the study variables in the first step the chisquare test was used to compare sociodemographic hfi and pregnancy characteristics between gwg categories the variables with a level of significance in this first analysis defined as p 020 were included in the multivariate analysis the decision to adopt a more conservative level of statistical significance followed the recommendations used in the literature 3738 in the second step a multinomial regression model was used to verify the variables associated with gwg we assigned the adequacy gwg category as a reference in relation to the inadequate gwg categories the data are expressed as odds ratios and 95 cis variables that in the bivariate analysis were associated with gwg with a significance level of up to 20 were considered in the adjusted model in the final model the level of significance was defined as a p value 005 all data processing and analysis were performed using the stata statistical package 39 results during the reference period of this study 286 pregnant women were referred to their first consultation in the obstetrics sector of the uh prenatal clinic and 117 of them were ineligible the final sample included 169 women with an average age of 302 years and their raceethnicity was predominantly blackmixedrace most were married or lived in a stable relationship had completed high school and had a family income ≤ twice the minimum wage regarding the gestational profile most women attended at least eight prenatal consultations and did not consume alcohol or smoke during pregnancy more than half of the women included in this study were exposed to some level of hfi considering their initial bmi there was a high proportion of pregnant women with obesity inadequate total gwg was found in most women 47 of women had excessive gwg and approximately 28 of pregnant women had insufficient gwg the categories of gestational weight gain were correlated with the following variables maternal age marital status educational level smoking and alcohol consumption during pregnancy number of prenatal visits weeks gestation at delivery and household fi insufficient gwg was more common in women with a lower educational level married marital status age up to 35 years and those who reported alcohol beverages consumption and cigarettes in turn excessive gwg was more common in women over 35 years old with a single marital status and with a higher educational level additionally more common were the number of prenatal consultations ≤ 8 and a gestational age at delivery greater than 40 weeks gestation for women with excessive gwg regarding fi exposure to moderatesevere fi was more common for women with both insufficient gwg and excessive gwg table 3 presents the unadjusted and adjusted multinomial logistic regression in the bivariate analysis more years of schooling and the womans age were considered protective factors for insufficient gwg living without a partner being a current smoker and having 8 total prenatal consultations were considered factors that increased the or of insufficient gwg an increased risk for insufficient gwg and excessive gwg was observed with an increase in the number of gestational weeks at delivery hfi was not related to gwg after adjusting the model only the educational level of the pregnant woman was significantly and inversely associated with insufficient gwg thus the higher the education level of the pregnant woman was the lower the risk of inadequate gwg was discussion our study showed that inadequate gwg was not associated with exposure to fi during pregnancy in this sample of women with highrisk pregnancies however after assessing the sociodemographic and health conditions of pregnant women a higher level of education was a protective factor against insufficient gwg this study demonstrated a higher prevalence of women with excessive gwg an analysis of secondary data from multicenter studies in the united states involving 8293 women showed that 73 had excessive gwg corresponding to approximately three in four women 40 zhao et al 4 identified approximately 50 of pregnant women with excessive gwg in a study conducted in china and 152 had insufficient gwg in brazil campos et al 41 evaluated the adequacy of gwg among pregnant women in the northern region of the country and observed a prevalence of excessive gwg in almost half of the sample and insufficient gwg in 19 of women a similar result was observed for pregnant women in rio de janeiro according to the authors almost 50 of women evaluated had excessive gwg and less than 30 had adequate gwg 42 a direct determinant of gwg is the initial bmi 14 in this study no associations were observed between these variables however we observed that more than half of the pregnant women had an initial bmi corresponding to overweight and obesity in contrast a low initial bmi was observed in only 26 of the sample a proportion close to the results of the brazilian food and nutrition surveillance system during 2019 when 25 of adult brazilian women were found to have a low bmi data from the brazilian sisvan also revealed an increase in the prevalence of overweight bmi among women of reproductive age 342 were considered overweight and 297 were obese based on bmi 43 in this study it was also found that more than half of the mothers were exposed to some level of hfi during pregnancy oliveira et al 44 investigated hfi in a group of pregnant women attending phc in northeastern brazil and identified a prevalence of 427 of hfi in the sample a value lower than the result in this study in addition in the present study we opted for the sum of the most severe levels of hfi thus it was observed that 123 of women had limited access to food in terms of quantity and quality and possibly continued to experience hunger this proportion was lower than that reported by marano et al 45 when investigating hfi in pregnant women in two cities in rio de janeiro other studies carried out in brazil evaluating hfi during pregnancy showed significant variations in the prevalence estimated by the ebia depending on the region of the country in studies carried out in the northeastern and southeastern regions of brazil the authors reported a higher prevalence of hfi among pregnant women ranging from 59 to 716 4647 and 378 in southeastern brazil 48 these differences in prevalence are consistent with the distribution of severe hfi in brazil although a higher prevalence of hfi was observed among the women in this study no relationship with gwg adequacy was found few studies have evaluated the relationship between gwg and hfi a metaanalysis identified that pregnant women exposed to home hfi had an increased prevalence of discrepant weight gain both excessive and inadequate weight gain 49 other studies have reported a lack of an association between gwg and hfi as observed by laraia et al 50 according to these authors no significant association was found between hfi and gwg among pregnant women in the united states however the authors observed that the average weight of women with hfi in the study was higher as well as the gwg adequacy rate suggesting hfi as an indicator for excessive gwg 50 in brazil a study of pregnant women in the northeastern region of the country to identify the association among different factors including hfi status and gwg showed no significant association with hfi and the gwg outcome this finding was similar to that of this study 44 the main finding of this study indicates a reduction in the risk of insufficient gwg for women with more years of schooling since pregnant women with access to secondary and higher education were more protected from this level of gwg than women with less than nine years of schooling in the literature a lower risk of insufficient gwg was also associated with higher levels of schooling 51 on the other hand a higher level of education was related to a higher risk of excessive gwg 845 in addition higher education has been described as being associated with a greater likelihood of gwg adequacy 28 and a lower likelihood of excessive gwg 52 pregnant women with less than four years of education had a risk of excessive gwg that was approximately five times greater than that of other pregnant women 53 these findings indicate that the increase in years of schooling may act as a protective factor for gwg in addition the risk associated with low education and a greater propensity for excessive gwg 5455 and insufficient gwg 56 point to the importance of education as a social determinant of health 57 thus understanding that inadequate gwg is a modifiable risk factor and that both excessive and insufficient weight gain during pregnancy can threaten the health of women and their children 58 is important for strengthening health services and factors related to the environment education and health promotion 59 this study has some limitations for the pregnant womans health booklet and height measurements when these measures were not available the selfreported data of the pregnant women were considered in such cases the possibility of biases attributed to overestimation or underestimation of measures must be considered 6061 researchers have corroborated the quality of the measures of weight and height measured by anthropometry versus those obtained by selfreport in populationbased studies for example conde et al compared the measured and reported weight and height measurements of the brazilian population and highlighted that the bmi estimates measured or reported were relatively close in addition a validation study of selfreported measures found that 84 of women who reported their weight and height measurements were categorized appropriately in regards to their bmi classification 62 health behaviors and interventions such as nutritional monitoring possible interactions of the diet to control gestational weight gain and physical exercise during pregnancy were not evaluated in this study however there is some evidence regarding the low impact of these measurements on weight gain during pregnancy 63 the investigation of family income in terms of minimum wages limited the assessment of income in relation to the number of family members conclusion in this population an important factor for gwg is maternal education among the other determinants evaluated and widely discussed in the literature as predictors of gwg additionally a lower level of education of the pregnant women evaluated may have preceded the effects of hfi on its relationship with the gwg of these women with high risks during pregnancy given the risk of inadequate gain during a highrisk pregnancy and given that gwg is a modifiable factor the importance of additional support and health counseling is highlighted particularly nutrition education interventions such as a healthpromoting tool for pregnant women and fetuses particularly for women who are more socially vulnerable and who have low levels of formal education ref 1 ref 1 ref 1 ref 1 ref 1 educational level 9 ref 1 ref 1 ref 1 ref 1 ref 1 ref 1 ref ref 1 ref 1 ref 1 ref 1 ref 1 ref 1 ref ref 1 ref 1 ref 1 ref 1 ref 1 weeks gestation at delivery 40 weeks ref 1 ref 1 ref 1 ref 1 ref 1 ref 1 ref abbreviations bmi body mass index ci confidence intervals ebia brazilian household food insecurity measurement scale gwg gestational weight gain hfi household food insecurity hfs household food security idhm municipal human development index iom institute of medicine or odds ratio phc primary health care r real sisreg national regulation system sisvan brazilian system of food and nutritional surveillance uh university hospital usd united states dollar authors contributions aar participated in the coordination collected and interpreted the data rsc and aar contribute to the study design statistical analysis and writing of the manuscript alpa conceived the idea of the study participated in the coordination and helped in the writing of the manuscript all authors participated in the study design read and approved the final manuscript authors information aar is a student of the graduate program in nutrition institute of nutrition josué de castro federal university of rio de janeiro rio de janeiro brazil alpa professor at the department of clinical nutrition faculty of nutrition emília de jesus ferreiro fluminense federal university rio de janeiro brazil rsc professor at the department of social and applied nutrition institute of nutrition josué de castro federal university of rio de janeiro rio de janeiro brazil competing interests the authors declare that they have no competing interests

background inadequate gestational weight gain gwg is associated with adverse outcomes in maternal and child health and can be enhanced by social inequalities such as lower education and household food insecurity hfi women are more vulnerable to hfi which has been associated with negative health effects for pregnant women during the prenatal and puerperal periods particularly in regard to the aggravation of pregnancy risks this study investigated the association between sociodemographic characteristics and hfi with respect to adequacy of total gwg among women with highrisk pregnancies methods this was a prospective cohort study that evaluated the total gwg of 169 pregnant women the women were seen at a public university hospital in the metropolitan region of rio de janeiro brazil their sociodemographic and gestational characteristics and the brazilian scale of domestic food insecurity were investigated to estimate the total gwg the difference between the patient weight at the last prenatal visit and the initial patient weight was verified with both collected from the medical records of the pregnant women the classification of the total gwg considered the recommendations of the institute of medicine iom 2009 a multinomial logistic regression model assessed the risk odds ratio or and confidence intervals ci 95 of insufficient and excessive gwg with exposure to hfi and other covariates p value 005 results insufficient and excessive gwg were observed in 278 and 479 of the pregnant women respectively more than half of the women 746 had a high education level exposure to mild hfi occurred in 442 of the women after adjustment the hfi was not associated with insufficient or excessive gwg the educational level of women was the only variable significantly associated with a lower risk of gwg insufficiency or 010 95 ci 001089 conclusions in this population higher maternal education was a protective factor against insufficient gwg we highlight the importance of additional health support and counseling for women in the most vulnerable social conditions considering the importance of access to information for reducing health risks

introduction quality of life is one of the emerging concepts in the world it consists of new ideas about the state of the environment happiness housing work material satisfaction and total wellbeing of the population living in the area it is an indicator of good housing and the economic conditions of the human population the most important development factors that influence the quality of life include education health income employment and environment the term high quality of life refers to a high standard of living where people avail themselves of all the basic facilities of life in the form of education health and a peaceful environment it is sustainable when they have a high standard of living a state or condition in a society having no need of other help and capable of fulfilling the needs of the poor furthermore seligman argued that a good quality of life enables people to perform the daily activities of life and attend to physical psychological and social wellbeing it is the capacity to perform different tasks in connection with a person hisher role in the society the physical environment includes quality accommodation and access to public services whereas the social environment contains social networks and level of social support from family members further the socioeconomic factors are the standard of living means and size of wealth at the same time cultural and health factors include age gender class religious tendencies general health and physical mobility of a person the world population of women depends directly or indirectly on men and their quality of life is less compared to men they avail fewer opportunities in all fields of life such as education land property credit health and paid jobs due to their low status in the world around two billion people in the world are considered poor and twothirds of this population are women women have more work hours as compared to men but earn less because 60 of this is unpaid only 1 of total world assets are in womens names additionally women are also far behind men in the field of education approximately ten million girls are out of school compared to boys twothirds of the worlds women are illiterate due to poor economic status less education and ignorance made women the victims of severe health hazards half a million women die during pregnancy and related diseases early marriages further lower their life quality in terms of income education and awareness violent behavior is the other big social problem for women as they face physical sexual and domestic violence gender representation is low in almost all fields of life especially in political institutions it has further restricted women from making required legislation for womens protection equality and better socioeconomic status all these made it extremely difficult for women to excel in the male status and improve the environment for a healthy life moreover the situation of quality of life in the context of health in tribal women has again been affected due to the lack of access to basic health facilities there are few professional doctors and lady health workers which is insufficient for the rest of the federally administered tribal areas due to the extreme level of discrimination against women in tribal society the health facilities are not being accessed and fulfilled properly women cannot make decisions without the consent of men many times the quality of female life is compromised due to a lack of basic health awareness the burden of female household duties combined with reproductive one results in both physical health problems and acute physical problems they also face cultural taboos in the case of consulting doctors they are based on false traditions and religious beliefs consequently high mantle anxiety prevailed in pakistan especially among women mainly due to bad economic conditions and lack of social support the united nations food and agriculture organization reported that women have low calories and protein in the border area of pakistan with afghanistan 56 of the population has food insecurity and health threats according to the government of pakistan housing census federally administered tribal areas face worse hygienic conditions only 10 of the population has adequate access to sanitation in the shape of toilets solid waste disposal and drainage livestock and agriculture are the main income sources of livelihood in tribal areas of pakistan womens involvement in both sectors is more than mens but they always depend upon the male members while doing so women have to do a lot of work both at home and in the fields however this is unpaid and unrecognized they have the capacity to sell milk eggs homemade products preserved vegetables and fruits in the market but could not do so due to purdah and cultural values furthermore federally administered tribal areas are dominating society the majority of women have been victims of patriarchy and feudalism a female child often grows up with learning to obey and serve the males the unequal gender distribution of relations hinders the process of development in fata in fact the social structure and institutions along with different norms and values systems compel women to follow patriarchy women are not allowed to make decisions regarding their basic amenities of life such as education marriage health and other basic rights women are totally excluded from jirga and dont participate in decisionmaking males on the other hand avail all the facilities in jirga women in fata are in worse conditions than the average pakistani female one main problem which is common for women in fata is the security and political situation in fact women in tribal areas have become the victims of double discrimination since the beginning of the colonial era of british rule to successive governments after the creation of pakistan in 1947 under the frontier crime regulation women suffered both from a patriarchybased social system and a law and order situation which made fata a safe haven for insurgents and criminals womens mobility and basic human rights have been further restricted due to deteriorated law and order situation all decisions in fata are made by the older family members in the joint family system they look after all the affairs of human life including the income sources that are jointly distributed the joint family system on the other hand made restrictions on young women in all the important daily affairs which proved to be a disaster for their mobility control over income and participation in decisionmaking moreover the majority of tribal people were of the opinion that they were in favor of womens education and access to better health services however in practice they are found against womens participation in the force the cultural and religious beliefs are extremely strong for women in fata they are considered to be the center of honor which ultimately affects womens mobility human rights and quality of life the women in tribal areas want immediate actions to change the fate of their lives they want constitutional rights that have already been given by the pakistan government to the rest of the countrys women the honor and rights of fata women cannot be improved under the strict fcr and jirga system women in fata not only suffer from a lack of protection under the law but also the victims of militancy and security operations forced marriages honor killing and the exchange of women between tribes and marriages have made women dependent on men many studies reported these as the worst for women in the whole region research question 1 does the unavailability of a strict culture system deteriorate the female quality of life 2 does the amalgamation of religious systems with culture affect the female quality of life methodology universe of study kurram agency was the universe of the study it had three administrative divisions namely lower kurram central kurram and upper kurrram the major tribes living in the kurram agency were turi bangash mangel maqbal ghiligi maso zai and ali shirzai the agency covered a total number of 3380 sq km with total population and household of 448310 and 39435 respectively it was the third largest agency of fata due to the size of the area and population it was not possible to collect data from the entire agency so the data for the present study were collected from the tribe of ali shirzai according to the 1998 population census report the total households of the ali shirzai tribe were 4495 households however for the present study data was collected from 4 randomly selected villages namely tindo wrasta mirbagh and tandoori the selected villages in kuram agency not only represented the pure pashtun culture but also had been the victim of insurgency in fata which ultimately affected the quality of female life particularly sampling procedure and sample size all the households belonging to the ali shirzai tribe were the potential respondents of the study according to the tribal areas 1998 population census report there were 4495 households in the selected villages though a large family size gives better results due to time financial constraints and human resources constraints data were collected from 279 households the sample size was drawn by keeping in the view table designed by sekaran a proportionate sampling procedure was used to select the sample size from each of the selected villages while a lottery method of simple random sampling method was used to pick the samples from each of the selected villages for more details see methods of data collection an interview schedule was designed in the light of the objectives of the study it was pretested in the study area and necessary changes were made to the interview schedule in light of the pilot survey for the collection of information from the potential respondents three females were trained and approached directly respondents of the study in order to make it possible to collect data from them while keeping all ethical considerations in the prior view of the tribe result and discussion univariate analysis culture is a manmade part of the environment pakistan is a dominant society and all the powers are in the hands of males most of the tribal people believe in tribal traditions and they consider their tribal culture superior to religion the wrong interpretation of religion and the mixture of culture into religion had a strong effect on womens quality of life the table shows that 520 of the respondents were in favor of the statement that women have no access to doctors due to restrictions imposed by tribal traditions while 427 negated the statement the remaining 50 were uncertain about the statement similarly 699 of the respondents disagreed with this statement that male family members feel shy to visit doctors with women while 301 of respondents were in favor of the statement that male family members feel shy to visit doctors with women for the outside movement 602 of the respondents responded that it is not fear that women in their family never travel beyond 25 square kilometers from outside the home for treatment purposes while 394 of the respondents were in favor of the above statement 685 of the respondents stated that their family wants to observe purdah whereas 288 of the respondents disagreed with the statement additionally 681 of the respondents further reported that women are considered a symbol of honor in the family while 197 and 122 of the respondents disagreed or were uncertain about the abovementioned statement regarding the participation of women in jobs 703 of the respondents reported that it is against basic pashtun ethics while 283 were in favor of womens participation in jobs 491 of the respondents were again of the opinion that religion in tribal society is interpreted through the eyes of pashtun culture whereas 369 of the respondents disagreed and 140 of respondents had no information about that statement 477 of the respondents further responded that the mixture of pashtun and religious culture is no threat to womens basic rights while 477 of the respondents reported that it is a threat to womens basic rights whereas 93 of respondents were not sure about the above statement as far as the share of women in family inheritance is concerned 674 of the respondents reported that women could not dare to demand their share in the family inheritance whereas 197 of the respondents agreed with the statement whereas 129 of the respondents were uncertain about the family inheritance moreover 498 of the respondents were against the statement that tribal culture has nothing to do with religion while 409 of the respondents were in favor of the statement the remaining 93 of the respondents were uncertain about the statement similarly 459 of the respondents were against the statement that more inclination toward culture made islam partial towards female basic human rights while 401 of the respondents were in favor of the statement and 140 of the respondents were uncertain 667 of the respondents reported that they are not allowed to enjoy legal rights while 294 of respondents agreed with the statement while 39 of respondents had no information about the legal rights of women furthermore the table as a whole reveals that culture and religion played an important role in the improvement of female quality of life these two were interrelated concepts and the wrong interpretation of religion and the mixture of culture into religion had made women deprived of their basic human rights there was a dire need to raise voices for the improvement of quality of life and challenge all cultural barriers in the way of womens development similarly ibrahim farina stated that our culture is intermixed with our religion and their combination does not permit women to enjoy any legal right given by our islam and the constitution pakistan is an islamic country but the different interpretation of islamic law by our culture has deprived women of the basic rights of human life this ultimately affects the females quality of life the cultural and religious beliefs are extremely strong for women in fata shinwari reported that they are considered to be the center of honor which ultimately affects womens mobility human rights and quality of life muhammad et al reported that they also face cultural taboos in the case of consulting doctors they are based on false traditions and religious beliefs consequently high mental anxiety prevailed in pakistan especially among women mainly due to bad economic conditions and lack of social support bivariate analysis association between cultural and religious beliefs and quality of life the table reports that in connection with the association between the quality of life and cultural and religious beliefs a significant association was found with the statements calling religion in tribal society is interpreted through the eyes of pashtun culture women are a symbol of honor in the family it is extremely difficult for women to do a job it is not easy for women in the tribal area to enjoy legal right for the outside movement women want to observe purdah and tribal women cannot dare to demand their share in the family inheritance the statements found nonsignificant included the mixture of pashtun and religious culture as a threat to womens basic rights women not accessing doctors due to restrictions imposed by tribal tradition male family members falling shyness to visit doctors with women most of the women in the family never traveled beyond 25 square kilometers from outside home for treatment purposes tribal culture has nothing to do with religion and more inclination towards culture made islam partial towards female basic human right the table as a whole reveals a strong domination of pashtun culture and religion in fact religion seems to be through the goggles of culture women in the study area were the symbol of honor and observed purdah participation in the workforce is a deviation from basic pashtun ethics no share in family inheritance and no legal rights all these affected female quality of life in one way or another way ibrahim in this regard states that the mixture of culture into religion in tribal areas does not permit women to enjoy legal rights which is given by islam and the constitution of pakistan the wrong interpretation of islamic law has also deprived women of their basic rights to human life this ultimately affects the females quality of life severely in tribal areas most of the tribal people believe that strong cultural and religious belief systems prevail in tribal areas similarly shinwari reported that they are considered to be the center of honor which ultimately affects womens mobility human rights and quality of life conclusion quality of life is one of the emerging concepts in the world a number of incentives and genderbased policies have been made to improve female quality of life in pakistan however the study reveals that low female literacy strong seclusion system a dominant society and deteriorated law and order situations of tribal people were the major causes of low female quality of life in fata most of the tribal people strongly believed in cultural and religious belief systems further the misinterpretation of culture and amalgamation of cultural traits into religion consider of women as a symbol of honor not being allowed to participate in jobs strong purdah system and share in family inheritance are another major factors that further affected the female quality of life in federally administered tribal area recommendations the study suggests following recommendations on the basis of the findings of the study 1 education is the key agent of promoting awareness and sensitization of local peoples lifestyles a quality life could be ensured in the selected area by providing them with adequate education the government in this regard emphasized the promotion of female education 2 community organizations can strengthen the voice of women as a result women being organized can initiate an advocacy and lobbying campaign to discourage those sociocultural practices and beliefs that might condense the role of women which ultimately leads to their poor quality of life 3 patriarchal social structure in the selected area is the prominent hurdles in the way of promoting womens quality of life so effective programs and policy interventions should be initiated to provide space for womens better lifestyles 4 health facilitation for the citizens is the prime responsibility of every welfare state therefore the government of pakistan should give special attention to maternal health issues in the selected area of the study

the current study was formulated to probe cultural and religious belief systems that affect the female quality of life in the feudally administrated tribal area fata the data for the study was collected through an interview schedule from 279 sample respondents belonging to four villages of kurram agency the statistical test ie chisquare was used to find out the association between the dependent and independent variables the results of religious and cultural beliefs show a significant association between females were not allowed to move outside the home and strictly observing seclusion p0002 female participation in a job is considered a violation of pakhtun ethics p0000 females not dare to demand their share in the family inheritance p0004 cultural values of pashtun society consider female as a symbol of honor p0000 with female quality of life the study recommends the female quality of life in fata can be improved through the merger of fata into the mainstream of khyber pakhtunkhwa province replacing fcr with constitutional rights providing all the basic facilities and discouraging all norms and practices developed on the basis of patriarchy misinterpretation of religion and culture by using clergyman ngos and other government functionaries