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i will never forget a rich arab businessman i met in new york at the clinton global initiative he had an american lady in charge of his nongovernmental organization she was a great woman dedicated to her work who would stay until midnight doing her job he said that women in the arab world will never succeed until they are ready to stay at work until midnight like the american woman he complained that arab women want to go home at five o clock to look after their families i was upset i told him that it should be their choice how long they want to work and if they have priorities such as family and want to leave at five then this should be respected it is men like him and in some cases women who undermine who we are the issues faced by women in science are beginning to receive more attention on this page last week athene donald highlighted one initiative to tackle gender bias i would like to offer a perspective from the islamic world despite the impression given by extremists islam gives women the right to education more than four in ten women who go to university in jordan go into science engineering or medicine women outnumber men on courses in natural science pharmacology and agriculture numbers are equal in maths and computer science and one in three engineering students in jordan is a woman some of the problems faced by women scientists in the middle east are the same as those faced by women around the world our productivity for instance is measured on a male scale the years we spend taking care of children are not calculated as part of the gross domestic product of a country what is more important to build physical things or to nurture a human being as an example of this male scale loréal and the united nations educational scientific and cultural organization are running a competition to award fellowships to arab women scientists but you have to be under 40 to enter this is biased and based on metrics from a maledominated world in which if a man doesnt make it by 40 he is a failure the feminist movement was a good thing but it was too focused on equality with men and failed to enable us to respect ourselves as women and to be proud of who we are another common challenge to all women scientists is lack of mentoring and networking most women scientists everywhere have two jobs work and home and most will not give up home for work they will always be worried about the children want to be with them and feel that the fathers presence wont compensate for their own absence so they dont take time after work to have a coffee with their colleagues yet this informal environment is where scientists learn what is going on where they lobby network mentor and get mentored women dont have the time networking is an extra effort men mentor each other and spend time together after work fostering the mens club women rush home to take care of children not because they have to but because they want to this is a major obstacle for women scientists in terms of opportunities learning and support that is why mentoring projects something we lack in the arab world are important but social media allow mentoring online and some women scientists now plan to start an online mentoring scheme for women scientists in jordan in collaboration with the countrys first woman university president rowaida maaitah women also have challenges specific to the middle east these may not be so obvious because they are subtle and must be identified studied and solved by arab women themselves for instance the september study about a bias among us scientists against women mentioned by donald last week would not necessarily translate to the arab muslim world where the prevailing attitude among both men and women is that women work hard and are more dependable than men one must not fall into the trap of transferring solutions from one culture to another i know of an american researcher who went to bulgaria to help women fight for their rights she went assuming that they would want to demand to work but bulgarian women who had lived under communism wanted the exact opposite they wanted the freedom to stay at home if they chose a muchmisunderstood issue is the covering of the hair and sometimes the face by muslim women in the west this is often considered a sign of oppression yet more than half the female students and academics in the arab world choose to cover their hair for religious reasons compared with fewer than 10 20 years ago these young women are educated affluent and independent i have a graduate student who covers her face who told me that she believed she would win a nobel prize this is not oppression i see the arab spring as an opportunity for women to learn about their rights and to advocate for them to distinguish between what is tradition and what is religion this would weed out extremists who through ignorance distort the image of islam and it would weed out opportunists who want to misrepresent muslim women throughout the islamic civilization that flourished in the middle ages there were more than 8000 women scholars there are many more on the way today 1 n o v e m b e r 2 0 1 2 v o l 4 9 1 n a t u r e 9 world viewa personal take on events © 2012 macmillan publishers limited all rights reserved

argues that true equality for women scientists requires recognition of their family roles as well

introduction the number of singleparent families with children under the age of 18 has increased sharply during the past few decades in the united states there were approximately 105 million singleparent households in 2021 compared to 15 million in 1950 a recent study indicates that among countries where census data are available the rate of singleparent households is highest in the united states as the number of singleparent families has increased many studies have examined childrens and adolescents developmental outcomes in singleparent families for example multiple studies indicate that adolescents living in singlemother households are at heightened risk for adjustment problems including internalizing issuesdifficulties directed primarily inward such as depression and anxiety as well as outwardly directed externalizing issues such as earlier initiation of substance use greater likelihood of engaging in delinquency and attentiondeficit hyperactivity disorder and conduct disorder unlike early research that reflected concerns about singleparent households recent research indicates that the family structure itself is not the dominant influence on adolescents developmental outcomes many children in singleparent families develop into welladjusted adults and in general recent studies report more multifaceted elements of single parenthood including both resilience and risk factors compared to earlier research nevertheless some risk factors associated with singleparent families have consistently emerged as predictors of adolescents problem behaviors for instance high rates of material hardship single parents depression and less optimal parenting behaviors are key risk factors for adolescent problem behaviors in singleparent families although examining the main risk factors for adolescents problem behaviors is very important identifying specific mechanisms underlying family processes that include those risk factors is necessary to explain the formation and progression of adolescents problem behaviors nevertheless few studies have explored family processes in singleparent households to understand adolescent problem behaviors specifically the higher poverty rate of singleparent households compared to twoparent households is a major risk factor linked to childrens developmental outcomes conger et al proposed the family stress model which explains adolescents problem behaviors through family processes that originate with parents economic burden particularly considering that femaleheaded singleparent households are more likely to be impoverished compared to maleheaded households and that financial problems are a major stressor in singlemother households applying the fsm to examine singlemother families processes that lead to adolescents problem behaviors could provide valuable insights this study extends previous studies that have employed the fsm examining the potentially protective role of adolescent school connectedness in the family processes that lead to adolescent problem behaviors school connectedness is students experience of belonging and engagement in school which is an important protective factor for adolescents healthy development family and school are two important institutions for adolescents providing emotional and social resources for healthy development according to ecological systems theory interactions between the two institutions are conceptualized as a mesosystem which refers to relationships among two or more immediate settings although studies considering the role of other institutions in investigating families effects on childrens and adolescents outcomes are scant some research has indicated the joint effect of the two institutions on development for example one study revealed the compensating effect of school on behavioral problems for children from families with lower socioeconomic resources additionally the influence of family violence on adolescents peer aggression is mitigated when adolescents have a stronger sense of belonging in school with few previous studies examining moderating effects within the fsm this study focuses on the moderating role of adolescents school connectedness in the paths to their problem behaviors to determine the impact of other important environmental factors on the development of adolescents in singlemother families applying the fsm the indirect association between single mothers material hardship and adolescent problem behaviors the fsm delineates how parents emotional distress related to economic hardship can impact childrens developmental outcomes the model indicates that economic pressure is not only a familys objective condition but also a factor that affects parents and children psychologically instead of focusing on economic hardships direct effect on childrens adjustment the fsm posits comprehensive family processes such as parents emotional and behavioral functioning as mediating mechanisms specifically parents economically influenced emotional distress can significantly disrupt their ability to maintain positive and nurturing parentchild relationships less adaptive behaviors such as harsh and uninvolved parenting in turn can lead to childrens emotional and behavioral problems and impaired competence empirical studies testing the fsm have demonstrated that it is a valid heuristic model that can be applied to families with children in diverse developmental stages research has indirectly linked parents experience of economic hardship to behavioral problems of children in early and middle childhood via parents emotional distress couples conflicts and harsh parenting behaviors studies targeting families of adolescent children with reports from both mothers and fathers have also demonstrated the significant indirect effect of economic hardship on adolescents behavioral problems through family processes empirical evidence for the fsms validity has also been established across diverse family contextual backgrounds for example economic pressures indirect effects on internalizing and externalizing problems have been reported in samples with various ethnic backgrounds such as families of african chinese and mexican origin as well as in samples with diverse geographic backgrounds however most studies applying the fsm to explain adolescent behavioral problems have targeted twoparent families or included parents regardless of their gender with little focus on diverse family structures additionally although some studies have explored stress processes in singlemother families most of them targeted single mothers of younger children while fewer studies have focused on identifying how family processes in singlemother households are linked to adolescents adjustment adolescents healthy development is important in itself but preventing and mitigating adolescents adjustment problems is significant as such problems can affect individuals throughout adulthood although few empirical studies have assessed how single mothers economic hardship is linked to adolescent problem behaviors via mental health and parentadolescent relationships previous studies that have examined parts of the fsm support the viability of the current studys research model previous research indicates that on average single mothers tend to suffer from higher levels of stress compared to married mothers specifically financial problems are the main stressor for single mothers and significantly impede their psychological functioning for example studies have showed that single mothers financial hardship is associated with their current and chronic depressive symptoms several studies have also reported the mediating role of parenting behaviors or parentadolescent relationships in the relationship between mothers mental health problems and adolescents behavioral problems although they did not focus on single mothers singlemother status itself may not be associated with insufficient functioning as parents but single mothers emotional difficulties are associated with less optimal parenting behaviors such as low levels of authoritative and involved parenting punishment physical abuse and neglect in addition the quality of parenting behaviors and parentadolescent relationships have consistently been found to be strong predictors of adolescent problem behaviors specifically instead of focusing on the disruptive parenting behaviors indicated as mediators between parents and childrens maladjustment in fsm this study focused on the mediating role of the motheradolescent closeness between single mothers depression and adolescents problem behaviors the reason for this is that the bond between a parent and an adolescent can be an essential facet of the relationship that explains adolescents adjustment the quality of parenting behaviors and parentadolescent relationships have consistently been found to be strong predictors of adolescent problem behaviors specifically the closeness between a parent and an adolescent is an important relationship factor that is often measured by indicators such as trust intimacy and communication closeness between a parent and an adolescent is often measured by indicators such as trust intimacy and communication lower levels of motheradolescent closeness motheradolescent communication affection and care are associated with higher levels of externalizing and internalizing problems among adolescents adolescents weak sense of belonging and low levels of trust and attentive listening between mothers and adolescents are mechanisms explaining the link between closeness with parents and problem behaviors frontiers in psychology 04 frontiersinorg in addition to the possibility that single mothers economic hardship is linked to adolescent problem behaviors through mothers mental health and the motheradolescent relationship a few studies also indicate that mothers depression may be directly associated with adolescent problem behaviors even after accounting for the mediating role of parentadolescent relationships emotional contagion among family members and genetic vulnerability to depression are a few mechanisms potentially explaining parents mental health and childrens negative adjustment adolescent school connectedness as a moderator there have been few studies examining potential risk or protective factors that moderate family stress processes previous studies have indicated that the level of poverty mothers personality and values and coping strategies and social support play significant moderating roles exacerbating or mitigating stress processes specifically in studies examining how stress processes are linked to problem behaviors the moderating role of neighborhood characteristics was reported including collective efficacy in the relationship between harsh parenting and behavioral difficulties as well as neighborhood adversity in the relationship between harsh parenting and adolescents internalizing problems although school is a significant institution in which adolescents spend most of their time outside of family providing multiple resources for resilience development adolescents relationship with school has seldom been examined in studies applying the fsm research shows that adolescents report better wellbeing when they feel like part of their school and are cared for by people in school there is also a wealth of studies reporting the relationship between stronger school connectedness and reduced externalizing and internalizing problems adolescents superior behavioral outcomes are explained by diverse resources in schools such as the opportunity to develop secure relationships that are the basis for social and emotional development as well chances to build psychological skills in a warm and supportive atmosphere observing positive adult and peer role models learning important values in life and participating in intervention programs aimed at enhancing socioemotional development many studies have examined the effect of school connectedness on adolescents problem behaviors focusing on variables related to school context with several reporting that both positive parent characteristics and school connectedness significantly decrease adolescent problem behaviors considering that few studies have tested the moderating effect of school connectedness in the relationship between parent characteristicsparentadolescent relationship characteristics and problem behaviors this study focused on the moderating role of school connectedness in the relationships between mothers depression and adolescent problem behaviors as well as between motheradolescent closeness and adolescent problem behaviors material hardship can negatively impact mothers depression and motheradolescent closeness but the buffering hypothesis posits that a strong social support system mitigates the negative effects of stressful events in short previous studies indicate that more studies are needed to understand how parental characteristics and adolescent school connectedness may interact to influence adolescents adjustment in diverse contexts the present study based on the fsm and the findings from previous research we hypothesize that single mothers material hardship is indirectly associated with adolescents internalizing and externalizing problem behaviors through sequential mediations of mothers depression and motheradolescent closeness single mothers material hardship is indirectly associated with adolescent internalizing and externalizing problem behaviors through mothers depression and school connectedness moderates the association between motheradolescent closeness and adolescent problem behaviors and the association between mothers depression and adolescent problem behaviors figure 1 shows our research model materials and methods data and sample this study analyzed data from the fragile families and child wellbeing study a longitudinal study that follows children born in the us between 1998 and 2000 the original sample was a stratified random sample of 4898 children born in 20 cities that was nationally representative and these individuals were followed beginning at ages one three five nine and 15 approximately we analyzed data only from wave 6 the ffcws includes both children and their primary caregivers interviews regarding their we restricted the analysis to single mothers whose primary caregiver report of the relationship to the adolescent was biological representing 1384 adolescents and their mothers we excluded cohabiting mothers because single mothers living alone are more likely to face economic difficulties table 1 displays the descriptive characteristics of the analyzed sample among the samples adolescents 50 were female and 9 were white 58 were black 17 were hispanic and 6 reported the other racial category adolescents average age was 1563 years for mothers the average age was 4048 years approximately 14 of mothers had graduated from college and 44 were living in poverty measures internalizing and externalizing behaviors adolescent behavioral development was assessed using selfreport questionnaires based on the 34 items of the behavioral emotional and social problems scales of the child behavior checklists 618 the subscales included were aggressive behavior anxiousdepressed behavior attention problems rulebreaking behavior social problems thought problems and withdrawal we calculated a score of internalizing behaviors by summing responses to six items regarding anxiousdepressed behavior and two items regarding withdrawal each measured on a 3point likert scale 0 1 or 2 the composite score ranged from 0 to 15 for externalizing behaviors we summed responses to 11 items regarding aggressive behaviors and nine items in rulebreaking behaviors each measured on a 3point likert scale 0 1 or 2 the composite score ranged from 0 to 36 the cronbachs alpha was58 for the internalizing behaviors score and89 for the externalizing behaviors score the average scores of internalizing behaviors was 211 and externalizing behaviors was 497 material hardship we assessed material hardship using the 11 items from pcgs questionnaire which was originally adapted from the survey on income and program participation new york city social indicators survey and the study of work welfare and family wellbeing of iowa families on fip each questionnaire contained yesno questions on the extent to which respondents experienced hunger homelessness utility shutoffs and forgone medical care due to insufficient financial resources we summed responses on items to generate a composite score with higher scores indicating greater material mothers depression the major depressive episode pcg questionnaires were derived from the composite international diagnostic interviewshort form section a whose criteria are consistent with those of the fourth edition of the diagnostic and statistical manual of mental disorders respondents indicated whether they have had feelings of depression or a general lack of pleasure in the past year that lasted for two or more weeks if those symptoms lasted most of the day or occurred every day within the twoweek period respondents were asked more specifically about whether they had lost interest felt tired experienced changes in weight had trouble sleeping had trouble concentrating felt worthless or thought about death we then calculated the major depressive score as the sum of the positive responses to each item which ranged from 0 to 8 the average score of mothers depression was 135 motheradolescent closeness we assessed motheradolescent closeness using two selfreport questionnaires asking adolescents to rate the extent to which they talk and 2 school connectedness we assessed school connectedness using selfreport questionnaires completed by adolescents which were used in the panel study of income dynamics child development supplement the measure comprises four items assessing inclusiveness closeness happiness and safety experienced at school items utilized a 4point likert response scale ranging from 1 to 4 with higher scores indicating higher levels of school connectedness we averaged responses to the items to create a composite score of school connectedness the scales cronbachs alpha was72 and the average score of school connectedness was 238 covariates this study also assessed the following adolescent and family characteristics adolescents gender adolescents age adolescents race mothers age mothers college graduation status and family poverty status analytic strategies this study used path analysis a structural equation modeling approach to examine the associations among material hardship mothers depression motheradolescent closeness and adolescents internalizing and externalizing behaviors sem considers associations among multiple pathways simultaneously and provides standardized regression coefficient for each pathway we used bootstrapping to compute biascorrected standard errors then we decomposed the direct indirect and total effects by using the nonlinear combinationofestimators function to test for mediations nonlinear combinationofestimators computes standard errors based on the delta method missing data rates for the study variables ranged from 0 to 968 we used the fullinformation maximum likelihood estimation to retain as many observations as possible and to mitigate missing data bias with respect to school connectednesss moderating effect we included interaction terms between motheradolescent closeness and school connectedness and between mothers depression and school connectedness in the regression models then we created a margins plot to illustrate the prediction of adolescents internalizing and externalizing behaviors by motheradolescent closeness and school connectedness and mothers depression and school connectedness we performed all analyses using stata 140 results correlational analysis table 2 shows pearson correlations for the primary variables adolescents internalizing and externalizing behaviors motheradolescent closeness mothers depression material hardship and school connectedness all were statistically significantly associated with correlations ranging from 020 to53 adolescents age was associated with school connectedness and mothers age was associated with adolescent externalizing behaviors material hardship and adolescents age associations among material hardship mothers depression motheradolescent closeness and adolescent internalizing and externalizing behaviors all variables were observed variables and all models demonstrated good overall fit to the data our first sem model predicting the path from material hardship to adolescent internalizing behavior suggested statistically significant paths via mothers depression and motheradolescent closeness increases in material hardship were associated with increases in mothers depression and increases in mothers depression were associated with decreases in motheradolescent closeness which in turn decreased adolescents internalizing behaviors mothers depression was directly associated with increases in adolescents internalizing behaviors the results for adolescents externalizing behaviors were similar to those for internalizing behaviors mothers depression was associated with increases in motheradolescent closeness which in turn decreased adolescents externalizing behaviors mothers depression was also directly associated with adolescents externalizing behaviors table 4 displays the indirect effects via mothers depression and motheradolescent closeness results indicated statistically significant effects for all indirect pathways material hardship was indirectly associated with adolescents internalizing and externalizing behaviors via mothers depression and motheradolescent closeness additionally material hardship was indirectly associated with adolescents internalizing and externalizing behaviors via mothers depression for supplementary analyses this study tested the alternative models switching motheradolescent closeness and mothers depression the results were consistent in that material hardship was indirectly associated with adolescents internalizing and externalizing behaviors sequentially via motheradolescent closeness and mothers depression this study also tested an sem path model including both adolescents internalizing and externalizing behaviors within the same model since these behaviors are closely related the findings were similar to those analyzed in separate models in addition the original models had smaller akaike information criteria and bayes information criteria values than the alternative models indicating better model fit in terms of the covariates female adolescents had mothers who were less depressed compared to male adolescents and black adolescents hispanic adolescents and adolescents reporting other as their race had mothers who were less depressed compared to white adolescents living in poverty was positively associated with mothers depression however adolescents age and mothers age were not significantly associated with mothers depression regarding motheradolescent closeness female adolescents were less close with their mothers than were male adolescents however adolescents age adolescents race mothers age mothers educational attainment families living in poverty were not significantly associated with motheradolescent closeness additionally black hispanic and other race adolescents exhibited fewer internalizing behaviors than did white adolescents adolescents living with poor families were more likely to exhibit internalizing behaviors however adolescents gender age mothers age and mothers educational attainment were not associated with adolescents internalizing behaviors in terms of externalizing behaviors female adolescents were less likely to exhibit externalizing behaviors than were male adolescents hispanic adolescents were less likely to exhibit externalizing behaviors than were white adolescents mothers age was negatively associated with adolescents externalizing behaviors adolescents living with poor families were more likely to exhibit externalizing behaviors however adolescents age the dummy variables for the black and other racial categories and mothers educational attainment were not significantly associated with adolescents externalizing behaviors moderating effect of school connectedness table 5 shows the results regarding the moderating role of school connectedness in the sem model motheradolescent closeness positively predicted adolescents internalizing behaviors and this effect was moderated by school connectedness in other words the association between motheradolescent closeness and adolescents internalizing problem behavior was weaker for adolescents with high levels of school connectedness figure 4 also shows that school connectedness moderated the association between motheradolescent closeness and adolescents internalizing problem behaviors these findings suggest that motheradolescent closeness effectively reduces adolescents internalizing behaviors when levels of school connectedness are high mothers depression positively predicted adolescents internalizing behaviors but this effect was not moderated by school connectedness additionally school connectedness did not significantly moderate the relationship between motheradolescent closeness and adolescents externalizing behaviors or that between mothers depression and adolescents externalizing behaviors predictors direct effect mothers depression motheradolescent closeness adolescents internalizing behaviors adolescents discussion although many studies indicate that adolescents in singleparent households are at heightened risk for problem behaviors few studies have explored family processes leading to adolescents internalizing and externalizing behaviors applying the fsm this study examined the processes in singlemother families that link material hardship to adolescents problem behaviorsnamely single mothers depression and motheradolescent closeness specifically with little research examining moderators in the fsm this study explored the moderating roles of adolescent school connectedness in the paths that link mothers depression and motheradolescent closeness to adolescents problem behaviors the results supported our first hypothesis indicating the sequential mediating roles of mothers depression and motheradolescent closeness in the relationship between material hardship and adolescents problem behaviors this aligns with previous research demonstrating single mothers psychological functioning and parenting as important sequential mediators in the relationship between family risk factors and african american adolescents adjustment it is also similar to the results from previous studies investigating adolescents raised in twoparent families or targeting adolescents and their parents regardless of parents gender or family structure this study indicates that economic strain is a significant extrafamilial stressor that exacerbates single mothers mental health and relationships with adolescents ultimately leading to both internalizing and externalizing problems although many studies have focused on adjustment of younger children in singlemother families to understand the impact of single mothers diverse stressors this study confirms that family is still an important contributor to adjustment during adolescence during which peers friends and other extrafamilial networks take on more important roles specifically motheradolescent closeness played a significant partial mediating role in the relationship between mothers depression and adolescents problem behaviors research indicates that warm close relationships with parents fulfill adolescents basic psychological needs and contribute to secure attachment which lead to adolescents behavioral and emotional adjustment on the other hand poor communication and negative parentchild relationships do not significantly change as children develop into adolescents and even worse interactions occur over time in singleparent families based on the fsm this study showed that the motheradolescent relationship in singlemother families is significantly indirectly associated with material hardship through mothers depression specifically previous studies have reported less frequent interactions and higher negativity in parentadolescent relationships among singlemother or singleparent families compared to twoparent families by applying fsm this study showed how material hardship and single mothers depression are associated with an important facet of the motheradolescent relationship which eventually led to problem behaviors this result also supported the second hypothesis positing the role of mothers depression as a single mediator between material hardship and adolescents problem behaviors as previous studies suggest although parenting and the parentchild relationship are the primary mechanisms that explain the relationship between parents and childrens mental health other elements such as emotion contagion and genetic vulnerability may also be important additionally because this study focused on motheradolescent closeness potentially significant mediating roles of other facets of parenting such as monitoring and autonomy granting should also be considered in further research taken together this study highlights the importance of interventions that address the deleterious effects of economic strain and depression in singlemother families above all although parents extrafamilial stress is an important factor that explains their childrens behavioral problems as crnic and coburn note only a few interventions have been developed to address such material hardship additionally most intervention programs for single mothers have focused on parents of younger children notwithstanding many single mothers challenges in providing financial and educational support for adolescent children and difficulties in dealing with new parenting roles required for raising adolescents moreover this study examined the moderating role of school connectedness in the associations of motheradolescent closeness and mothers depression with adolescents problem behaviors as expected we found that school connectedness significantly moderated the relationship between motheradolescent closeness and adolescents internalizing behaviors although little attention has been paid to this moderating variable several studies have reported a significant association between school connectedness and adolescents problem behaviors aligning with our study findings specifically considering that experiencing connection with others is an important psychological need linked to adolescents wellbeing it is likely that adolescents feelings of connectedness with friends teachers and school itself buffered the negative effect of distance from mothers on internalizing problem behaviors research has indicated that school can play an important role in nurturing resilience the capacity to successfully adapt to challenges that threaten normal functioning or healthy development particularly as this study found that school can protect against internalizing behaviors when adolescents in singlemother households experience negative family processes that originate from material hardship enhancing school connectedness which can provide multiple relationship opportunities for adolescents should be highlighted in reducing internalizing behaviors however unexpectedly school connectedness moderated neither the relationship between mothers depression and adolescent internalizing and externalizing problem behaviors nor that between motheradolescent closeness and adolescents externalizing behaviors because few studies have explored school connectednesss moderating role in the fsm we cautiously suggest a few possible explanations of our results above all regarding the lack of significant moderation of school connectedness in the relationship between mothers depression and adolescents problem behaviors the diverse pathways through which the former can affect the latter offer one explanation that is school connectedness may have a significant indirect effect on adolescents problem behaviors through aspects of familial relationships rather than there being a direct association between mothers depression and adolescents problem behaviors which can be explained by various potential mechanisms such as emotional contagion genetic vulnerability and ineffective discipline additionally this study produced inconsistent results on adolescents internalizing and externalizing behaviors in terms of the interactive effect of motheradolescent closeness and school connectedness a large body of research indicates cooccurrence and codevelopment of internalizing and externalizing behaviors however some studies also indicate that the antecedents and contexts of the two problem behaviors can differ for example depending on adolescents peer networks and school activity types more engagement in school social networks can be associated with increased delinquency despite the direct and significant association between interaction between school connectedness and motheradolescent closeness in the prediction of adolescents internalizing behaviors as school connectedness itself was significantly associated with adolescents internalizing problem behaviors it may be possible that the influence of mothers depression offset this moderating effect similarly our findings contrast with previous evidence on the protective effects of school connectedness on adolescents problem behaviors because the adolescents of our sample were approximately 15 years of age prospective studies need to explore whether the protective role of school connectedness is more evident among older adolescents as previous studies have found stronger association between school connectedness and externalizing problem behaviors for older high school students future studies should focus on later adolescents and examine whether school connectedness mitigates externalizing problem behaviors limitations although this study has many strengths a few limitations must be noted first although this study used both motherreported and teenreported measures there is a methodological limitation due to the use of a monomethod selfreported design which may have led to inflated statistical associations and biased estimates future studies may consider including observational methods to measure constructs of interest such as parentadolescent closeness second based on the fsm this study investigated material hardship as an important stressor that may directly or indirectly affect mothers mental health mothers relationships with their adolescent children and adolescents problem behaviors however future studies should also consider diverse known risk factors in singlemother households that may influence family processes that is single mothers challenges should be addressed comprehensively to understand the complex family processes that explain adolescents problem behaviors for example insufficient social support lack of coparenting and adolescents childhood stressors and chronic problem behaviors could majorly affect family processes and adolescents life outcomes third this studys crosssectional design precludes making causal inferences although the directionality of our research model was guided theoretically by the fsm the increasing effect of children on their parents during adolescence should also be considered for example the influence of adolescents problem behaviors on mothers depression and motheradolescent relationships could be examined in the future additionally as adolescents problem behaviors may have been influenced by their childhood development future research may consider using a longitudinal design to clarify the directionality and causality of the complex mechanisms lastly although our study focused on singlemother families further research should consider diverse and complex family structures including singlefather families and how their family processes influence adolescents healthy development conclusion despite some limitations this study contributes to the literature as one of the few studies examining specific family processes in singlemother families to explain adolescents problem behaviors specifically previous studies have indicated that adolescents in singleparent households are at a heightened risk for adjustment problems although many studies suggest various risk factors for adolescent problem behaviors investigating the processes associated with the behaviors is necessary specifically although not all single parents live in poverty single mothers are more likely to suffer from economic hardship compared to single fathers accordingly using samples in which households under the poverty threshold are overrepresented this study revealed the significant indirect effect of material hardship on adolescents problem behaviors through mothers depression and the quality of mothers relationships with adolescents which was guided by the fsm furthermore with few studies investigating moderating effects in the fsm this study investigated the moderating role of school connectedness in the paths leading to problem behaviors although the moderating effect of school connectedness was significant only in the relationship between motheradolescent closeness and internalizing problem behaviors this study provides valuable initial findings regarding protectiverisk factors in adolescents environments within the family stress process research should continue to elucidate the riskprotective factors that ultimately determine adolescents developmental outcomes additionally considering that single mothers depression and motheradolescent closeness are significant elements that explain the relationship between single mothers material hardship and adolescent problem behaviors interventions that address emotional and relational problems associated with economic hardship in singlemother families should be devised data availability statement publicly available datasets were analyzed in this study this data can be found at lee and joo 103389fpsyg2022937698 frontiers in psychology 13 frontiersinorg ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements written informed consent to participate in this study was provided by the participants legal guardiannext of kin 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 937698full supplementarymaterial

objective previous research has shown that adolescents in singlemother households are at heightened risk for adjustment problems however limited studies have investigated the mechanisms leading to adolescent problem behaviors in singlemother households to address this research gap this study applied the family stress model to examine how single mothers material hardship is linked to adolescent problem behaviors focusing on the mediating roles of mothers depression and motheradolescent closeness the moderating role of adolescent school connectedness in the relationships between motheradolescent closeness and school connectedness and between mothers depression and school connectedness was also investigatedthe study analyzed data from 1384 adolescents and their single mothers who participated in the fragile families and child wellbeing study at wave 6 the associations between study variables were analyzed using structural equation modeling by decomposing the direct indirect and total effects of material hardship on adolescent problem behaviors school connectednesss interactions with motheradolescent closeness and mothers depression were also examined results results showed a significant indirect relationship between material hardship and adolescent problem behaviors through sequential mediation of mothers depression and motheradolescent closeness mothers depression also significantly mediated the relationship between material hardship and problem behaviors lastly school connectedness moderated the relationship between motheradolescent closeness and adolescents internalizing behaviors the association between motheradolescent closeness and adolescents internalizing behavior was weaker for adolescents with higher levels of school connectednessthe results indicate the important indirect effect of economic strain on adolescents problems behaviors in singlemother households which has been less emphasized compared to the effects in earlier childhood high rates of material hardship and adolescent problem behaviors in singlemother families call for multifaceted interventions focusing on family processes and protective factors including school environment

introduction the transition from the adult age to older ages results in several inevitable lifecourse events among them retirement from incomegenerating activities and reduced social participation pose a significant risk of cognitive loss in old age 12 cognitive performance has long been studied to determine the threshold age of retirement predominantly in the developed nations 3 4 5 in a developing nation like india greying of the population has an economic implication in terms of ascertaining the appropriate age for retirement 6 7 8 the population of 60 years and above is projected to increase to 19 from 8 the increase in the population of the elderly is also high in india 9 a substantial rise in aging has led to an increase in the incidence of physical limitations cerebral pathologies and alterations in socioeconomic conditions like economic dependency widowhood and social isolation there has also been an increase in the health burden due to mental morbidity and brain inactivity 10 as an indicator of healthy aging cognitive health in later life helps to understand the quality of life of the elderly 11 cognitive aging is explained by different stress pathways that consider intellectual engagement 2312 retiring from employmentrelated activities adds worries in regard to financial security health care and health expenditure the nature of cognitive decline after retirement varies with occupation duration since retirement and participation in alternative activities in later life as found by several longitudinal studies 2 13 14 15 older persons with a higher cognition often continue to work until late in life early retirees tend to be individuals with a poor educational background and those who were engaged in low skill jobs 14 however in india due to the absence of a strong social pension system or support from the family individuals in older ages continue working out of compulsion 9 cognitive loss as a result of strenuous and involuntary work participation has been shown in a large number of studies mainly in the advanced economies the lowand middleincome countries too have started to face challenges arising from the growth of the longer living elderly financial and social insecurity among the elderly heightens during the postretirement phase due to an inadequate or dysfunctional social security system forced participation in employment in old age can be potent enough to alter the process of healthy aging among the fastgrowing elderly population 1617 lowgrade occupation is associated with poor educational attainment which leads to a higher cognitive decline during old age 5 besides retirement from financial activities reduced participation in social activities increases the risk of cognitive impairment in later life 21819 the theory of retirement and cognitive decline is supplemented by the idea of involvement in various social and leisure activities presence of a we feeling availability of social support and social involvement influences cognitive health of the elderly group engagement is more important than individual engagement during old age to maintain cognitive wellbeing at the extreme ages group participation saves 10 years of cognitive outcomes if an individual remains active and involved 20 in india a number of older individuals are left alone in the family without adequate financial and social support increase in physical limitations altered family structure and low financial strength have been identified as stimulating agents for an increase in the feeling of insecurity among the elderly 19 effective social involvement and interaction are known to safeguard against the development of depressive symptoms low psychological resources negatively influence physical functions and cognitive wellbeing 21 a better cognitive outcome can decrease the chances of degenerative diseases like dementia depression alzheimers diseases and other mental disorders in later years of life 722 chronic and multimorbid conditions are gradually increasing across the older ages increasing the likelihood of functional limitations and disability 2324 among the elderly in india and lowmiddle income countries a persistent increase in functional limitations has been observed as a result of multiple chronic morbidities 25 it is well known that functional limitations through various ways aggravate psychological distress which can further influence cognitive performance 26 cognitive performance is not the same across gender 11 gender shows a differential pattern in how work participation and social connectedness determine the cognitive behavior of individuals in india women have a lower participation in incomegenerating activities due to social norms andor lower educational attainment physical inability restricts social participation and worsens the overall health conditions decline in functional health and the resultant comorbid conditions affect social engagement and increase mental stress significantly 27 however women benefit from close contact with others or from social participation through their participation in hobbies or volunteer groups they preserve cognitive functions 28 that are otherwise at stake in the older ages in india studies regarding cognitive functions among individuals are mostly limited to morbid conditions education and financial distress 11 even though a large number of elderly suffer from events like withdrawal from public interactions due to work restrictionsretirement social isolation discrimination or socialfinancial neglect 9 the transitory impact of work and social participation across the age groups in later life is scarcely evaluated retirement affects the physical and mental health of the elderly thus restricting their participation in social activities the importance and extent of social participation has rarely been understood in the indian context which is grappling with a rapid increase in the greying of population the gender association of labor participation reveals a substantially higher male work participation and better pay for males than females which is reflected in the differential financial security decision making and health outcomes in later life aging outcomes are being affected as the female elderly is living a longer life with poor health outcomes and support the differential male and female patterns of social connectedness can demarcate the pathways of cognitive decline in older ages the complex interactions of incomegenerating activities and social participation have been necessary to understand the implication of cognitive aging work and social participation restrictions together have the potential to significantly aggravate cognitive decline in that context there is a policy relevance to modify the labor norms opportunities and social development such that there is an inclusive development in india this study focusses on the patterns of cognitive decline among the elderly through proximate and dynamic factors those are retirement and social connectedness this is essential so as to understand the cognitive aging of the elderly as it is associated with health care and social support methods data source and study population for our study we used the world health organizations study on global ageing and adult health conducted in india in 200708 to measure dimensions like health living arrangement care and support and wellbeing among adults it is a sister of the multicountry survey conducted in 6 countries including india china ghana russian federation south africa and mexico this is a nationallyrepresentative sample survey conducted in 6 states of india including assam uttar pradesh west bengal karnataka maharashtra and rajasthan a multistage clustered sample design and probability proportional to size sampling method were used to conduct the survey the states were selected on the basis of development indicators like infant mortality rate female literacy percentage of safe deliveries and per capita income a total of 5212 samples aged 50 and older were studied after dropping missing observations in selected cofounders for the purpose of analysis stata 13 package was used in this study the details of the study are mentioned in the whosage report 29 independent variables we selected the age group of 50 and above as representing the young elderly population that transitions to the age of retirement which for the most part is 60 years in india the age groups were categorized as 5059 6069 and 70 the place of residence was categorized as rural and urban gender as male and female marital status as never married currently married and others caste as unreserved and reserved education as no formal primary secondary and college and more wealth index as low medium and high and depression as yes and no 30 depression in the whosage survey wave1 was ascertained with a set of selfreported as well as symptombased questions the selfreported questions sought to determine whether any diagnosis had been done and if any medication or some other treatment had been taken during 12 months preceding the survey the symptombased questions sought to determine whether a respondent had experienced sadness emptiness or depression loss of interest or decrease in energy lasting more than 2 weeks during 12 months preceding the survey respondents who expressed agreement with any of the last three symptoms were asked another set of symptombased questions the survey questionnaire used for ascertaining depression is available at healthinfosystemssurveydataindexphpcatalog65 the working status the working status variable was created as a combination of ever worked and currently working responses responses to previously worked and not working presently generated the retired variable never worked was another category it was out of scope to include the duration since retirement in our study social participation social participation was assessed through nine indicators for how often an involvement in society had occurred during 12 months preceding the survey the aspects were public meeting attending a club participating in society or other meetings etc the responses were categorized as 1 for daily 2 for once or twice per week 3 for once or twice per month 4 for once or twice per year and 5 for never a composite score was generated by using multiple classification analysis with the principal component the response variable social participation was categorized into three categories as 1 for lesser 2 for sometimes and 3 for more the reliability score for the scale was 0752 as measured through cronbachs alpha functional restrictions to assess the functional restrictions the world health organizations disability assessment schedule version2 and instrumental adl was utilized in the study the questions sought to ascertain the extent of difficulty experienced during 30 days prior to the survey in 22 activities including sitting for a long period walking 100 meters moving around inside home getting to and using toilet going somewhere with public or private transport etc response options were coded as 1 for none 2 for mild 3 for moderate 4 for severe and 5 for extreme cannot the response variable of functional restrictions was described as 1 for low 2 for medium and 3 for high the cronbachs alpha for reliability was 0948 outcome variable a battery of tests was performed in order to understand the cognitive functions of the individuals these tests were verbal fluency verbal recall and forward and backward digit span to test the semantic memory respondents were asked to recall as many words as possible in a oneminute time span vr required recalling 10 words in 3 rounds of trial after listening to the words before each trial to saturate the learning curve the test was inclusive of both immediate vr and delayed vr for fwd and bwd the individuals read a series of digits and were asked to recall the numbers in forward and backward directions the test is used for measuring the working memory of an individual for the purpose of comparison we standardized the vr vf fwd and bwd scores the summation of the 5 standard scores gave a composite value to assess cognitive performance statistical analysis descriptive statistics with percentages mean standard deviations and maximum and minimum score have been shown to measure the impact of social connectedness on cognition it was essential to observe the interaction between the two events in the life of the older individuals the effect of work and social participation on cognition was measured by using regression along with measuring the genderspecific effect on the type of participation we applied a multivariate linear regression with the interaction among the prime variables in 3 different models to identify the significance of the predictor for gender and type of participation while controlling other background characteristics model 1 took into consideration the effect of individual background characteristics on the cognitive score of the respondents in model 2 the interaction of gender and work was observed after controlling other background characteristics in model 3 we observed the effect of gender and social participation in model 4 the interaction of work and social participation was observed to measure the significance of the genderneutral effect of participation on the cognition of the elderly after controlling other background characteristics we checked the assumptions of the modelfor eg linearity normality and multicollinearitybefore performing the analysis postestimation was used to measure the cognitive scores of the individuals with respect to their age groups and work participation scenario after performing the regression for model 4 we kept social participation constant to understand the persistence of the social situations this yielded 3 social participation groups as per the categories of the variable utilized for the study results descriptive statistics for the study population the description of the study population for the age groups of 50 and above together with the mean cognitive scores is presented in table 1 in our study sample the majority of the respondents were in the age group of 5059 years were males resided in rural areas and were currently married castewise 63 of the respondents were unreserved and about 50 had no formal education the study found that nearly 10 of the elderly were depressed the mean cognitive score was seen to declinefrom 0794 to 1086as age increased females had lower mean cognitive scores than males older persons living in urban areas had higher mean cognitive scores than their rural counterparts in terms of marital status other categories had lower mean cognitive scores than the currently and never married respondents unreserved castes scored higher on mean cognitive scores than reserved castes higher levels of education were seen to be associated with better mean cognitive scores the scores being as follows no formal education primary secondary and college similarly better wealth conditions also improved the mean cognitive outcome of the elderly elderly in the low wealth category had a mean cognitive score of 1242 those in the medium category had a score of 0046 and those in the high wealth category had a score of 1594 the study found that 2638 of the elderly had never worked 2945 had retired and 4417 were presently working a higher cognitive outcome was exhibited by the elderly who were presently working than those who had retired and those who had never worked elderly with a higher social participation showed a higher mean cognitive score those with lesser social participation had a lower mean cognitive score than those who participated sometimes and those who participated more the elderly suffering from depression comprised 1028 of the study sample depression was linked with lower mean scores for cognition than no depression the elderly in the low functional restrictions category exhibited a higher mean cognitive score than those in the medium and high functional restrictions categories the mean cognitive score of the study sample the sd and the range are shown in table 1 details of the descriptive statistics of cognitive scores are given in additional file 1 association and interaction of work status and social participation on cognition table 2 gives an estimate of multivariate linear regression for the cognitive scores of the elderly with selected background characteristics model 1 predicted that having a higher age being a female residing in rural areas and belonging to the reserved caste categories were significant and had a negative coefficient for cognitive performance among the elderly higher educational qualification more wealth and presence of depressive symptoms had a positive coefficient for cognitive outcomes in terms of work participation retired and presently working had a positive coefficient for the cognitive score higher social participation too showed a positive coefficient for the cognitive scores increase in functional restrictions led to higher whodas scores resulting in a negative and significant coefficient for the cognitive score the fstatistic for model 1 was 1663 in models 2 and 3 interaction of gender with work and social participation showed no significant outcome for the coefficient of cognition scores however the association between work and gender was positive model 3 yielded a negative direction of coefficient for the interaction between social participation and gender in model 4 after controlling all other variables we found the interaction between work and social participation to be negative and significant for selected interaction effects as compared to those who had never worked and had lesser social participation those who were retired and participated sometimes in social activities and those who were presently working and participated sometimes in social activities had a positive and significant coefficient for the cognitive outcomes there was a stronger coefficient between being retired and participating sometimes in social activities than between being presently working and participating sometimes in social activities the fstatistics for models 2 3 and 4 were 1504 1506 and 1386 respectively the interaction effect was significant for model 4 for the selected combinations model 4 also showed marginally higher r2 values and a lower fstatistic than the full model that is model 1 which explains the strength of the model the postestimation for cognitive scores among the elderly has been illustrated in fig 1 with respect to the social participation categories higher is the social participation better is the mean cognitive scores among the elderly in our study a decline in the cognitive scores was observed with increase in age groups corresponding to lesser social participation both among individuals who had never worked and those who had retired individuals who continued to work in the age group of 70 and above had a marginally higher mean cognitive score those who participated in social activities sometimes and never worked had a lower cognitive outcome in every age group compared to those who were presently working retired elderly individuals in the 5059 age group had a lower cognitive score than those presently working however in the age group 6069 years retired older persons had a matching score with presently working older persons in the category of more social discussions changes in the lifecourse activities are stressors of cognitive outcome in later years of life the rising number of older individuals in india necessitates measurement of one of the understudied health outcomes that is cognition the study used crosssectional data to investigate the effect of major participation restrictions on cognitive outcomes of the elderly our study made a few important findings which provide a comprehensive understanding of the impact of changes in the lifecourse events on cognitive health of the elderly elderly who had never worked before had the worst mean value for cognitive health compared with the others after adjusting for the selected demographic and socioeconomic factors after controlling the sociodemographic and health factors it was found that reduction in work and social participation significantly decreased cognitive performance the pattern of decline was distinctive for the type of social participation practiced by individuals across different levels of labor participation the theory of disuse perspective explains this nature of activity pattern and cognitive decline of the elderly 18 the findings are consistent with the studies on retirement that evoke the theory of use it or lose it it proves that retirement significantly declines the cognitive health in old age retirement from a highly complicated job negatively affects cognitive abilities in old age a sudden discontinuation from an intellectuallychallenging job makes the deterioration in cognition very pronounced a long involvement in an occupation mainly in the informal sectors stimulates mental abilities up to a certain time employment in lowgrade jobs and poor educational performance often have a degrading effect on financial security in old age lack of pension and social security in the informal labor market compels the elderly to continue to work beyond the statutory age of retirement individuals having low levels of education and those belonging to poorer wealth quintiles experience a stressful impact on cognition in old age 31 in the upcoming decades more years are expected to be added to the life expectancy of the 60 years and older population there is a pressing need to address the issue of retirement in regard to the pension system and health expenditure for the elderly population in india 32 physical infirmities during old age reduce the working capacity at the same time the need to engage in work to overcome financial distress leads to dissatisfaction and depression the notion of better cognitive functions due to an association with labor market was not supported by our study since financial distress is a reason for continuing work 2 the effect of retirement on the decline in cognitive outcomes is relatively lower for the age group of 6069 years this is substantiated by the theory of relieved effect on mental functioning retirement from an occupation that is monotonous and repetitive in nature takes away mental worries retirement also provides a fair opportunity to engage in longpending activities having social and cultural value usually known as the honeymoon effect 33 other research suggests that retirement and involvement in voluntary activities meeting with relatives and participation in other social activities results in cognitive preservation 5 the initial increase in cognitive outcome in the age group of 6069 is a good reason to perform socially meaningful activities 14 the indian society acknowledges the elderly for their experience in life and their contribution to social activities 22 for those in the postretirement phase of life or those who continue to work in older ages social participation preserves cognitive functions the interaction between work and social participation shows a positive and significant coefficient with cognition for the selected type in model 4 of multivariate regression retirement accompanied with more social participation is beneficial for the maintenance of cognitive health in the later years of life as exhibited by fig 1 by contrast more social participation by those presently working affects their health as they suffer from agerelated functional restrictions other studies support our findings in that more frequent social participation restricts the cognitive decline regardless of an individuals level of cognition or physical activity 34 therefore strong social support for the elderly is required to preserve wellbeing in the later stages of life our study didnt find any gendered pattern for work and social interaction through interactions in the multivariate analysis this opens the scope for further research to understand the particular patterns for cognitive decline exclusion from incomegenerating activities along with reduced social participation can lead to a longterm deprivation such exclusion has a strong impact on mental health and it also escalates the prevalence of chronic diseases and functional limitations the evidence of a lower mean score for cognitive scores for depression calls for more social ties to deal with chronic health conditions among the elderly 22 the present study is a first effort to look into how work status and social participation affect an individuals mental health the crosssectional nature of the data limited the understanding of the longterm effect on cognitive health at different working conditions as age progresses we were also limited to include social security measurement to control the effect on cognitive health in old age however all of the possible risk factors were taken into consideration conclusion cognitive aging among the elderly is attenuated by an active participation in work and social activities retirement from work has a significant impact on the cognitive health of the elderly cognitive decline resulting from retirement can be contained if social participation is increased in the later years of life to control the stressful negative pathways of cognition it is essential to facilitate the participation of the elderly in social interactions cognitive health in later years is a matter of concern as we vigorously discuss healthy aging this study highlights the pressing need for care and support in the old age to preserve cognitive health it also makes a case for modifications in the policies and programs on labor participation with an emphasis on increasing the retirement age to promote healthy aging additional file additional file 1 table s1 description of the questions and algorithm used for construction of depression in whosage survey table s2 descriptive statistics for the cognitive scores of the elderly in india whosage survey 200810 table s3 competing interests the authors declare that they have no competing interests

introduction transition to the oldage marks a change in work and social participation socioeconomic and physical conditions arising from this change pose a risk for cognitive outcomes among the elderly gender shows different pathways to deal with the pattern of participation and to maintain cognitive health in india work participation in the oldage is an outcome of financial deprivations and lack of support at the same time alterations in social interactions can induce stress and precipitate cognitive decline in oldage a dearth of studies in this domain motivates us to estimate the effect of change in work and social participation on cognitive performance of the elderly in the indian context methods the study has used the crosssectional data on 5212 elderly from the world health organizations study on global ageing and adult health wave 1 200708 in india a composite score for cognition was generated interaction between gender work status and social participation with respect to cognition was performed using multivariate linear regression a linear prediction of the cognitive scores across all levels of social participation was postestimated thereafter results the study found that the elderly who were presently working and showed more social participation had a higher mean score for cognitive performance than their counterparts results of regression did not indicate any gender interaction with work or social participation participation in social activities sometimes by those who were retired or presently working showed a positive and significant coefficient with cognition among respondents the postestimated values for cognition specified that retired and presently working elderly had higher cognition scores in the age group of 6069 years cognition scores were higher for those who were retired and did more social participation as compared to the other elderly conclusion cognitive aging is attenuated by higher participation in work and social activities adequate financial schemes or the pension system can protect the elderly from developing further stress retirement at an appropriate age along with a reasonable amount of social participation is a boon for cognitive wellbeing hence building more support can contain the detrimental effect of participation restriction on cognitive outcome among elderly

introduction modern online sociotechnological systems are producing a deep change in our traditional networking paradigms and in the way we communicate with each other at the same time online social media constitute nowadays efficient and fast means to group together many social agents around a common issue in this way new types of economic financial and social phenomena are arising an example of the latter is given by the socalled arab revolts which have materialized thanks to these new communication platforms the protests have been mediated by the use of social networks such as facebook twitter and youtube which have been critical for the birth and consolidation of campaigns involving strikes demonstrations marches and rallies on the other hand online social networks not only modify in a radical way the dynamics of information and opinion spreading but are also making our world even more global more importantly these platforms generate an enormous amount of timestamped data making it possible for the first time to study the fast dynamics associated to different spreading processes at a systemwide scale these novel and rich data niches allow testing different social dynamics and models that would otherwise be highly elusive with traditional datagathering methods additionally the availability of data enables the study of phenomena that take place on time scales ranging from a few minutes or hours to a yearlong duration an example of the former kind of fast dynamics is given by large sport or cultural events whereas cooperative content production such as the case of wikipedia typically occurs in months or even years thus in a much slower time scale in this paper we study the structural and dynamical patterns of the network made up by twitter users who have been involved in a social phenomenon that is currently taking place in spain the socalled may 15th movement this movementinthemaking had been brewing for a while in the social media but took off on may 15th when the first demonstrators camped in a central square in madrid spain from that moment on the protests and camps spread throughout the country as many of the adherents are online social media users the growth and stabilization of the movement was closely reflected in timestamped data of twitter messages which we have gathered and analyzed this will allow us to elucidate the mechanisms driving the emergence of this kind of social phenomenon and whether it shares dynamical and structural features with other natural social and technological processes 12 additionally on more general scientific grounds a social phenomenon like the 15m movement is an excellent opportunity to understand network formation processes and online spreading dynamics the ultimate aim is to further advance our understanding of this kind of dynamics and eventually be able to make predictions based on real time data monitoring in what follows we present the results of our analysis on the one hand we statistically characterize the structural patterns of the network of users who sent or received tweets containing keywords related to the 15m movement we find that this network displays the typical features of other networks in nature such as scalefree degree distributions a community structure at the mesoscale and high structural robustness 12 on the other hand we have also analyzed the dynamical patterns characterizing the spreading of information over the 15m network our results show that the 15m diffusion dynamics is highly asymmetric admittedly a relative large fraction of the system is actively trafficking but a great part of the overall traffic is delivered to a few users that do not pass them anymore thus constituting a sort of information sinks we round off our analysis by comparing our results with those reported in the literature for other kinds of online dynamical processes methods ethics statement the data are publicly available as they come from a public online social site however any private information has been analyzed anonymously data analysis the data used in this study is a set of messages that were publicly exchanged through twittercom the whole timestamped data collected comprises a period of one month and it was archived by a local startup company cierzo development ltd using the smmart platform this platform is evolving into a new concept called open social crm which combines concepts in monitoring tools crm tools social tools and a philosophy of open innovation the company restricts its collection to messages in spanish language that come preferentially from users within or related to spain the internals of data collection are private to the company but basically 23 hours of data are homogeneously collected each day always leaving the same timeframe to readjust the database due to the introduction of new spanish nodes purging of the nonspanish related ones etc to filter out the whole sample and choose only those messages related to the 15m movement we selected 70 keywords which were systematically used by the adherents to the demonstrations and camps next the extracted sample was examined for missing hashtags of the top ten only one of them was not in the selected set this being likely related to its bilingual nature acampadabcn the filtered data set appears to be representative enough of the total traffic related to the 15m movement produced during the period analyzed as a matter of fact a comparison with other databases such as topsycom which aims to collect the whole set of twitter messages shows that for the same period there were about 390000 messages with the word acampadasol and 190000 for the hashtag nolesvotes our sample is made up of 189000 and 66000 messages and hashtags respectively ie roughly above a third of the total number of messages once this process is finished the final sample consists of 581749 tweets out of which 46557 were identified as retweets of unknown origin and therefore were discarded on its turn these tweets were produced by 85851 different users to complete the data set we located the references to other users inside each message these references are marked in the system by an arobase a user receives a notification usually via email each time a mention happens and the messages having mentions are also copied to a special tab in the user interface the total number of messages having at least a reference was 151222 in some cases the tweet is addressed to more than one user so that the total pairs extracted from these messages was actually higher 206592 this is the number of directed arrows in our network we stress again that our network is a dynamical instance of a larger underlying network finally although not directly related to the study presented here but important for complementary studies data for all the involved users were scrapped directly from twittercom using a cloud of 128 different nodes of a subnet the scrap was successful for 84229 users for whom we also obtained their official list of followers moreover about a half of them can be associated to a location which is later translated to geographical coordinates via a standard geolocalization service from yahoo it is worth remarking that the extraction of followers gave a list in the order of 3 millions users which roughly coincides with the order of the audience estimated by twitter in spain results and discussion the availability of timestamped data allows us to closely track the birth and development of the network made up of users who exchanged tweets related to the 15m movement during the period analyzed in this network every node represents a user while a link between two nodes is established whenever they exchange a message we have made a movie that reproduces the temporal evolution of the networks and the dynamics of messages exchange during the period analyzed the reader will note the highly dynamic character of the network as well as the dimension of the social phenomenon being analyzed the network constructed as described above is weighted and directed ie a link from i to j means that i sent at least a message to j and the weight of the link ij stands for the actual number of such messages therefore the adjacency matrix of the network is not symmetric moreover it is worth noticing that we always work with accumulated data such that the network at a certain time t includes every message produced at any time tƒt ie once a link is established it connects the two end nodes forever once the network is built we are able to characterize it from a topological point of view within the framework of complex network theory 12 in doing so we discuss local and global descriptors as well as the network structure at the mesoscale level additionally we also analyze the dynamics of information spreading over the 15m network and compare our results with those already reported for other dynamical processes that are mediated by the web 20 network growth and structure the first point of interest concerns the structural growth pattern we wonder whether a collective mobilization of thousands of agents demands a slow progressive increase in size or rather social networking platforms enable an abrupt emergence in figure 1 we present three snapshots of the system for different days relative to day d colors stand for the age of the node early active users are coded in yellow where those that adhere the network in successive days are coded in green red etc black is left for the latest adopters besides the size of the nodes has been made proportional to their activity taking into account both incoming and outgoing tweets even this simple representation of the evolution of the 15m network is already indicative of the growth in the number of agents once the movement took off and time goes on the results depicted in the bottom panel of figure 1 further illustrate the way in which the network evolves by gaining adherents the figure represents the proportion of active nodes at time t in the giant component relative to the total number of users in the network at the end of the growth process as we can see from the figure the formation of the network and its later increase in size does not proceed in a gradual proportional process but in a sequence of bursts concentrated in just a few days obviously this process is driven by the events surrounding the movement as mentioned at day d the protesters decided to camp at puerta del sol square in madrid which in turn elicited huge attention from the media and made the difference as far as the spread of the movement to a country wide scale concerns besides from our data it appears that the number of active users saturates after dz7 it is interesting to note that in may 21st the day preceding local and regional elections more than the 80 of the network was already formed beyond structural growth a second key aspect of the network under study concerns the distributions of strengths the strength s of a given node i is defined as usual by the sum of the weights of the links that are incoming and outgoing to node i in our case it is also important for the discussion that will follow to further divide this magnitude into two contributions one the one hand we have the strength derived from the weights of links incident to the node s in this magnitude accounts for the total traffic that a given node receives from its neighbors conversely s out represents the sum of the traffic generated at a node ie the number of tweets this user sends out additionally let p and p be the cumulative distributions of both strengths which we can be measured at different instants t of the network development figure 2 shows the cumulative distributions of the previous quantities for several times as can be seen even before the occurrence of the events that triggered public protests on day d both p and p follow powerlaws p s c but with different exponents similar plots for the degree of the nodes exhibit the same behavior it is wellknown that the statistical properties of these variables in other technological social and natural systems are also heterogeneously distributed therefore the fattailed distributions that characterize the topology of the 15m network are not unique but are rather ubiquitous in nature nonetheless the fact that the 15m network is scalefree has deep consequences regarding a number of relevant issues including its origin complexity robustness and from a dynamical point of view the way in which information flows over the system as the network obtained comes from the activity of the nodes the heavytailed distribution of both nodes degrees and strengths suggests a dynamics lacking any typical or characteristic scale different colors stand the age of the nodes evolution of the systems giant component relative to the final size of the network note that growth does not proceed progressively but it rather explodes from day d due to socially relevant events on that date doi101371journalpone0023883g001 on the other hand the dynamical asymmetry between incoming and outgoing degrees or strengths is not surprising either indeed individual behavior which ultimately determines the resulting dynamics is an intended social action but the emergent properties of the collective behavior of agents are unintended 3 essentially subjects decide when and to whom a given message is sent therefore the aggregate behavior of all agents and their popularity result from individual choices this is what is reflected in the in and out distributions as a matter of fact the exponent of the power law characterizing the degree probability distribution p lies in the interval ½23 as usually found in most realworld networks interestingly spreading dynamics such as rumor and disease propagation processes are most efficient for scalefree networks whose exponent is precisely in this range 4 5 6 finally the strength distribution for the tweets sent p also resembles a power law function with an exponent larger than 3 although in this case the distribution exhibits an exponential cutoff this might be due to the fact that sending messages has an associated cost in terms of bandwidth availability the cognitive capacity to produce different messages and ultimately an unavoidable physical limitation to type them 7 8 9 another aspect of capital interest regards how the overall traffic is generated and delivered one of the main consequences of the functional form of the strength distributions is presented in figure 3 the emergence of hubs namely the signaling feature of scalefree networks leads to a predictable oligopoly in the way information is spread in figure 3 we observe that the number of tweets sent grows with the number of active users of the network the curves corresponding to different days nearly collapse into a single one this means that as users join the network the traffic generated scales accordingly moreover the figure indicates that for instance roughly the 10 of active subjects generate the 52 of the total traffic this is another indication of the dynamical robustness of the network to random failures but at the same time of its fragility to attacks directed towards that 10 of users more remarkably the results depicted in the figure are in sharp contrast with the activity patterns corresponding to received tweets in this latter case as time goes on the number of instrength hubs decreases as shown in the figure by dz10 less than 1 of users receive more than 50 of the information as we will show later on these nodes correspond to authorities or mass media which the adherents identify as main receptors of or potential spreaders for their messages however what at a priori seems to be a good choice turns out to be harmful for the process of information spreading as a matter of fact we have checked that these hubs which we call information sinks do receive a lot of messages but rarely act as spreaders within the network as a consequence almost all messages that arrive to those nodes are not redelivered and hence lost in this sense our results show that while the delivering of information is shared by a relative large number of users that keep the social temperature of the movement most of this information is simply directed towards a few highly connected targets that might not pass the voice any longer nonetheless the information exchanged is public and users can therefore access it this would however imply an individual action that is not captured in our twitter data community structure the modular structure is pervasive in many natural social and technological networks generally speaking modules are islands of highly connected nodes separated by a relatively small number of links this mesolevel skeleton is likely to be relevant to understanding dynamical processes in networked systems agents strength distributions for both received and sent messages display a powerlaw behavior as early as at d 2 the fattailed distributions indicate that the 15m network is scalefree with the implications this fact bears note that the exponents that define the powerlaws differ significantly between sent and received messages doi101371journalpone0023883g002 figure 3 information flow the figure represents the density of tweets received and sent as a function of the cumulative fraction of active users for each day data are normalized by the number of active users at that date as a reference the horizontal line corresponds to 50 of emittedreceived tweets note that on dz10 less than 1 of the nodes receive half of the messages on the contrary the pattern of tweets sent hardly evolves from the beginning of the movement 10 of the active nodes produce 50 of the messages this asymmetry is coherent with the differences observed for the strength distributions doi101371journalpone0023883g003 in social networks tend to gather with those who share cultural traits or professional interests 10 11 12 13 and more specifically political communication networks tend to exhibit a clustered structure along political opinion lines 1415 we have analyzed the community structure of the 15m network once its size stabilizes ie at t dz10 we have applied a random walkbased algorithm that optimizes a map equation on a network structure 16 although alternative community detection algorithms are at hand we chose the previous strategy because it is suited for networks as it is actually our case in which the dynamics of information flow is relevant these type of algorithms rely on the intuitive idea that if communities exist a random walker tends to get trapped in them due to their dense withinconnectivity 16 17 18 the output of such information theoretic algorithm is a partition made up of 6388 modules most of these communities have less than ten nodes we focus our analysis on the 30 most important modules from a dynamical perspective ie those which concentrate most of the random walkers activity these modules do not necessarily coincide with the first 30 communities ranked according to their size but all of them contain over 100 nodes figure 4 shows these 30 communities in a compact view 19 furthermore each community is assigned a tag corresponding to the most central node in that community again these nodes have been identified as being dynamically dominant within their modules thus they play an outstanding role in the dynamics of information our results show that modules are highly hierarchical and that nodes that are central to their communities ie local hubs are mostly hubs at the global scale as well the mesoscale structure allows to get deeper insights into social aspects of our case study first tags identifying the 30 largest communities are highly heterogeneous 6 of these modules correspond to important mass media which points to the otherwise intuitive fact that users rely on these agents to amplify their opinion the same can be said of 3 modules corresponding to famous journalists more interestingly 7 modules correspond to online activists andor veteran bloggers these agents are unknown to most people but they are present in the network from its birth and enjoy a solid reputation that facilitates their being considered a reference in the movement remarkably 7 modules are formed by camps in 7 different cities madrid is of course the main one as the movement began there other cities are barcelona granada zaragoza valencia seville and pamplona the fact that communities are geographically defined suggests some additional conclusions the mesoscale reflects the autonomy of each of the assemblies throughout the spanish geography each of these modules hardly connects to any other indicating a low communication between them the exception to the previous point is madrid each minor camp holds a strong communication interchange with the community represented by acampadasol taking points and together it can be safely said that the movement is highly centralized because in most cases a peripheral settlement is only influenced by madrid and one or two minor ones finally despite the potential of web 20 communication platforms data indicates that these media are mostly used to communicate with geographically close people in other words the network is global but communication is mainly local this is further verified in table 1 where we have summarized the percentage of people whose geolocated information coincides with that of the module popularity evolution the web 20 has brought to network science the challenge to deal with highly dynamic changing structures besides source and target nodes and a link between them one must now consider a new ingredient time in this context an interesting issue is related to the evolution of particular nodes understanding how an element comes to existence and develops of further interest is to elucidate how a subset of these networks components ends up as a popular entity this is a key aspect in network development as popular agents eventually have an impact on other agents opinions acting as a referent be those opinions related to politics culture or business to capture the dynamics of popularity we follow the framework recently proposed in 320 the natural quantity to measure popularity in a communication network is the number of messages that arrive at a node which corresponds to that nodes instrength s in and the rate at which s in changes hence a way to grasp how the activity of a node evolves is to consider its logarithmic derivative ½dss t s t 1 ie the relative variation of strength in a time unit figure 5 displays the evolution of the latter variable for some arbitrarily chosen nodes among those that are information sinks beyond an initial surge typically observed in many nodes the time series of the logarithmic derivative evidence a bursty behavior fluctuations depend on exogenous events in a strong parallelism with the external circumstances that drive the whole networks strong changes it is noteworthy that these patterns closely resemble other less conflictive examples of popularity evolution in the wikipedia or the web 20 on the other hand figure 6 shows how bursts are distributed according to their magitude for two different time intervals but the same time granularity the observed pattern which is the same regardless of the time intervals under consideration clearly shows heavytailed distributions again in close resemblance to results already reported for other webmediated dynamics 20 and a variety of critical phenomena in physical economic and social systems as a matter of fact a simple model can account for the observed bursts distribution the socalled rank model is specially conceived for networks in which prestige rather than degreebased preferential attachment plays a central role to determine nodes connectivity 21 the rank model depends on a prestige measure that is used to rank nodes in this model the probability that a new node that joins the network at tz1 connects to an older one j is given by p r a j p t i 1 r a ið1þ where r j is the rank of node j and aw0 determines the exponent c of the resulting powerlaw degree distribution p such that c 1z 1 a figure 7 compares the bursts distributions resulting form the data and from the model the results shown correspond to the case in which nodes are ranked according to their age and a has been set to 09091 moreover we note that in order to simulate the non steady growth of the network we have considered for the synthetic case that 1 day has gone by when the size of the network being generated coincides with that of the empirically assembled network for that time as we can see from the figure even under the simplest rank rule the burst magnitude distribution is nicely reproduced as for our specific social context the previous results do not imply that the driving mechanism behind the evolution of the 15m network is that simple but illustrate that bursty activity of this sort can be produced by generic mechanisms given that this selforganized activity is widespread in nature there are no reasons to consider that the network has its origin in external actions nonetheless it table 1 geographic origin of nodes in regionbased communities community tag area fraction of users from same area acampadasol madrid 54 acampadabcn barcelona 81 acampadavlc valencia 63 acampadazgz zaragoza 82 acampadagranada granada 53 acampadasevilla sevilla 83 15mpamplona pamplona 71 regionbased modules are mostly formed by nodes whose geographical origin coincides with that of the most central node in the community this statement is clear for almost all these modules except in the case of madrid and granada the case of madrid is not surprising given that acampadasol is the reference of the whole movement thus the community organized around this actant is a more heterogeneous one granada is a more intriguing exception doi101371journalpone0023883t001 must be pointed out that although the rank model grasps the main observed trends both regarding structural characteristics and dynamical facts yet other important aspects extracted from the data are not captured by the model these limitations demand model refinements beyond the scope of the present study conclusions the social phenomenon here presented as a case study is a collective endeavor that is expressed at many levels ranging from public demonstrations and camps to the presence of news in the mass media in this work we have analyzed data from timestamped online activity in a specific social networking site during the formation and stabilization of this social movement from a scientific point of view these data represent a challenge as most network studies typically deal with a static structure undoubtedly there are many facts that can be easily identified as the grounds of the 15m movement among them the worldwide economic crisis and the impact it has had on society nonetheless the particular events that triggered the growth of the whole movement remain unknown and are beyond the scope of figure 5 popularity dynamics the increase in the strength of the selected nodes markedly changes after day d the logarithmic derivative dss provides a finer interpretation in terms of the bursts in popularity democraciareal had been an active agent long time before d seemingly the movement was gathering strength a newer user in the social network emerges and quickly takes over from d onwards as the reference of the whole movement on the other hand two rightand leftwing newspapers el mundo and el paı ´s respectively undertake similar changes which indicates that a large sets of nodes identified them as relevant actants in the context of protests note however that this does not imply that the same nodes are active senders too as a matter of fact they are not doi101371journalpone0023883g005 figure 6 burst size distribution popularity efervescence in the whole system unsurprisingly most nodes hardly undergo noticeable changes in their popularity however a small fraction of nodes does experience significant increases this pattern is not exclusive of this communication network doi101371journalpone0023883g006 this work addressing these questions would probably require an indepth semantic analysis of the contents of interchanged messages from its onset our statistical characterization of the communication network built from tweets exchanged between adherents reveals a strong resemblance to wellknown phenomena in natural and manmade systems which are admittedly selforganized additionally the 15m movement also raises relevant questions with sociological consequences we argue that information centralization as well as patterns of popularity growth are indicative of a tendency towards a hierarchical structure opinion leaders emerge spontaneously and minor actants devote much energy to communicate with them this proclivity is coherent with economy of attention 22 ie the system tends to avoid the overabundance of opinions to prevent scarcity of attention but raises doubts about the possibility of converging to an egalitarian social system in which information flows and is received in an efficient manner as far as our analysis concerns we have shown that in a dynamics such that the one at work for our case a relative large number of information sources exist which is behind the robust functioning of the system conversely communication sinks where information is lost are also generated on the other hand our analysis of the community structure reveals some interesting facts geocentered modules are abundant but ideological or famerelated ones are also remarkable it is important to keep in mind that timestamped data is the dynamic result of the activity on top of a more stable underlying structure that of following and followers in the social networking site for this reason the communication network we observe is everchanging and we argue that modules within it have not a straightforward interpretation finally we have studied the patterns by which nodes become increasingly more visible results indicate that popularity growth in the context of political conflict does not display significant differences from other less fashionable examples popularity is dominated by a fluctuating behavior and popularity burst distributions lack of a characteristic scale this fact connects the dynamics of popularity with other critical phenomena in many natural and artificial systems in summary online social networks and the web 20 provide new challenges to network theory events in the real world ranging from economic phenomena to political protest stand as the driving forces leading to the emergence of complex timeevolving communication patterns in this scenario network theory stands as a suitable tool to unfold the structural and dynamical facets of such emergent systems

the number of people using online social networks in their everyday life is continuously growing at a pace never saw before this new kind of communication has an enormous impact on opinions cultural trends information spreading and even in the commercial success of new products more importantly social online networks have revealed as a fundamental organizing mechanism in recent countrywide social movements in this paper we provide a quantitative analysis of the structural and dynamical patterns emerging from the activity of an online social network around the ongoing may 15th 15m movement in spain our network is made up by users that exchanged tweets in a time period of one month which includes the birth and stabilization of the 15m movement we characterize in depth the growth of such dynamical network and find that it is scalefree with communities at the mesoscale we also find that its dynamics exhibits typical features of critical systems such as robustness and powerlaw distributions for several quantities remarkably we report that the patterns characterizing the spreading dynamics are asymmetric giving rise to a clear distinction between information sources and sinks our study represents a first step towards the use of data from online social media to comprehend modern societal dynamics

introduction over the last 20 years social media has become an indispensable part of modern civilization while sites like facebook and twitter emphasize personal connections and networks others offer a space for content creation information sharing and discussion both private and public around shared interests users of these sites often use a pseudonym and may take care to conceal their reallife identities but nonetheless participate in communities that both reflect cultural norms and affect society at large advice forums may fall into a few categories some like stack exchange offer more of a pragmatic howto or problemsolving service with an emphasis on topics like programming and it the information exchanged rarely requires personal disclosure outside what may be relevant context to address technical issues others like the recently shut yahoo answers see a broad range of factual and opinionbased inquiries but offer only superficial and often counterfactual results without any moderation or filtration reddit a popular social news and discussion site founded in 2005 hosts over 4000 topical forums or subreddits each with its own rules conventions participants and moderation team popular forums range from the practical to the political from ask an expert to sharing everyday tips and tricks each subreddit offers not only a space to share and learn about a particular topic but a community built around a shared affinity or attitude regular participants through their pseudononymous profiles often get to know each other and reinforce the culture of that community reddits advice forums such as rrelationships and ramitheasshole offer semistructured discussions around social interactions that also reflect and contribute to discourse off the site as posts are shared and discussed widely on other social platforms these forums provide posters with an opportunity to provide a uniquely high level of personal disclosure while remaining anonymous the rrelationships and ramitheasshole subreddits were chosen since they are frequently the source of bestof listicles 1 and other media coverage exploring themes around sexism 2 and politics 3 as well as scholarly research 4 we are interested in analyzing the users interaction metrics and text of some of these forums as well as drawing distinctions between them based on our observations of the target subreddits we predicted that most users requesting advice are in their 20s and 30s and are evenly split between men and women although in general male users outnumber female users on reddit by about 21 5 we believe the demographics are more evenly split on advice subreddits because they appear to be more popular with women the lower number of posts by males seeking advice can be attributed to the societal definitions of masculinity and advice seeking which is considered a predominantly female genre both historically as well as academically 6 also posts have more interaction if they are entertaining in some way for example if the post is outlandish or if the advice requester is arguing with the commenters advice forums reinforce cultural norms and moral decisionmaking in a crowdsourced fashion forum posters can appeal to the wisdom of the crowd and find themselves redeemed or appropriately chastened while all participants and observers gain new insight into good and bad behavior what biases might be inherent in this system who seeks advice from such a forum and what do they hope to learn from it what is it about the adviceseeking itself that garners community input by answering these questions we can gain valuable insights into how users interact with social media platforms in this paper we have explored these questions by applying various natural language processing techniques on reddit post data we created a dataset containing the natural language of reddit forums which contain massive amounts of genuine interactions that are largely uninfluenced by third party stakeholders the main contribution of this paper is an exploration of how natural language processing tools and techniques can be used to examine reddit whether those examinations are fruitful and limitations and opportunities with this type of data our research questions could be summarized as follows rq1 what natural language features can we extract from unstructured reddit posts rq2 how do online communities with specific and similar interests compare in terms of their natural language features such as sentiment scores and high frequency words rq3 is there any correlation between a posts natural language features and its engagement metrics the introduction is followed by section 2 which describes current research using reddit data and explores related psychological and humancomputer interaction works next section 3 includes the description of the data collected section 4 explains the feature generation process and the machine learning algorithms used for analysis section 5 discusses the results of our analysis while section 6 provides an overall summary of the work done points out the limitations and provides direction for future research background and related works the value of social media sites as an information resource is well established on a surface level various social media sites including facebook twitter reddit and numerous others appear relatively similar however each site contains information flows that dictate the depth truthfulness and originality of interactions cinelli et al 7 explored the frequency of echo chambers across different social media platforms finding that facebook and twitter are more prone to siloed information exchanges choi et al 8 compared social media sites to learn their individual qualities as resources for analysis they measured frequency of posting presence of external links and uniqueness of word usage these types of analysis provide a framework for selecting the appropriate social media site for a given research question among the major social media platforms reddit is a particularly rich resource while reddit communication remains entirely digital nevard 9 suggested that reddit is a public sphere that extends beyond the boundaries of the reddit environment and influences individuals as they interact with society at large yadav et al 10 highlighted the absence of marketing schemes on reddit as individual users can report spam this feature of reddit ensures the genuineness of the individuals by reducing incentives for profit and discouraging misaligned motivations another key feature of reddit is the presence of metadata provided by the author of the posts this often appears in a shorthand format that can be extracted using natural language processing tools 11 collisson et al 12 highlighted this feature and concluded that reddit seems to be an ideal source of realworld dyadic data from people seeking and offering relationship advice reddit is built upon a vast and diverse ecosystem of subreddits the benefits of reddit as a data source are common across many of these subreddits and it is common for researchers to draw on individual subreddits to collect social media data that fits the criteria for their work for example collisson et al 12 specifically examined the subreddit called rrelationships where posters seek individualized relationship advice the subreddit ramitheasshole is an immensely valuable expression of human morality and ethics that proves useful across multiple domains of study including gender psychology ethics and morality human computer interaction and sociology obrien 13 created a public dataset of ramitheasshole posts to support such explorations studies examining gender differences on reddit endeavor to profile the experiences and behaviors of different gender groups across the site this type of profiling could lead to improved understanding of gender dynamics transferable to a broad range of social interactions thelwall stuart 14 found gender differences in participation rates across different subreddits flesch 15 established the practice of collecting gender information from posters selfdeclaration and confirmed the value of extracting linguistic features from the reddit corpora to understand gender differences as they relate to different discussion themes while these works capture gender participation within the reddit ecosystem li et al 16 replicated established gender theories in anonymous digital communities their results showed a connection between emotional disclosures and assumptions of female identity the anonymity present on reddit creates a unique space where posters are often willing to disclose personal experiences more candidly than normal this creates a vast collection of personal accounts that psychologists can use to research the human mind using unobtrusive methods curiskis et al 17 studied data processing techniques to improve the usability of such data because a careful analysis of linguistic features can reveal significant insight into the cognition and emotion of both posters and commenters 121819 jaerch et al 20 investigated the relationship between user reputation and engagement on the site the possibility of transferring results across subreddits is a persistent theme in the literature most notably botzer et al 4 classified the moral judgements of ramitheasshole then applied that knowledge to numerous other subreddits their results revealed characteristics of individual posters whose behavior is deemed to have a negative morale valence botzer et als 4 work is relevant from a psychological perspective but also as an example of the value of reddit for designing artificial intelligence the ramitheasshole subreddit asks participants to tag the original posts as a judgement of the original posters behavior in addition to botzer et al 4 zhou et al 18 and lourie et al 21 utilized ramitheasshole for the development of machine learning systems that classify or generate ethical decisions dataset to answer our research questions it was necessary to obtain data from two of the popular subreddits first we collected a sample of posts from two popular advice forums on reddit ramitheasshole and rrelationships we used the reddit api to scrape the top 1000 posts in the month prior to the collection date from each subreddit 22 in all we collected 989 posts from ramitheasshole and 977 from rrelationships features collected include unique post id created timestamp post title and text gilded count flair label number of comments overall score and upvote ratio in table 1 we provide a brief summary of the features for each of the two subreddits we processed the text and used a variety of algorithms to generate scores and counts to add to the dataset columns added to the dataset included word count sentiment cosine similarity a count of instances of masculine and feminine words in each post and the age and gender of the original poster each of these will be explored later in the paper as the text analysis process itself creates interesting pieces of analysis feature methodology in this section we explain how we generated and used quantitative data and encoded labels to perform regression analysis and clustering our analysis as explained in the following subsections helped us to identify patterns in the data text analysis analyzing reddit posts without performing text analysis would be very limiting since most of what makes reddit interesting is in the rich unstructured writing that often reflects the social norms and rules of each subreddits distinct community because we were looking at advice forums in particular there was a tremendous amount of text to process and little variety in terms of post type the text analysis processes described here address rq1exploring the top 1000 posts from ramitheasshole and rrelationships by computing quantitative values from the two text corpora preprocessing varied by task but typically involved converting text to lower case removing extraneous characters and in some cases stemming lemmatization and stopword removal we added a column to the dataset that concatenated the post title and the body so all relevant text could be easily accessed from a single document sentiment there is a wide range of sentiment dictionaries available for use with python for this research we made use of two afinn and vader according to a process laid out by caren 23 afinn afinn analyzes preprocessed text by comparing it to a list of around 2400 words each with positive or negative integer values and applying a total score to each document in a dataset because this number is affected by the length of the document itself and the word count of each post varies considerably we further calculated an adjusted afinn by dividing the original afinn score by the document word count the scores themselves are not necessarily that interesting but the summary statistics for different flair values are somewhat enlightening for example ramitheasshole posts judged nta or not the ahole have an overall lower afinn score than those judged yta or youre the asshole among rrelationships posts which have a wider range of flair infidelity has a much lower average and minimum score than the rest vader vader differs from afinn in that it analyzes the whole document not just individual words therefore context and emphasis are considered by vader the polarity scores reflect the proportion of a document that is positive negative and neutral and there is also a combined score 23 again these scores may not be much interesting on their own but illustrate the variability of the data demographics the nature of both the forums suggests a lot of gender politics are at work digging into that is beyond the scope of this paper but we are interested in trying to extract and quantify gender and other demographic features from these unstructured text documents that nonetheless follow some conventions around expressing identity extracting demographics because posters often follow a similar format to post their age and gender or 34f it is possible to extract demographic information to gain a better understanding of the people who post on these subreddits we used the regular expressions python library to extract information that followed the pattern number number letter or letter number number plus the three characters before this pattern next we searched for instances of i me or my which would imply that the poster was discussing their own age and gender overall we were able to extract demographic information for 653 posts using this method a manual review of the dataset was conducted to ensure accuracy and fill in demographics data the script missed the review more than doubled the coverage of demographics data though many posts did not include this information figures 1 and2 show the post count per subreddit by identified gender and age in figure 2 the ages have been grouped by range and all unknowns have been excluded from the analysis while the number of unknown genders reduce our sample size for the study we prefer to acknowledge the complexity of gender in terms of identity disclosure and language instead of assuming a binary gender system gender and age were added to the dataset only if they were explicitly stated in the post and did not include age that were described as a range such as 20s or 30s we avoided coding genders for posts that one might assume were written by a binary cisgender heterosexual man or woman because although we observed a very low number of nonbinary posters in our dataset we cannot be certain that is representative of the user community we did not for example assume that just because a person referred to their husband they were automatically a wife unless the poster explicitly identified themselves or used clearly gendered language to refer to themselves their gender remains unknown masculine and feminine words overall rrelationships had 90 coverage for poster demographics while ramitheasshole only had 64 coverage moreover the manual review process made some of the differences in identity disclosure practices between the subreddits obvious rrelationships posters nearly always shared their age and gender as well as the age and gender of people they write about in a semistructured format near the beginning of a post ramitheasshole posters however did not consistently share this information and did not always use the standard format seen in other forums in fact our review identified only gender or age for 138 posts in that subreddit compared with only 45 partial demographics in rrelationships curiously while ramitheasshole posts were less likely to explicitly disclose the posters identity they routinely state the ages and genders of people the post discussed the posters ages ranged from 13 to 60 the gender breakdown can be seen in figure 1 caren 23 described a process for making use of custom and specialized word lists with male and female words as an example while the original source of those lists a browser addon that swaps gendered words on websites included hundreds of words to accommodate a wide range of content our use case is more narrow so simplified brief lists of masculine and feminine words were created to suit our purposes primarily covering gendered words for related people adviceseekers are likely to post about such as mother and father girlfriend and boyfriend wife and husband we considered whether gender neutral word lists could also be created to include genderdiverse posters but decided against it as it seemed likely to result in false positives similarity there are many vector space modeling tools that calculate cosine similarity scores for a set of text documents we wanted one that would help us explore both similarity and uniqueness and let us add a single score to our dataframe for further analysis doc2vec compares documents and assesses the similarity between them on a ndimensional space the use of doc2vec has been common for similar tasks such as identifying unique movie plot descriptions 2425 first we transformed the corpus into document vectors then trained an autoencoder neural network to predict the vectors the autoencoder accuracy score takes into account both predicted and actual vectors with any result above 095 being excellent the scores for each subreddit surpassed this threshold further we generated the top five most unique posts for each subreddit to get the singular similarity score and apply it to each document we calculated the cosine similarity between input vector and the output vector of i th data point to better understand the content of the posts in rrelationships and ramitheasshole we extracted a list of post titles parsed the text into individual tokens and examined the nouns and verbs they contained then we classified and applied parts of speech tagging using the python nltk library to reduce token redundancy we normalized verb and noun tokens then filtered by base word to group variants and sorted by frequency feature generation features 14 in the following list were generated directly from the reddit api we define these reddit features as interaction metrics that may be a predictable outcome the rest of the features numeric and required for statistical analysis were generated using the text analysis processes described in the previous section and can be described as follows 1 gilded numeric value between 0 and 4 denoting the number of paid gold stars that were given to a particular post 2 numcomments numeric value between 0 and 6821 indicating the number of comments on a post 3 score numeric value between 1 and 35188 representing the total number of upvotes minus the total number of downvotes 4 upvoteratio numeric value between 055 and 1 representing the ratio of upvotes vs downvotes 5 afinnscore calculated numeric value between 98 and 133 representing a measure of sentiment analysis 6 wordcount calculated numeric value between 74 and 6494 7 afinnadjusted calculated numeric value between 22047244 and 27108434 that accounts for word count 8 vadercompound calculated numeric value between 09994 and 09999 representing a normalized weighted composite sentiment score 9 vaderneg calculated numeric value between 0 and 0293 representing the proportion of a text that has a negative sentiment score 10 vaderpos calculated numeric value between 0011 and 029 representing the proportion of the text that has a positive sentiment score 11 mascwords calculated numeric value between 0 and 210 based on a list of masculine words created for this task 12 femwords calculated numeric value between 0 and 337 based on a list of feminine words created for this task 13 cosinesimilarity calculated numeric value between 0167519 and 099984 based on doc2vec 14 opdemographics the age and gender of the poster formatted as agegender 15 opage the age of the poster expressed as a number 16 opgender the gender of the poster expressed as either m f n or unknown results and discussion in the following subsections we discuss our results sentiment polarity to answer rq1 we extracted several natural language features from reddit posts we captured each posters age and gender whenever possible overall word count as well as a count of how many matches against our gendered word lists existed for masculine and feminine words are simple calculations to quantify sentiment we used two algorithms afinn and vader to generate a total of five numeric features afinn score afinn adjusted for post length vader compound vader positive and vader negative to explore language and similarity we generated a cosine similarity score for each post and performed additional text processing to determine how often words were used in each subreddit including partofspeech analysis our comparison of the two sentiment detection algorithms afinn and vader show that for this dataset afinn and vader compound disagree on the positivity or negativity about 35 of the time with vader being more than twice as likely to consider a post to have a positive sentiment when afinn calculates it as having a negative sentiment subreddit comparison to answer rq2 we compared the subreddits in terms of length demographics sentiment commonly used language and gender these features paired with qualitative explorations of each subreddit and and its community rules enabled us to make observations about the nature of personal disclosures and relationships of interest for users of these forums broadly speaking rrelationships posts are on average 55 words longer than the average ramitheasshole post and more than 90 of those include semistructured demographic disclosures compared to just 64 of ramitheasshole posts while manually reviewing the data for agegender disclosures missed by the automated extraction we observed a marked difference in each communitys norms around such information which other researchers such as botzer et al 4 had also observed posters on both subreddits routinely shared identity markers about the subjects of their posts but many ramitheasshole posts failed to explicitly identify themselves in the same way in some cases their identities were stated as part of the post narrative or in an edited comment added to the post body in response to community feedback there were also more partial disclosures that is only age or gender summarizing their ask which could account for the difference in average length the primary rule on rrelationships is that ages genders and relationship length are required components of any post which is not the case on the other forum where the first rule is be civil curiously ramitheassholes strictly enforced rules describe it as not an advice sub though in the context of this analysis wed argue that asking both what one should do and what one may have done wrong have behavioral implications for human interaction the subreddits distinctive rules and structure also affect how we might compare the two on the question of flair on ramitheasshole flair is used by moderators to label judgment ass for predominantly yta responses and not for nta other judgments exist on the site that are not found in this dataset reflecting situations like no ones the ahole and everyones an ahole posts without a final verdict have no flair at all rrelationships uses flair to classify posts by topic predominantly relationships and updates but also nonromantic infidelity breakups and so on posters assign their own flair after submitting a post because of these major differences in the nature of each subreddits flair we were limited in how effectively we can compare them on a feature level for example when we looked at whether there are gender differences among flair labels only a few outliers emerged 45 of unknown gender posts in rrelationships have a new label and may be edited postsubmission to comply with the rules on ramitheasshole where nta outnumbers yta 8to1 and there are more than twice as many female posters than male men are disproportionately likely to receive an youre the ahole judgment a minor difference between the subreddits was observed regarding posts that explicitly called out their use of alternative profiles for the purpose of anonymity 48 ramitheasshole posts used throwaway or anon compared with 27 rrelationships posts this represents too small a sample in our dataset for deeper analysis but could be explored in future with targeted sampling methods sentiment we calculated sentiment using two different models afinn and vader in aggregate vader showed few subredditlevel differences but afinn did looking at afinn scores rrelationships have a wider range of both positive and negative scores compared with ramitheasshole and its average score is slightly positive instead of slightly negative there were some outliers when we further analyzed afinn by flair and gender but they were unlikely to be significant as they represent relatively lowfrequency groups female ramitheasshole posts with no flair male update posts in rrelationships and infidelity posts by posters whose gender is unknown overall sentiment does not offer much in the way of useful differentiation between the subreddits language we compared these subreddits on a word frequency level to get a sense of whether common themes emerged looking at just verbs we found that ramitheasshole post titles disproportionately use verbs like tell want get refuse give and let while rrelationships posters are more likely to be do feel and know it makes sense that users of the formers arguably more aggressive forum might be more interested in what they desire or say while the latter demonstrates more interiority switching to nouns we see prominent use of words for relations but interestingly ramitheasshole posts tend toward family terms like mother sister daughter husband father brother family wife kid son and parent while the adviceseeking rrelationships posters use more i boyfriend girlfriend relationship and partner in addition to most of these nouns being gendered they also suggest some clear divergence in the nature of these forums in terms of the information posters seek as well as disclose about themselves cosine similarity enabled us to compare the subreddits at the word level and additionally to explore uniqueness at the post level table 4 shows the post titles for the top five most unique entries in both subreddits genderedness when we dig into expressed gender identity and gendered word use we find that in general these subreddits are broadly but not exclusively cisheteronormative just four posts could be attributed to gender diverse individuals while we did not call out posts that described a binary transgender experience we observed that this is not a common theme in ramitheasshole especially where a large percentage of posters do not explicitly state their own gender identity there may be a presumption of gender from context if we assume heteronormativity differentiating between those posts where the user deliberately concealed that aspect of their identity from those where the user assumed they would be read as their assigned gender based on a provided description of their relationship with others could be a project unto itself users may make these assumptions but careful researchers should not for those posts where we can safely account for gender we explored the relationship between gender and gendered language for these subreddits 1 while womens rrelationships posts used gendered language more than twice as often as mens womens used almost three times as many masculine words as feminine on the other hand mens posts had a similar ratio of feminine words to masculine 2 similarly ramitheasshole posts by men used gendered language half as much as womens and men used twice as many feminine words than masculine womens posts used only slightly more masculine words than feminine 3 womens posts are on average 12 words longer than mens on rrelationships and 35 words longer on ramitheasshole posts with an identified gender are around 30 words longer than those without on both subreddits 4 on rrelationships womens posts garner more comments on average than mens but posts where the gender is unknown the average is higher than both on ramitheasshole mens posts have more comments on average 5 looking at average sentiment rrelationships posts by men are marginally more positive than those by women according to both afinn and vader the opposite is somewhat true for ramitheasshole womens afinn adjusted scores are less negative than mens and vader compound scores more positive that these models disagree on positivitynegativity suggests there may be some language used more often in ramitheasshole posts thats computed as negative in only one model the nature of ramitheassholes flair assignments gives us the opportunity to explore the relationship between gender and crowdsourced behavioral judgments while yta posts are undersampled in our dataset and women outnumber men men are more likely to receive the ahole judgment 177 of mens posts vs 68 of womens but in terms of total yta posts a plurality are earned by those with an unknown gender to explore this difference further we would need to collect more data that oversamples for lesscommon flair values including yta engagement metrics to answer rq3 we investigated whether there were any correlations between natural language features and post engagement metrics in our dataset first we compared engagement across subreddits rrelationships posts received far fewer comments 34 on average compared with ramitheassholes 540 in fact of our sample ramitheasshole post engagement metrics towered over rrelationships overall this was reflected in the score a straightforward measure of total upvotes minus downvotes despite scraping the top 1000 posts in each subreddit for the same time period and at the same time rrelationships includes at least one post with no comments at all and a score of just one the minimum score of an ramitheasshole post in this dataset is more than seven times higher than the average score for rrelationships one might attribute an inflated upvote ratio 19 higher comment counts could also be related to subreddit rules debate is banned on ramitheasshole while judgment is swift lowering the bar for contribution compared with rrelationships which may require a more thoughtful response than nta although rrelationships has more subscribers its ramitheasshole posts that tend to go viral perhaps attracting engagement from reddit users who do not regularly participate in the community however this dataset includes neither post username information nor comments so the question of virality and the nature of community participation is best left for future study however if we look at how much engagement metrics correlate with the computed and extracted language features in our dataset the relationship is very weak at best both overall and for each subreddit although the correlation coefficients are low overall we were particularly interested in the impact of uniqueness as represented by low cosine similarity if we graph cosine similarity scores it is clear that a vast majority of posts are very similar 050 or greater there are 138 posts with negative similarity scores and 555 if we include all posts with a score of 025 or less there are slight differences between the subreddits in terms of correlation between similarity and engagement conclusions and future work in this work we developed a methodology to extract demographic information from a social media site where user demographics are neither always shared nor presented in a structured format we investigated what natural language features could be extracted from unstructured reddit post text compared two adviceoriented subreddits in terms of those features and looked for correlations between language features and engagement metrics the features we extracted included sentiment similarity word frequency and intext demographics we examined how the post authors selfdisclosures reflect the unique communities in which their posts are shared and how the authors language use choices might be related to broader social patterns we found some differences between ramitheasshole and rrelationships especially in terms of word frequency demographics disclosure and gendered language but nothing significant in terms of sentiment or overall similarity a more indepth analysis of partsofspeech tagging seems like the best path forward in terms of text analysis we obtained the most common verbs and nouns found in the top 1000 posts of each of the rrelationships and ramitheasshole subreddit communities which could be a practical tool to help the scholarly community identify and compare high frequency words in other advice forums in future studies our observations on the differences in aggression and interiority of different subreddits could inspire future studies to explore how posters perceived locus of control and relational depth influences their query formulation while these topics fall outside the scope of this study future researchers could examine additional online advice communities improve demographics extraction methods and perform more detailed parts of speech tagging and token analyses of posts text to look for patterns this study is limited in that it relies on a onetime scraping of top reddit posts that may be biased in favor of higher engagement it does not attempt to account for time or oversample for certain areas of interest that are unbalanced like flair and gender diversity we did not collect comments or user metadata so it cannot address a broader look at interactions and networks on reddit future work could take these into account apply more robust processes to extract demographic information from posts and identify coding methods for key words and phrases for deeper analysis we would also love to explore the relationship type between the original poster and subject without relying on assumptions about the gender binary the scope could be broadened to include other relationshipand behaviorcentric forums to explore how different communities create and share information about ethical decisionmaking and human behavior another aspect to explore is the memeification of the posts in these forums that is how posts in some subreddits are captured and shared on other social media networks which may further reflect cultural values and acceptable behaviors

advice forums are a crowdsourced way to reinforce cultural norms and moral behavior sites like reddit contain massive amounts of natural language human interaction with rules and norms unique to each individual subreddit community to explore this data we created a dataset with top 1000 posts from each of two such forums ramitheasshole and rrelationships and extracted natural language features including sentiment similarity word frequency and demographics using both algorithmic and manual methods further we developed a method to extract demographic information from the subreddits examined how the post authors selfdisclosures reflect the unique communities in which their posts are shared and discussed how the authors language use choices might be related to broader social patterns we observed some differences between the subreddits in terms of word frequency demographics disclosure and gendered language in general both subreddits had more female posters than male and posters tended to use more words about their opposite gender than the same genderdiverse posters were uncommon implications for future research include a more careful inclusive focus on identity and disclosure and how that interacts with adviceseeking behavior in online communities

introduction all of society is affected by mental health problems not just a small isolated part they are a serious challenge to global community health and development there are no groups of human beings that are immune to developing mental distress the risk of suffering from md is higher among the poor homeless the unemployed those with little education victims of violence migrants and displaced people native populations children and young people abused women and the abandoned elderly 1 there is chance of developing mental or neurological disorders for one in four people in the world at some point during their lives currently about 450 million people are dealing with these issues with md among the leading causes of morbidity and disability worldwide about 12 of the global burden of disease is linked with mental and behavioral disorders only 1 of total budget is allocated to the mental health budget or expenditure in the majority of countries there is a clear disproportionate relationship between disease burden and disease spending 2 according to whos global burden of disease 3 neuropsychiatric disorders constitute 33 of the years living with disability about a third of global disability adjusted life years were found in china and india 4 which is attributable to mental neurological and substance use distress this figure is larger than that in all developed countries combined in subsaharan africa including ethiopia rates of psychological distress in adults are particularly elevated as it is clearly stated in the national mental health strategy of ethiopia 5 mental disease is the leading key to noncommunicable disorder in terms of burden in ethiopia about 11 of the total burden of disease is affected a predominantly rural area of ethiopia in the top ten most burdensome conditions schizophrenia and depression are listed outranking hivaids these shocking statistics demonstrate that mental illnesses have been neglected as a main health priority in ethiopia however there is limited information about the perception and the attitude of the public regarding mental health problems 6 a study conducted in borana ethiopia revealed drivers with respect to supernatural causes such as perceptions of being controlled by evil spirits being cursed bewitched having exposure to wind and subsequent attacks by evil spirits in postnatal women moreover biopsychosocial causes such as infections loss overthinking and alcohol and khat abuse are the leading causes of mental disturbance in ethiopia 78 other studies also showed that regarding mental illness the main factor leading to stigmatization and labeling is linked with peoples belief a significant barrier to positive outcomes across cultures and nations is stigma against people with mental illness this is relevant to the level of threat of mental symptoms intolerance towards diversity and inaccurate perceptions of md 910 however there are only a limited number of studies conducted in ethiopia and specifically in the tigrai region context examining community health knowledge and beliefs about md or mental illness therefore this study examined community knowledge perceived beliefs and associated factors of mental illness in mekelle city tigrai ethiopia the study also investigated the prevalence and associated risk factors of md to fill a huge perceived research gap in this area definition of mental health and the major mental illness an overview mental health is considered as the vital asset to human health and wellbeing however this term is narrowly defined and may be conceptualized as the absence of mental illness the terms mental health problems and mental illness link with the range of cognitive emotional and behavioral disorders these issues interfere with the lives and productivity of people they are the most commonly reported type of mental health complaint and are commonly the result of a reaction to life stresses or negative life experiences 11 according to the hunter institute of mental health 12 mental health is a positive concept relevant to the social and emotional wellbeing of people and societies as bland et al 13 pointed out mental illness does not occur in biological or genetic isolation it takes place due to the messy reality of our lives today mental health problems are recognized as a public health problem in developed and developing countries 6 how people think and how they perceive their environments are altered by mental problems and illness this can affect levels of hope trust selfefficacy and personal relationships and results in significant impacts on community wellbeing mental illness puts at risk the construction of our identities at a time when we are trying to find our personalities in relation to ourselves others and the wider society 1314 low level of mental health literacy is the one of the causes of high incidence 15 based on conducted study by jorm 16 the term mental health literacy has been defined as knowledge and beliefs about md which help their recognition management or prevention additionally several components are linked with mental community health literacy including being capable of recognizing specific disorders or different types of psychological distress recognizing risk factors and causes beliefs about selfhelp interventions knowledge and beliefs about professional help available attitudes which facilitate recognition and appropriate helpseeking and knowledge of how to follow mental health information careful evaluation of the norms beliefs and tradition within the individuals cultural environment also belong to the recognition of md 17 in ethiopia where poverty war famine displacement and homelessness are common mental health is also becoming a major public health problem 18 the following work will review studies on community health knowledge perceived beliefs and associated factors of mental illness the review will take a deep dive on community knowledge and ideas about causes symptoms of md public attitude and perception towards people with mental diseases the review also provides empirical evidence on the prevalence of common md and its associated factors therefore this review has two major parts the first part discusses the findings of different studies on community knowledge and perceived beliefs about md the second part of the review highlights and discusses evidence on the prevalence as well as associated factors of mental illness mental community health literacy the high lifetime prevalence of md is drawing the attention of the public towards the importance of greater mental health literacy the dimensions of mental health literacy in western countries are totally different from some developing countries where more than half of the population may be illiterate supernatural causes of md are more widely known traditional sources of help are better accepted than medical advice in these countries 19 this part of the review therefore emphasizes on community recognition of md beliefs about the etiology of mental illness and help seeking and community reaction to the mentally ill recognition of mental disorders based on the conducted study in united kingdom assessing community health knowledge of mental illness and reactions towards mentally ill people reported that 21 of respondents had no idea about different types of mental illnesses 19 could only name one and 60 could name two or more the mean number of correct mental illnesses cited was 21 schizophrenia was the most commonly known type of mental illness other known mental illnesses were depression manic depression and paranoia 19 in sri lanka a study was designed to categorize aspects of mental community health literacy in terms of ability to recognize problems helpful interventions helpful referral options and outcomes in a target adolescent population 20 in another study conducted in agaro ethiopia aimed to assess how mental health problems were perceived by a community schizophrenia was identified by a significant number of people as a mental health problem in this study 58 29 and 15 of the respondents identified epilepsy generalized anxiety disorder and major depressive disorder respectively as mental health problems a total of 728 people were interviewed with a response rate of 995 21 to determine the levels of mental health knowledge different methods are being used the mental health knowledge schedule score is a mental health knowledge scales that is widely used in developed countries to measure or determine level of mental health knowledge one study conducted at the university of tennessee used the maks tool to find the overall knowledge of mental health the highest maks score was 30 and the mean score among participants was 2588 22 a relatively similar finding was observed in a study conducted in ireland results of this study indicated that attitudes among the study sample were generally positive 23 the factors associated with a statistically significant higher total knowledge score on the maks were identified in another study conducted in england according to this study factors such as female gender higher socioeconomic status and knowing someone with a mental health problem were found to be strongly associated with higher total knowledge score on the maks 24 knowledge and beliefs about appropriate help seeking md is associated with stigma and this may affect seeking help for instance in the germany there is a greater reluctance in discussing md with relatives and friends as compared to discussing physical disorders 25 it was found by the national italian survey that 99 of the study participants thought that the best way to recover from depression was to find help from the outside 26 there are other conducted studies in other european countries which gained similar findings based on a study in the united kingdom most respondents would contact a general practitioner if a friend or neighbor was showing signs of mental illness other important contacts were social workers hospitals police the patients family and one of the patients friends 27 unlike the propsychiatric treatment findings from developed countries one study conducted in delhi india highlighted adverse attitudes towards seeking psychiatric treatment for mental illness 28 in another study conducted in agaro town ethiopia respondents preferred modern medicine for the treatment of epilepsy schizophrenia major depression and generalized anxiety disorders respectively about 21 and 19 of the respondents preferred holy water for the treatment of epilepsy and schizophrenia respectively 6 community reaction to people with mental illness there is higher risk in mental illness often for those affected because of stigmatization by members of the community 29 it has been concluded in studies in north america and western europe that stigma is a major problem in the community 30 31 32 in iraq one study aimed to assess public perception of mental health their results revealed that around half of respondents believed people with mental illness should not get married and have children while just under half believed people with mental illness should be limited and have no contact with others 33 there are similar results reported from tehran iraq which all respondents reported that they had experienced feelings of alienation discrimination and social withdrawal 34 other studies in africa also suggested that stigma is a common experience faced by people with mental illness results from the study in zambia revealed that stigma towards people with mental illness is harmful across zambian society 35 the agaro ethiopia study showed that there was a positive attitude concerning the four mental health problems by respondents towards work opportunities marital prospects chance for education and cure by modern medicine epilepsy was considered as the most serious problem followed by schizophrenia the least serious problem was the major depressive disorder 6 community prevalence and associated factors of common mental disorders a high prevalence of psychiatric disorders worldwide was consistently reported by epidemiological studies especially in developing countries 2 effective treatment is not provided for disorders including insomnia anxiety fatigue irritability depressive moods difficulty concentrating and somatic complaints but they very common issues among adults and are quite often overlooked 2 36 37 38 the group of common mental disorders has been compromised by the set of symptoms 2 cmds refer to conditions of psychic distress that meets the nosological criteria of the international statistical classification of diseases and related health problems the diagnostic statistical manual for the most prevalent disorders includes the groups of anxiety depressive and substance abuse disorders in their mild or even moderate forms these are wellknown causes of major functional incapacity and are often as significant as those seen in wellestablished psychiatric conditions 38 in santiago chile a crosssectional survey of private households aimed to investigate the prevalence of common md and sociodemographic correlates among adults their results revealed that the most common symptom was worries with a prevalence of 43 other nonspecific symptoms were also common 39 to assess common mental health problems another study was conducted in agincourt the rural limpopo province of south africa and in khayelitsha a periurban township near cape town their main approach was to use selfreport instruments in two random population samples and among respondents at primary care and traditional healer settings 40 another study in a rural district of kenya also showed that the point prevalence of common mental disorders in the study sample of 1000 households was 108 largely comprising mixed anxiety depression panic disorder generalized anxiety disorder and depressive episodes 41 likewise two studies from ethiopia assessed the prevalence of common mental distress and its factors among residents of jimma and kombolcha towns to determine the prevalence of cmd both studies followed a community based cross sectional study design and used a selfreporting questionnaire the results of both studies indicated that there is a high prevalence of cmd among different groups of the society 42 overall as we can see from the aforementioned empirical evidences there are numerous studies on community prevalence to md and community health knowledge perceived beliefs and associated factors of md and mental illness in different parts of the world both in developing and developed countries setting however to best of our knowledge there is a lack of systematic studies on this topic in ethiopia and they are almost nonexistent in the tigrai region context considering this gap hence the study aims to address the following research questions 1 what is the level of community health prevalence of md 2 what are the associated risk factors of md among the community in mekelle city 3 what is the level of community mental health knowledge 4 what are the key factors associated with good mental health knowledge 5 how are the causesrisk factors and preferred sources of help for md perceived among community in mekelle city materials and methods background of the study area this study was conducted in mekelle city ethiopia mekelle is located in the northern part of the country 783 km from addis ababa the total population of the city was 215546 people as reported by 2009 central statistics authority data females constitute 514 of mekelles population and males represent 486 the population under the age of 25 constitutes 63 of the total population twelve percent of the population are children under the age of 5 children of school age constitute about 38 of the population in mekelle these children are aged between 4 and 18 fiftytwo percent of the female population are women of reproductive age sixty percent of the total population is in the labor force five percent of the population are elderly it is expected that by 2015 assuming a medium growth rate of 27 the population of the city will be 332013 people 43 overall there are 7 sub cities 35 tabias and 105 ketenas in mekelle city the main subsub cities comprise ayder kedamay weyane hadnet quiha adihaqi hawelti and semien in this study two subcities were selected namely kedamay weyane and hawelti based on the information obtained from the health offices of these two subcities the estimated population and household data is as presented in table 1 survey design and sampling a communitybased crosssectional study was conducted in the purposely selected two subcities of mekelle city namely kedamaywoyane and hawelti this is done because according to the mekelle citys health desk office there is a relatively higher level of poverty in the aforementioned sub cities compared to the other sub cities it is known in the literature that md is associated with the level of poverty in selecting the sample respondents then four tabias were randomly selected using simple random sampling method accordingly a sample household is selected using a systematic random sampling technique with a sampling interval of 6 and the household heads were automatically selected as a study sample according to probabilities proportional to the size technique the sample size was distributed by each tabias the list of households obtained from the subcity administration in the selected tabias was used as a sampling frame figure 2 presents the sampling procedure used in the study survey design and sampling a communitybased crosssectional study was conducted in the purposely selected two subcities of mekelle city namely kedamaywoyane and hawelti this is done because according to the mekelle citys health desk office there is a relatively higher level of poverty in the aforementioned sub cities compared to the other sub cities it is known in the literature that md is associated with the level of poverty in selecting the sample respondents then four tabias were randomly selected using simple random sampling method accordingly a sample household is selected using a systematic random sampling technique with a sampling interval of 6 and the household heads were automatically selected as a study sample according to probabilities proportional to the size technique the sample size was distributed by each tabias the list of households obtained from the subcity administration in the selected tabias was used as a sampling frame figure 2 presents the sampling procedure used in the study sample size according to studies conducted in other parts of the ethiopia the prevalence of cmds was found to be 117 in addis ababa and 193 in haromaya 4445 in this study the sample size was calculated using the prevalence rate of 117 to obtain a maximum sample size at 95 certainty ±4 error margin and a 5 nonresponse rate this provided a sample size of 260 see the steps for sample size computation below n 196 𝑝 𝑑 n 0117 2 data data collection tools and procedures a quantitative data has been collected from a randomly selected 260 households constituting 83 households from kedamay woyane sub city and 177 households from hawelti sub city in this study the source population included adults aged 18 and above who lived in mekelle city for at least 6 months or more individuals who were found to be too seriously ill or cognitively disabled to give consent and those who were unable to hear and recall events were excluded from the study sample size according to studies conducted in other parts of the ethiopia the prevalence of cmds was found to be 117 in addis ababa and 193 in haromaya 4445 in this study the sample size was calculated using the prevalence rate of 117 to obtain a maximum sample size at 95 certainty ±4 error margin and a 5 nonresponse rate this provided a sample size of 260 see the steps for sample size computation below n 196 2 p d 2 n 2 0117 2 data data collection tools and procedures a quantitative data has been collected from a randomly selected 260 households constituting 83 households from kedamay woyane sub city and 177 households from hawelti sub city in this study the source population included adults aged 18 and above who lived in mekelle city for at least 6 months or more individuals who were found to be too seriously ill or cognitively disabled to give consent and those who were unable to hear and recall events were excluded from the study generally a structured questionnaire was used to collect the primary data the questionnaire was initially prepared in english and later translated in to tigrinya the content of the questionnaire included sociodemographic variables maks to measure mental health related knowledge variables designed to assess the perceived causes of md and the preferred sources of help for md questions related to community reaction towards people with mental illness and srq20 items to determine the community prevalence and associated factors of md in the current study to assess the prevalence and presence of md the selfreported questionnaire items were adopted originally the srq was designed as selfadministered scale because of the low literacy rate in developing countries it is also suitable for intervieweradministered questionnaires each of the 20 items is scored 0 or 1 the presence of symptom during the past month is showed by score of 1 the absence of the symptom is showed by score of 0 in developing countries the most commonly used cutoff point is 78 and sensitivity were optimum at 78 cutoff points in this study a cutoff point of 7 and above was taken as having a md based on findings in other parts of the country 19 in the last step the internal consistency of the srq20 item in this study was measured and it provided a reliability coefficient of 0698 which indicates that the items have acceptable level of internal consistency the mental health knowledge schedule was another standardized tool adopted and used for this study 12 items are comprised by maks there are six items of stigma linked with mental health literacy areas including help seeking ability to give advice support employment treatment and recovery and also six items assessing knowledge of mental illness diagnoses a 5point scale was used to show total disagreement and strong agreement better mental health literacy was indicated by higher scores 47 then a median point of the first 6 items was taken to determine the level of mental health knowledge among study participants the internal consistency for the maks items is found to be 449 and this low result might be associated with the second part of the maks items were dichotomized the finalized and translated questionnaire was converted in to a mobile app to facilitate the data collection using a mobile phone of 26 individuals the questionnaire was pretested from part of the city which was not included in the sample three data collectors were employed and trained for 2 days on the questionnaire and the mobile app designed for the data collection an interview was conducted for the respondents in private setting with the close supervision of the principal investigator the data extracted from the server was reviewed and checked for completeness before exported to spss for analysis variables both dependent and independent variables were identified and measured to address the research questions the dependent variables are mental distress and mental health knowledge likewise socioeconomic and demographic variables comprising age sex occupational status marital status religion educational status gross family income and family size were taken as independent variables in addition behavioral variables such as alcohol use cigarette smoking khat use level of social support financial difficulty and previous mental and medical illness historyrelated variables such as history of mental illness and history of chronic physical illness were also taken as independent variables for the measurement attributes of all the variables under consideration see table 2 methods of data processing and analysis the data that was sent to the server by the data collectors was extracted checked and exported to spss version 20 for analysis results obtained from questions designed to assess community knowledge and perceived beliefs of md were interpreted and analyzed descriptively using proportions percentages means range and measures of central tendency bar charts and graphs were also used for the interpretation of results the prevalence of md was estimated from a cutoff point defined according to the number of positive answers for symptoms subjects are classified as suspected of md cases when they had seven or more yes responses for the srq20 items both bivariate and multivariate analysis was conducted in order to explore associations and identify independently linked variables with pattern of md and mental health knowledge to do so each independent variable was separately entered into bivariate analysis then variables with statistical significant association on bivariate analysis were entered into multivariate logistic regression once then it was concluded that variables with pvalue had a significant association with md or mental health knowledge pattern the strength of association of the variables was determined using odds ratio and 95 confidence level ethical consideration ethical clearance was obtained from tigrai regional health bureau ethical clearance committee written consent was also obtained from all of the respondents participated after the data collectors briefed them all the terms and conditions of participating in this study to keep the respondents anonymous respondent unique code was used and it efforts were made to maintain the privacy and confidentiality of the information provided by the study participants study participants who were identified as having a md were advised by the data collectors to contact a psychiatrist or a mental health professional model specification in this study to examine community knowledge perceived beliefs and associated factors of md a communitybased cross sectional study was conducted in two subcities of mekelle city tigrai ethiopia a logistic regression was used to investigate the independent factors associated with md and the independent predictors of good mental health knowledge logistic regression is the most commonly used model to examine the effects of the independent predictor variables on binomial outcomes 48 to predict the independent factors or predictors associated with the two binomial dependent variables y 1 and y 2 that takes values of with md and without md and poor mhk and good mhk the following regression function is used as logit log p 1 β 0 β 1 x 1 β 2 x 2 β k x k in the first step of the model building a univariate analysis was applied to explore the unadjusted association between the independent variables and outcome variables separately to do so each of the 16 independent variables was included in a logistic regression model one for each time the univariate model is therefore constructed as follows log odds y 1 x 1 log   p y 1 x 1 1 p y 1 x 1   β 0 β 1 x 1 based on the results of the univariate analysis variables with pvalue of smaller than 025 were included for further multivariate analysis the cutoff value of 025 is recommended by different studies 49 in the second step variables identified in the first step were fits in to the multivariable model then variables that failed to contribute to the model are eliminated and the two models are compared using partial likelihood ratio test finally goodness of fit test was conducted to check the fit of the model then the hosmerlemeshow inferential goodnessoffit test was applied for this purpose results and discussion community prevalence of mental distress the point prevalence of md in this sample was 254 determined using the srq20 items with a cutoff point of 7 and above the most prevalent symptoms were frequent headaches feelings of nervousness tenseness and wariness and poor appetite the least reported symptoms of md were suicidal intentions trouble thinking clearly and feelings of worthlessness based on the results of the univariate analysis variables with pvalue of smaller than 025 were included for further multivariate analysis the cutoff value of 025 is recommended by different studies 49 in the second step variables identified in the first step were fits in to the multivariable model then variables that failed to contribute to the model are eliminated and the two models are compared using partial likelihood ratio test finally goodness of fit test was conducted to check the fit of the model then the hosmerlemeshow inferential goodnessoffit test was applied for this purpose results and discussion community prevalence of mental distress the point prevalence of md in this sample was 254 determined using the srq20 items with a cutoff point of 7 and above the most prevalent symptoms were frequent headaches feelings of nervousness tenseness and wariness and poor appetite the least reported symptoms of md were suicidal intentions trouble thinking clearly and feelings of worthlessness factors associated with mental distress after adjusting the confusing factors on multivariate logistic regression analysis findings from table 3 showed that the likelihood of md was about two folds higher among females as compared with males occupational status of study participants was also found to have a significant statistical association with md employed and selfemployed participants had a six and five times increased chance of having a md respectively as compared to housewives daily alcohol use was significantly associated with the risk of developing a md study participants who reported daily consumption of alcohol had a five times increased risk of developing md compared to nonusers or who reported never use of alcohol regular use of khat was also found to be a risk factor for md it is found that regular or daily khat users had a five times higher chance of experiencing md than nonusers of khat history of accident or traumatic life events was significantly associated with md accordingly study participants who reported experience of accident or traumatic life events during the last one year found to have a three times increased risk of developing md as compared to study factors associated with mental distress after adjusting the confusing factors on multivariate logistic regression analysis findings from table 3 showed that the likelihood of md was about two folds higher among females as compared with males occupational status of study participants was also found to have a significant statistical association with md employed and selfemployed participants had a six and five times increased chance of having a md respectively as compared to housewives daily alcohol use was significantly associated with the risk of developing a md study participants who reported daily consumption of alcohol had a five times increased risk of developing md compared to nonusers or who reported never use of alcohol regular use of khat was also found to be a risk factor for md it is found that regular or daily khat users had a five times higher chance of experiencing md than nonusers of khat history of accident or traumatic life events was significantly associated with md accordingly study participants who reported experience of accident or traumatic life events during the last one year found to have a three times increased risk of developing md as compared to study participants who report no traumatic event or experience in the last one year similarly previous mental illness diagnosis and treatment found to be significantly associated with md study participants with previous history of mental illness were having 11 times higher md than study participants with no history of mental illness diagnosis or treatment variables such as age level of education marital status religion gross family income family size cigarette smoking and feelings of financial insecurity and level of social support showed no significant statistical association with md mental health knowledge of study participants table 4 shows study participants responses to mental health knowledge schedule items according to the findings from the first part of maks items 122 of the study participants do not approve of notion that most people with mental health problems should have paid employment one hundred and twenty four participants agree that people with mental illness can have a paid job or employment a large majority of the study participants gave a positive response to the item i know what advice to give a friend to get professional help if she has a mental health problem similarly the idea that medication could be an effective treatment for people with mental health problems was favored by the majority of the study participants while 41 were not in favor the idea in addition 224 of the participants were agreed with the idea that psychotherapy could be an effective treatment for people with mental health problems while the remaining 20 expressed their disagreement around 224 of the study participants strongly expressed that people with severe mental health problems could fully recover while 48 of them show their strong disagreement with the idea the idea that most people with mental health problems went to a community healthcare professional to get help was favored by 153 of the study participants while 88 of the participants responded that they did not think or agree that most people with mental health problems should go to a healthcare professional to get help in the second part of maks the participants were asked to classify various conditions as mental illness to this effect 147 of the study participants ¡failed to recognize depression as a mental illness while the remaining 113 of the study participants recognized depression as a mental illness stress was classified by the majority of the study participants as a mental illness and only 44 of the respondents classify stress as a nonmental illness condition in total 234 of the study participants responded that schizophrenia is a mental illness while the remaining 26 of the respondents recognized schizophrenia as a nonmental illness condition bipolar disorder was recognized by 226 study participants as a mental illness while the remaining 34 of the participants responded that it is not a mental illness or a mental health condition in addition 169 of the participants were able to recognize drug addiction as a mental health condition but a significant number of study participants failed to recognize drug addiction as a mental health condition grief was classified as a mental health condition by 59 of study participants however a majority of the study participants were able to recognize grief as a nonmental health condition factors associated with mental health knowledge table 5 shows the final model adjusted for potential confounders to recognize independent predictors associated with mhk in this model male participants were nearly two times more likely to have a better mental health knowledge than female study participants a higher level of education was found to be strongly associated with good mental health knowledge study participants with diploma and above level of academic qualification had a four times higher level of mental health knowledge than that of illiterate study participants study participants who reported having a strong level of social support found to have nearly 3 times increased chance of having a better mental health knowledge than those who reported that they had poor level of social support more than half of the study participants expressed the view that substance abuse or misuse could cause md the second most commonly endorsed cause of md was found to be biological factors or brain disease in total 125 of the study participants responded that md can be caused by biological reasons or factors that are related with brain diseases the third most commonly cause of md reported by study participants was financial distress or poverty divine punishment or gods will was reported by 92354 of the study participant as a cause of md heredity and medical problems were the least endorsed causes of md perceived beliefs about causes of md preferred source of help for md perceived causes of mental distress more than half of the study participants expressed the view that substance abuse or misuse could cause md the second most commonly endorsed cause of md was found to be biological factors or brain disease in total 125 of the study participants responded that md can be caused by biological reasons or factors that are related with brain diseases the third most commonly cause of md reported by study participants was financial distress or poverty divine punishment or gods will was reported by 92354 of the study participant as a cause of md heredity and medical problems were the least endorsed causes of md preferred sources of help for mental distress it was required that the study participants respond to the following question do you think mental and behavioral disorders are treatable to assess their perception before they are asked to report their preferred sources of help for md accordingly the majority of the study participants reported that mental and behavioral disorders can be treated or people with md can fully recover or be cured however 5421 of the participants had a perception that mental and behavioral disorders are not treatable or people with md or illness cannot fully recover or cured preferred sources of help for mental distress it was required that the study participants respond to the following question do you think mental and behavioral disorders are treatable to assess their perception before they are asked to report their preferred sources of help for md accordingly the majority of the study participants reported that mental and behavioral disorders can be treated or people with md can fully recover or be cured however 5421 of the participants had a perception that mental and behavioral disorders are not treatable or people with md or illness cannot fully recover or cured it was required that the study participants provide a report about their preferred sources of help for md as indicated in figure 6 psychiatrists were the most preferred sources of help for md followed by holy water and psychologists they were reported by 160 147 and 106 of the study participants respectively as preferred sources of help for md community health professionals also preferred by 70 of the study participants as preferred sources of help for md friends or relatives and priests were the least preferred sources of help for md problem 9 and 6 of the study participants preferred friends or relatives and priests as a source of help for md respectively it was required that the study participants provide a report about their preferred sources of help for md as indicated in figure 6 psychiatrists were the most preferred sources of help for md followed by holy water and psychologists they were reported by 160 147 and 106 of the study participants respectively as preferred sources of help for md community health professionals also preferred by 70 of the study participants as preferred sources of help for md friends or relatives and priests were the least preferred sources of help for md problem 9 and 6 of the study participants preferred friends or relatives and priests as a source of help for md respectively preferred sources of help for mental distress it was required that the study participants respond to the following question do you think mental and behavioral disorders are treatable to assess their perception before they are asked to report their preferred sources of help for md accordingly the majority of the study participants reported that mental and behavioral disorders can be treated or people with md can fully recover or be cured however 5421 of the participants had a perception that mental and behavioral disorders are not treatable or people with md or illness cannot fully recover or cured it was required that the study participants provide a report about their preferred sources of help for md as indicated in figure 6 psychiatrists were the most preferred sources of help for md followed by holy water and psychologists they were reported by 160 147 and 106 of the study participants respectively as preferred sources of help for md community health professionals also preferred by 70 of the study participants as preferred sources of help for md friends or relatives and priests were the least preferred sources of help for md problem 9 and 6 of the study participants preferred friends or relatives and priests as a source of help for md respectively discussions community prevalence and associated factors of mental distress the community prevalence of md in this community based study was found to be 254 a similar community based study conducted in kombolcha ethiopia using a similar screening tool and cutoff point found a prevalence of 324 with 95 a confidence interval of 50 another study conducted in jimma town ethiopia found a community prevalence of 336 42 the prevalence of the current study was found to be lower than the studies conducted in kombolcha and jimma towns the likely reason could be the sample size for this study was lower than those studies and 745 individuals were participated a study conducted in the yoruba speaking parts of nigeria showed a lower prevalence of md compared to the present study but unlike the present study the nigerian study used the world mental health version of the composite international diagnostic interview to determine the prevalence of md 9 the current study showed that the likelihood of md was nearly twofolds higher among females as compared with males regarding the factors associated with md other studies conducted in different parts of the world and ethiopia such as south africa 40 south west and northern parts of ethiopia 4250 and chile 39 obtained a similar result this study revealed that factors such as being unemployed selfemployment and employment at the government or other organization were found to have a significant association with md this finding is somehow in agreement with findings of the study conducted in south africa khayelitsha that showed being unemployed is strongly associated with md 40 contrary to the findings of the current study a study conducted in addis ababa found that employment was inversely associated with risk of md 44 job stress can be attributed to the increased risk of md among employed and selfemployed study participants of this study overwork lack of clear instructions unrealistic deadlines lack of decisionmaking job insecurity isolated working conditions surveillance and inadequate childcare arrangements are considered as some potential causes of work related stress 51 the current study revealed that daily alcohol use was significantly associated with the risk of developing a md study participants who reported daily consumption of alcohol had five times increased risk of developing a md compared to nonusers or participants who reported never use of alcohol similarly a study conducted in kombolcha town ethiopia found that current alcohol drinkers had an increased chance of developing common mental distress or md than nonalcohol drinkers 50 alcohol counselling program combined with social and family support plays an essential role in alcohol control and prevention of psychiatric comorbidity 52 regular khat use was also found to be a risk factor for md in the current study 4250 according to the findings of the study conducted in jimma town khat use was strongly associated with md 42 based on the current study findings the participants who reported experience of accident or traumatic life events during the last one year found to have a 3 times increased risk of developing md as compared to study participants who report no traumatic event or experience in the last one year study participants with previous history of mental illness were also having 11 times higher md than study participants with no history of mental illness diagnosis or treatment however one study done by yim 53 in hong kong indicated that there was no statistically significant difference on md prevalence between the groups with and without a previous psychiatric assessment strong level of social support was found to be inversely associated with the risk of md this finding is in line with the findings of the kombolcha study 50 mental health knowledge and predictors of good mhk to measure the mental health knowledge of the study participants the current study employed a mental health knowledge schedule items according to this study the mean total score for the maks part a was 214308 results indicated that 154592 of the study participants had a poor knowledge of mental health while the remaining 106408 of the study participants demonstrated that they have a good knowledge of mental health since there are no similar studies using maks method in ethiopia and other developing countries it was mandatory for the current study to crosscheck the findings with studies conducted in developed country to this effect a study conducted at walden university to evaluate the effectiveness of an educational mental health program found a mean total mask score of 2446 which is relatively higher than the results obtained by this study 54 the disparity might be explained by different mental health education programs implemented to improve community mental health knowledge in developed countries the main core of this study was to assess the effectiveness of mental health education program similarly another study conducted at the university of tennessee showed that the highest maks score of 30 and the mean score among participants was 2588 the median and mode was 26 the minimum score was 20 and the maximum was 30 22 the current study reported a relatively higher level knowledge as compared to a study conducted in dodoma municipality tanzania the results of this study showed that most of the study participants 859 had poor knowledge about mental illness 55 this could be due to the disparity in the academic qualification of the study participants of these two studies the second part of the maks was designed to assess study participants ability to recognize a mental disorder the current study revealed that 147 of study participants failed to recognize depression as a mental illness while the remaining 113 of the study participants recognize depression as a mental illness similarly due to the limited application of the maks score the findings of this study was compared with the results of other studies obtained from using a different approaches in a study conducted in gimbi ethiopia only 29 of the respondents identified major depressive disorder as a mental health condition 21 the huge disparity might be due to using a vignette of the condition based on the icd10 criteria while this study asked the participants to say true or false by just naming the condition without providing detail description of the condition another comparative study conducted in australia and japan revealed that 653 of the australia and 226 of the japan participants were able to recognize the depression vignette correctly 19 similarly stress was categorized by the majority of the study participants as a mental illness and only 44 of the respondents classified stress as a nonmental illness condition this could be due to the fact that the equivalent tigrinya term for stress mental health knowledge and predictors of good mhk to measure the mental health knowledge of the study participants the current study employed a mental health knowledge schedule items according to this study the mean total score for the maks part a was 214308 results indicated that 154592 of the study participants had a poor knowledge of mental health while the remaining 106408 of the study participants demonstrated that they have a good knowledge of mental health since there are no similar studies using maks method in ethiopia and other developing countries it was mandatory for the current study to crosscheck the findings with studies conducted in developed country to this effect a study conducted at walden university to evaluate the effectiveness of an educational mental health program found a mean total mask score of 2446 which is relatively higher than the results obtained by this study 54 the disparity might be explained by different mental health education programs implemented to improve community mental health knowledge in developed countries the main core of this study was to assess the effectiveness of mental health education program similarly another study conducted at the university of tennessee showed that the highest maks score of 30 and the mean score among participants was 2588 the median and mode was 26 the minimum score was 20 and the maximum was 30 22 the current study reported a relatively higher level knowledge as compared to a study conducted in dodoma municipality tanzania the results of this study showed that most of the study participants 859 had poor knowledge about mental illness 55 this could be due to the disparity in the academic qualification of the study participants of these two studies the second part of the maks was designed to assess study participants ability to recognize a mental disorder the current study revealed that 147 of study participants failed to recognize depression as a mental illness while the remaining 113 of the study participants recognize depression as a mental illness similarly due to the limited application of the maks score the findings of this study was compared with the results of other studies obtained from using a different approaches in a study conducted in gimbi ethiopia only 29 of the respondents identified major depressive disorder as a mental health condition 21 the huge disparity might be due to using a vignette of the condition based on the icd10 criteria while this study asked the participants to say true or false by just naming the condition without providing detail description of the condition another comparative study conducted in australia and japan revealed that 653 of the australia and 226 of the japan participants were able to recognize the depression vignette correctly 19 similarly stress was categorized by the majority of the study participants as a mental illness and only 44 of the respondents classified stress as a nonmental illness condition this could be due to the fact that the equivalent tigrinya term for stress ጭንቀት might be confusing for the study participants in total 234 of the study participants responded that schizophrenia is a mental illness while the remaining 2610 of the respondents recognized schizophrenia as a nonmental illness condition however in the study conducted in agaro it was found that 74 of the participants identified schizophrenia as a mental health problem 21 it was found in the current study that 16965 of the participants were able to recognize drug addiction as a mental health condition however a significant number of study participants failed to recognize drug addiction as a mental health condition study participants with diploma and above level of academic qualification were fourtimes higher level of mental health knowledge than that of illiterate study participants the mentioned findings lacks adequate support from other study findings but educational level was found to be associated with better recognition of mental illness in a study conducted in sri lanka 20 perceived beliefs about causes of md preferred source of help for md perceived causes of md this study revealed that more than half of the study participants expressed the view that substance abuse or misuse could cause md the second most commonly endorsed cause of might be confusing for the study participants in total 234 of the study participants responded that schizophrenia is a mental illness while the remaining 2610 of the respondents recognized schizophrenia as a nonmental illness condition however in the study conducted in agaro it was found that 74 of the participants identified schizophrenia as a mental health problem 21 it was found in the current study that 16965 of the participants were able to recognize drug addiction as a mental health condition however a significant number of study participants failed to recognize drug addiction as a mental health condition study participants with diploma and above level of academic qualification were fourtimes higher level of mental health knowledge than that of illiterate study participants the mentioned findings lacks adequate support from other study findings but educational level was found to be associated with better recognition of mental illness in a study conducted in sri lanka 20 perceived beliefs about causes of md preferred source of help for md perceived causes of md this study revealed that more than half of the study participants expressed the view that substance abuse or misuse could cause md the second most commonly endorsed cause of md was found to be biological factor or brain disease and financial distress or poverty was reported as the third most commonly cause of md divine punishment or gods will was reported by 92354 of the study participant as a cause of md this finding was somehow in line with the findings of study conducted in karifi vilage nigeria the study reported misuse of drugs as the most commonly endorsed cause of md followed by divine punishmentgods will and magic or sprit possession 17 in addition a study conducted in teheran found a different result compared to the current study the teheran study indicated that stress traumatic physical events and psychological trauma were among the most frequently reported causes of md and the will of god and evil spirits were the least reported causes of md 34 the discrepancy between the findings of present study and the tehran one might be attributed to the difference at the level of mental health knowledge between the two study populations preferred sources of help for md to examine the preferred sources help for md the study assessed the perception of the study participant about whether md is treatable or not and it has been found that majority of the study participants reported that mental and behavioral distress can be treated or people with md can fully recover or be cured however 5421 of the participants had a perception that mental and behavioral disorders are not treatable a study conducted in delhi india reported that 40 of the urban samples or higher than the current sample believed that mental illness or md is untreatable 17 concerning the preferred source of help for md psychiatrists were the most preferred sources of help for md followed by holy water and psychologists they were reported by 160 147 and 106 of the study participants respectively as preferred sources of help for md this finding is supported by studies conducted in developed countries such as italy the italy study reported that psychologists primary care physicians psychiatrists and neurologists as the most preferred sources of help 26 in a similar study conducted in agaro ethiopia holy water was preferred by 21 of the study participants 6 which is way lower than the current study result and it might be due to the fact that the study sample for this study is largely dominated by orthodox christian followers according to another study done by walters et al 56 the most popular sources of help endorsed by study subjects were talking to family or friends advice from gp or nurse relaxation or yoga talking therapy and exercise sport or hobbies however the current study doesnt include relaxation or yoga and exercise or sport as preferred sources of help assuming which these activities are less common in the study area context and as a treatment preference for md in addition this study did not explore healthrelated applications on mobile phones or mobilehealth applications which appear to be a feasible approach for disease and health management especially among young adults 57 however advice from gp or nurses and talking therapy or psychotherapy were preferred by a significant number of study participants in the current study conclusions this study indicated that md is prevalent among community in mekelle city and frequent headaches feelings of nervousness tense and wariness and poor appetite were found to be the most frequently endorsed or reported symptoms of md the likelihood of having a md was found to be higher among study participants who were female employed selfemployed and daily alcohol and khat users history of accident or traumatic life events and previous mental illness diagnosis and treatment history are also key risk factors for md the protective factor from md was found to be the strong level of social support the study also revealed that the low level of mental community health knowledge among study participants it was demonstrated by the more than half of the study participants that they had poor knowledge of mental health factors such as being a male gender having a high level of education having a strong level of social support and having a perception that md is treatable were found to be independent predictors of good mental health knowledge according to the evidence the role of social support to improve mental health or protect from developing a mental illness can be explained in either of the two ways firstly social support has a positive effect on mental health regardless of whether or not the individuals are under stress secondly they work as a stress buffer in other words social supports by acting as a buffer or moderator enhance the wellbeing of people under stress this study also found that history of accident or traumatic life events and previous mental illness diagnosis and treatment history were significantly associated with md however these two factors were not assessed by the studies reviewed for the purpose of this study in addition to assess level of mental health knowledge the current study assessed predictors of mental health knowledge according to this study it was found that male participants were nearly two times more likely to have better mental health knowledge than female study participants higher level of education also found to be strongly associated with good mental health knowledge there was a positive perception regarding treatment outcome of mental illness in community mental hospital has been identified as a preferred place by the participants for treatment this indicates preference for specialized care for patients with mental illness therefore a comprehensive communitybased mental health promotion and communication program is needed to ensure the effective implementation of community based mental health care and prevention activities to this end enhancing the engagement of community level platforms in terms of program planning implementation and evaluation is vital the stigma attached with mental illness will be decreased by health education and increase in public awareness regarding factual information about mental illness these measures also improve the helpseeking behavior of the community and lead to reducing burden of psychiatric morbidity in addition since mental health is already integrated in to primary health care package building the capacity of health extension workers and health care professionals is necessary to improve the quality of mental health prevention care and treatment services this study suggests that information education communication programs should be launched to teach the community on the causes symptoms treatability of mental health problems and the roles of people with mental health problems in the society furthermore future research works need to investigate this topic using similar assessment instrument in a similar community setting and with a relatively larger sample size to find more about the community knowledge beliefs and associated factors of md although the current study was carried out in ethiopia the goal of improving mental health literacy is seen as important in many countries the current findings suggest that considering adequate time and investment of resources it is possible to achieve significant changes in population mental health literacy now the main question is how these changes translate into enhancements in population mental health therefore to investigate these changes there is a need for further monitoring of population mental health notes i a region is an ethnicbased administrative territoriality of ethiopia that is larger than a district ii a tabia is the smallest administrative unit of ethiopia similar to a ward or hinterland iii a ketena refers to the smallest urban administrative unit of ethiopia similar to a street author contributions for research articles with several authors a short paragraph specifying their individual contributions must be provided aga and atm performed the study and developed the main text and ha read the first draft enriched and helped the others to address the reviewers comments

background all of society is affected by mental health problems not just a minor isolated part mental health problems represent a major challenge to the global development of community health this study examined the community health knowledge perceived beliefs and associated factors of mental distress md in mekelle city in northern ethiopia methods the current study used a crosssectional approach calculating a sample of 260 adults living in the two subcities of mekelle city to select the sample households in each subcity systematic random sampling was used selfreported questionnaire srq20 with a cutoff point of 7 and mental health knowledge schedule maks instruments were included within the structured questionnaire tool to clarify community occurrence and the level of health mental knowledge results the likelihood of having md was higher among the study participants who were female employed selfemployed and daily alcohol and khat users the results also showed that the level of mental health knowledge among the participants was low conclusions factors such as being male having a higher level of education and having strong levels of social support were found to be the independent predictors of good mental health and community mental health knowledge

introduction physical activity sedentary behavior and weight status are a triumvirate of variables that has attracted much of the recent research on children and adolescents due to their health consequences the increases in the prevalence of overweight and obesity in children and adolescents 12 is widespread similarly it is known that pa and sb patterns are determinant in the weight status of youth 3 4 5 several longitudinal studies support that pa decreases with age 67 whereas sb increases as adolescents get older 89 since pa has energy expenditure associated 10 and sb reduces energy consumption 11 weight status is often known as the result of an energy imbalance 12 and a prevailing sb time upon time devoted to pa is usually associated with weight gain 7 according to must and tybors review 13 of longitudinal studies on weight and adiposity in youth an increase in time spent on pa and a decrease in sb protected against relative weight and fat gain during these years however there are studies that bring some counterintuitive ideas about the triumvirates relationships collings et al 14 found that larger increase of body fat appeared in adolescents who reported being more active other studies report that although pa has some influence on body mass index results tend to show weak relationships between pa and overweight status and obesity 1516 there is even a study that questions whether sports programs protect youth from becoming overweight or obese 17 research evidence suggests that overweight and obesity are strongly associated with sb particularly with screen media usage 1819 and even more than pa 20 nonetheless there are studies that found no ties between smu and the risk of being overweight or obese in youth 2122 nor that depended on the type of sb 23 while tv viewing is a sb often related with being overweight 24 other leisure or academic activities such as playing videogames using computers or reading seem not having clear effect on weight 25 regarding gender differences research indicates that boys are more active than girls who also tend to be more sedentary 26 however while increased hours spent in smu is associated with being overweight or obese in both boys and girls who do not comply with pa guidelines it is only significant regarding physically active girls 27 gender differences in sb indicate that boys devote more time to computer and videogames usage 28 while girls spend more time on socialleisure sedentary activities such as meeting with friends or using mobile phones for socialcommunication 8 although linear statistical models have been employed to assess the relation among pa sb and weight it would be desirable to use other innovative methods to explain the complexity of the biological and social dimensions of these variables as different aspects of the adolescents lifestyle hence following laurson et al 29 we suggest working with the triumvirate of variables through an alternative analysis such as selforganizing maps commonly used to classify and display both the linear and nonlinear relationships among variables the purpose of this paper is to examine longitudinal changes in pa sb and bmi in spanish adolescents specifically focusing on adolescents who migrate towards a lower weight cluster in order to achieve such a purpose two concatenated phases are developed initially a clustering som analysis is performed to understand interrelationships among pa sb and bmi and how adolescents are grouped som is a nonlinear model of analysis especially adequate to visualize and establish topological links among complex interrelationships such as studied in this paper the second phase is developed to quantify adolescents who migrate from one cluster to another in a threeyear time period and to identify through a classification tree the behavioral characteristics of the groups that change towards a different weight cluster materials and methods ethics statement the individual schools the school districts and the ethics committee of the universitat de valència approved materials and procedures used in this study parents and participants aged 18 years or over provided written informed consent forms variables and instruments the sevenday physical activity recall was employed to assess the information related to different intensities of pa low moderate and vigorous pa 36 for the present study the average time of each pa intensity from the previous seven days was considered adolescent sedentary activity questionnaire 37 was used to assess the time adolescents spent on daily sedentary behaviors variables regarding mobile phone usage were added in order to update the questionnaire for the purposes of this paper sb was organized into three sedentary categories academic activities technologicalbased activities and socialbased activities asaq and 7dpar have been proven reliable and valid 3738 and used in previous longitudinal studies with heterogeneous samples in terms of weight status 394041 finally to establish weight status standardized bmi was calculated and recoded in three categorical variables average weight overweight and obese to obtain these variables participants height was measured to the nearest 01 cm using a stadiometer and weight was measured using a digital balance to the nearest 01 kg both in light weight clothing and with shoes removed standard procedures were used for all measurements 42 bmi was recorded as weight height 2 sbmi was obtained from zscores for bmi for the study population using international age and sexspecific bmi cutoff points 4344 who anthroplus software was used to calculate scores data analysis selforganizing map analyses were used to detect and visualize changes of subjects characteristics between the first and second assessment som was carried out with matlab r2008a program 45 and the som toolbox for matlab the process to obtain som can be explained in three steps the first step is the construction of a neuron network which size depends on the number of cases included in the analysis the data matrix used as input has a length of 1510 cases using this data matrix the size of the matrix was 20 x 10 neurons the second step was the initialization during this process a value or weight was assigned for each input variable to each of the neurons som initialization was performed in two different ways randomized and linear initialization the third step was the training of the som the training process was used to modify the weights or values of the neurons assigned initially two different training algorithms were applied in this study eq 1 was used to do the calculation during the neural network training w j ðn þ 1þ ¼ w j ðnþ þ zðnþ á h jiðxþ ðnþ á ðx à wðnþþð1þ where w j is the weight vector of the j th neuron η is the learning ratio h ji is the neighborhood function and x is the input vector n is the iteration and i is the winning neuron of the x input vector as can be seen the changes of the neuronal weights depend on the difference between the starting weights and the input vector the neighborhood function and the learning ratio the neighborhood function allows the adaptation of the neural weights of the neurons that are far away from the winning neuron to decrease for this study four different neighborhood functions were tested i gaussian ii cut gaussian iii epanechicov and iv bubble the learning ratio had a high value during the first iterations and gradually decreased to very low values at the beginning of the training large changes in the neuron weight were produced however their modification was more discreet as the process progressed the process described was repeated 100 times because the result of the final analysis depended on some randomized processes by repeating the process 100 times the odds of finding the best solution to the problem were increased since we used two different training methods four neighborhood functions and two initialization methods 1600 som were obtained the map with the least amount of errors when multiplying the quantization and topographical errors was selected after som analysis we used a kmean method to classify the neurons in groups according to their characteristics as reported by davies and bouldin 46 the clusters found are shown in fig 2 overlying the hit plane lastly the pearson correlation matrix between variables was calculated using the neuronal values the type i error was established in less than 5 moreover the migrations of subjects from one cluster in wave i to another in wave ii were quantified the number of subjects per cluster that changed to different clusters three years after the first measurement was also calculated 1 rectangles on the right of each component map indicate the lower and higher values of each variable values for sex are 0 boys and 1 girls weight status is represented in categories the rest of the variables are expressed in hours in order to better understand the maps it is important to note that participants included in every neuron are the same in all component planes it should also be noted that each neuron represents the same subjects in all of the variable maps moreover the neurons that are close to each other are more similar than those farther away therefore x and y axis are related to the neuron placement in a multidimensional space the x and y axes of each map do not represent any variable but indicate the neuron position a classification tree was established using matlabr2008a program to discern the behavior modifications that facilitate the change of cluster the difference between the post and pretest for each of the pa and sb variables was included as input variables as well as the bmi at the beginning of the study the objective of the classification tree was to distribute the subjects using the input variables in two different groups those who changed clusters and those who did not thus classification trees made it possible to determine which variables best discriminated between young people who changed from one cluster to another from those who remained in the same cluster in both assessments starting with the entire data pool this method divides it into two groups using an independent explanatory variable a cutoff point from the explanatory variable is determined meaning the cases that are below the threshold forms one group and the cases that are above the threshold form the other group this process is repeated for each subgroup until all subjects are classified correctly in the case of this study cart algorithm with the ginis diversity index as split criterion is used to obtain the classification tree therefore the classification tree divides youth according to key discriminating variables in order to classify all of the subjects according to their change of cluster nevertheless the tree was pruned to avoid having a wide tree with possibly a low external validity the criteria used to choose the prone level was the highest that maintain the sensitivity and specificity above 80 results before describing the results it is necessary to explain some aspects of the analysis that will help the reader to better interpret the som at the time the analysis algorithm finished all sample subjects were placed in a given neuron thus subjects were grouped in the same neuron with those colleagues with whom they shared more characteristics and they would always be placed in the same place in this sense each component plane represents the value of one variable for the subjects allocated to each neuron it should be noted that the subjects remain in the same neuron in all the component planes for example the upper left corner neuron contains subjects with high bmi while they show medium to lower values in the rest of variables som description and clusters as a result of the som analysis a final group of 7 maps corresponding to the 7 variables of our study emerged the gender map for instance showed that boys and girls were located on opposite sides the visualization of the component plane as a whole permitted establishing reciprocal links or topological relationships among the maps these relationships indicated that boys spent more time on mpa than girls and this difference was sharper in vpa moreover girls devoted more time than boys to academic activities and socialbased activities especially a group of them on the contrary boys spent more time than girls on technologicalbased activities mainly a group of them it is also worth noting that the overweight and obese boys and girls located in the east zone of bmi map devoted less time to aa sa ta mpa and vpa than averageweight and underweight adolescents although there was a small group of overweight and obese boys that spent a considerable time in vpa other topological relationships indicate that girls who spent more time on aa and sa devoted less time to mpa and vpa and boys who spent more time in ta devoted less time to mpa and moderate time in vpa these results were also supported by parametric analyses between the studied variables particularly significant negative associations emerged among academic activities with mpa and vpa and socialbased activities with mpa while the association between technologicalbased activities and vpa turned out positive on the other hand bmi was related positively with vpa but negatively with socialbased activities and academic activities hits plane is placed at the bottom right corner of fig 2 this map presented four identified clusters clusters 1 and 3 referred to overweight adolescents and clusters 2 and 4 represented averageweight adolescents moreover girls were grouped in clusters 3 and 4 and boys in clusters 1 and 2 descriptive data and confidence intervals of each cluster are presented in table 1 cluster migrations the trajectories followed by the participants during the period of time between the two measures are showed in fig 3 it is remarkable that some subjects placed in clusters 4 and 2 migrated to the opposite side 3 years later specifically the changes in adolescents bmi indicate that 103 girls from cluster 2 reached cluster 1 and 98 boys from cluster 4 migrated to cluster 3 after this time period in other words around 2266 of the adolescents sampled had changed from the overweightobese zone to the averageweight status zone after three years no changes were observed from cluster 3 to cluster 4 nor from cluster 1 to cluster 2 changes towards a different weight cluster a classification tree was carried out to exhibit adolescents groups of change in their weight status towards a different weight cluster all changes corresponded to migrations towards a lower weight cluster in particular ten of the eighteen groups identified comprised the majority of participants who had changed although the behavioral patterns of these groups are presented in table 2 in particular three were highlighted for diverse reasons the accuracy of the classification using the decision tree was of 91 group number 18 represents the highest percentage of the adolescents entire sample who changed from an overweightobese cluster to an averageweight cluster out of the total adolescents who changed clusters these participants decreased their mpa and their aa in at least 072 and 133 hoursday respectively group number 11 exemplifies the group in which all of the adolescents changed from an overweightobese cluster to an averageweight cluster these participants decreased their mpa in at least 037 hoursday either decreased their aa or increased it by a maximum of 133 hoursday increased their sa by at least 106 hoursday and increased their ta or decreased it by a maximum of 146 hours finally group 4 represents the group which showed the lowest percentage of change these participants either increased or decreased their mvp but by a maximum of 072 hours they also increased or decreased their vpa by a maximum discussion this study examines longitudinal changes in pa sb and bmi in spanish adolescents specifically focused on those who migrate towards a different weight status or category previous longitudinal studies have studied these changes by using a linear statistical method but this is the first time that a clustering som analysis is performed in a longitudinal study to examine this triumvirate of variables and the migrations between clusters this paper is also innovative in using a classification tree to focus on the behavioral characteristics of the groups of adolescents who migrated towards a different weight status the main longitudinal results from cluster migrations indicate that an important group of adolescents that were classified as overweight or obese in wave i changed to averageweight in wave ii therefore 2266 of the adolescents from the total sample changed their weight cluster to a lower category and none of them changed in the opposite direction although this is a surprising result it is necessary to pay attention that some participants may increase or decrease their weight three years later but their original behaviors have not changed enough to move towards another cluster even so these changes of cluster move towards a reduction of weight while many studies refer to the increase in the prevalence of overweight and obesity in adolescents 247 a possible explanation of this counterintuitive result refers to a biological or developmental reason due to the growing ages of the sample 48 the behavioral characteristics of the groups of adolescents that move into a lower weight cluster do not enlighten us about the longitudinal results these characteristics do not support the hypothesis that the change to a lower weight cluster is a result of an increase in time devoted to pa or a decrease in time spent on sb 141529 the longitudinal results of this paper are closer to the studies that report pa exerts a weak influence on overweight and obesity 23 as well as other studies that found no clear effect of academic activities socialbased activities and technologicalbased activities on weight 25 therefore the results suggest that there may be other ways of changing to a lowerweight status in adolescents apart from those in which pa and sb are involved the results about interrelationships among pa sb and bmi obtained from the visualization of som are consistent with those studies that indicate boys are more active and tend to be less sedentary than girls 26 nevertheless in terms of sb this paper is in line with previous studies which show that boys devote more time to ta such as computer and videogames than girls 28 and that girls spend more time on sa such as meeting with friends or using mobile phones for social interaction than boys 8 the results also show a moderate competing effect between sb and pa especially in girls since the groups of girls who spend the highest amount of time on aa and sa are the same as those who devote less time to mpa and vpa in a similar vein as a recent som analysis that focused on girls 49 finally overweight and obese adolescents devoted less time to aa sa ta mpa and vpa than averageweight and underweight adolescents although there is a small group of overweight and obese boys that spent a considerable amount of time in vpa these topological links suggest as do many other studies 36 that overweight and obesity are negatively associated with pa although a small group of overweightobese adolescents shows a positive relationship with vpa probably due to an assumed necessity to increase time spent in vpa to lose weight 14 there are some limitations that should be considered when interpreting the results from this study the first limitation emerges from the selfreported measures of behavioral variables due to previous evidence concluding that subjective methods of data collection such as questionnaires may overestimate or underestimate specific information reported by teenagers 50 some concern about the reliability and accuracy of the data arises however these instruments were previously proven reliable and valid 3738 and have been used in several international studies 304951 furthermore measurement errors were minimized by employing standardized protocols and guidelines a second limitation of this research study is its modest capability to explain some of the studied phenomena adolescents changes towards a lower weight status are not explained by longitudinal changes in pa and sb a plausible explanation for these limitations might be the complexity of the triumvirate relationships among pa sb and weight status furthermore the potential effects of several variables that were not regarded in this research such as sleep time school ethos peer acceptance or rejection motivation toward physical activity or caloric intake should be considered despite the aforementioned limitations this study exhibits several strengths to examining longitudinal changes in pa sb and bmi in spanish adolescents focusing especially on those adolescents who migrate to a different weight status results from this study highlights that almost a quarter of the adolescents from the total sample changed their weight status to a lower category and none of them changed in the opposite direction moreover characteristics that stem from the innovative classification tree do not support the idea that pa and sb exert a substantial effect on overweight and obesity therefore these results are useful for exploring other ways to change to a lowerweight status in adolescents apart from those in which pa and sb are involved the biological and developmental factors associated to the growing ages of adolescents become particularly important in the informed consent form the authors did not indicate that they would share data to third parties therefore this data is available upon request to the ethics committee of universitat de valència at vicerec supporting information s1 table pearson correlation coefficients among variables data curation jdd jl cpv formal analysis jl xgm

this study examined longitudinal changes in physical activity sedentary behavior and body mass index in adolescents specifically their migrations towards a different weight cluster a cohort of 755 adolescents participated in a threeyear study a clustering selforganized maps analysis was performed to visualize changes in subjects characteristics between the first and second assessment and how adolescents were grouped also a classification tree was used to identify the behavioral characteristics of the groups that changed their weight cluster results indicated that boys were more active and less sedentary than girls boys were especially keen to technologicalbased activities while girls preferred socialbased activities a moderate competing effect between sedentary behaviors and physical activities was observed especially in girls overweight and obesity were negatively associated with physical activity although a small group of overweightobese adolescents showed a positive relationship with vigorous physical activity cluster migrations indicated that 2266 of adolescents changed their weight cluster to a lower category and none of them moved in the opposite direction the behavioral characteristics of these adolescents did not support the hypothesis that the change to a lower weight cluster was a consequence of an increase in time devoted to physical activity or a decrease in time spent on sedentary behavior physical activity and sedentary behavior does not exert a substantial effect on overweight and obesity therefore there are other ways of changing to a lowerweight status in adolescents apart from those in which physical activity and sedentary behavior are involved

1992 kerrigan et al 2003kerrigan moreno rosario sweat 2001 and hotel and resort employees have reported high rates of sexual contact and sexual risk behaviors with foreigners among dominicans studies of tourist behavior revealed significantly higher levels of hivstirelated risk behaviors during vacation than in communities of origin in particular tourists reported that they were more likely to engage in sexual activity less likely to consistently use condoms and more likely to have sexual intercourse with more than one partner while they were on vacation ethnographic and public health studies among sex workers in the caribbean also suggest that sexual vulnerability is heightened in cases in which intimacy and regular visiting relationships are established between tourists and locals because condom use rates precipitously decline as more intimate relationships are established the convergence of these findings strongly supports the need for greater research aimed at identifying the specific contextual features of caribbean tourism areas that contribute to risk for hiv and other sexually transmitted infection and to develop initiatives to ameliorate these factors although some global studies have documented an increased risk of hiv through sexual behavior associated with alcohol and drug use in tourism environments much of the available global health literature approaches substance use and sexual risk practices as separate phenomena rather than as practices linked to the larger social and material environments in which people live and work this fosters the notion that each of these health outcomes involves distinct behavioral pathways to be addressed through separately targeted interventions rather than examining the social and contextual factors that might produce aggregate vulnerabilities across a range of health outcomes here we argue that although the behavioral focus of most health research permits the measurement of alcohol and sexual risk practices the exclusive focus on specific health outcomes compromises the ability to understand the social and ecological conditions that might precede or function as antecedents to both of these practices this is consistent with recent contributions to qualitative health research that have similarly argued for contextual approaches to hiv risk and drugusing behaviors we explored the ways that alcohol consumption illicit drug use and sexual practices are intertwined within the tourism environments in which a growing proportion of caribbean populations live and work through indepth interviews with tourism industry employees in sosúa dominican republic we elicited narrative descriptions of the social environments and situations that circulate around alcohol consumption illicit drug use and sexual encounters the goal was to develop a contextual understanding of how these practices are integrated into the daily lives and interactions of tourism industry employees in a popular caribbean tourism zone by focusing on participants descriptions of the social contexts in which alcohol consumption and sex occur we sought to examine these practices not as behaviors but as deeply embedded social practices that are linked to broader relations of gender sexuality and economy the growth of the tourism industry in the dominican republic is typical of the growth of the industry throughout the caribbean in 2007 3398374 tourists entered the country a third of whom were from the united states 17 from canada 6 from germany 4 from italy 29 from other european countries and 11 from other nations for 2009 the world travel and tourism council estimated that 546000 dominicans were engaged in tourism work and the industry accounted for 159 of gross domestic product although many studies have been focused on the health effects of tourism most emphasized the effects on tourists themselves rather than the workers who engaged in tourism labor although not often discussed in detail in studies of hiv in the caribbean alcohol and illicit drug consumption are escalating rapidly and closely track the development of the tourism industry in the dominican republic the amount of alcohol consumed per adult per year increased from 118 l in 1961to 611 l in 2001 reaching a peak of 771 l per person in 2000 much of this increase can be attributed to the growth of transnational alcohol companies that have marketed and invested heavily in major caribbean tourist destinations expanding the supply and availability of alcohol in the caribbean has often been viewed as an important way to support the tourism industry globally studies consistently document an increased risk of hiv through risky sexual behavior associated with alcohol use and alcohol venues and indicate that individuals employed in the tourism and sex industries are particularly vulnerable to alcohol and substance abuse moreover alcohol venues in the dominican republic are closely linked to transactional sex environments or the exchange of sex for money or resources alcoholserving businesses such as bars nightclubs and discos often operate as formal or informal sex establishments where waitresses or dancers working on the premises can also exchange sex for money with patrons an illustration of this is the emergence of the liquor store and the centro cervecero as sites where local sex workers and clients gather to drink and arrange commercial sexual encounters in sum the evidence from a variety of studies demonstrates that the social and economic logic of tourism areas produces a synergy among alcohol illicit drugs and sex within the basic fabric of daily life illicit drug use has been increasing throughout the caribbean although research is limited studies in the dominican republic indicate that the illicit drug epidemic is primarily oriented toward the use of powder cocaine crack cocaine heroin and marijuana with smaller rates of ecstasy and inhalant use one of the largest studies on substance use in the region compared ratios of exposure opportunity to actual use of substance use among adolescents across seven latin american countries the 2023 dominican adolescents sampled were significantly more likely than those from any other country to report actual use of illicit drugs following exposure opportunities for alcohol crack cocaine ecstasy and heroin although research on the factors contributing to the illicit drug epidemic in the caribbean is underdeveloped one recent regionwide analysis of drug crime statistics noted that islands that have experienced either acceleration or high levels of drugrelated criminality tend to be both highly tourism penetrated and major destinations for narcotraffic bahamas dominican republic jamaica puerto rico and the us virgin islands the most significant factor linked to illicit drug crimes was visitor density suggesting that the tourism industry strongly shapes drug use our conceptual approach to alcohol use illicit drug use and hiv risk practices is informed by recent medical anthropological theories of syndemics as they apply to marginalized populations in the united states inspired by the groundbreaking work of merrill singer and colleagues and subsequently elaborated by the centers for disease control syndemic theory centers on the idea that economic demographic and social factors produce constellations of epidemics in populations that are multiply marginalized in such syndemics vulnerability to one health risk exacerbates or magnifies vulnerabilities to others as in the case of hiv risk and illicit drug use which has been described in a range of studies aiming to move beyond diseasespecific or singleissue approaches to research and prevention singer and colleagues developed syndemic theory to explain the very low overall health profile of poor drugusing puerto ricans in the northeast united states subsequently syndemic theory has been applied to a range of other marginalized communities such as refugees sex workers and gay and bisexual men recent research on syndemics indicates that the social and economic environments of urban spaces produce syndemic situations for poor and socially marginalized populations in which the overall health profile rather than separate disease risks is severely compromised here we adapt the contextspecific perspective of syndemic theory to examine qualitatively how poor marginalized persons who work in the dominican tourism sector describe the intermingling of alcohol use illicit drug use and sexual practices in sosúa a tourism town on the north coast of the dominican republic known for its resorts beaches and commercial sex economy anthropologist denise brennan has described sosúa as a sexscape a transnational social space dominated by both fantasies and practices of exotic sexual transactions that traverses global boundaries tourism areas can produce distinct sexual cultures within the same countrya phenomenon that hirsch and colleagues recently described as sexual geographies ethnographic work in the region documents that dominicans often perceive tourism areas such as sosúa as entirely distinct global spaces where different ideas values practices and economies of gender and sexuality are enacted tourism areas also require growing numbers of tourism workers to circulate continuously in and out of these environments research on male tourism migrants on the southern coast of the dominican republic has shown that the vast majority of these men are internal migrants who relocated to the tourism area for work a finding that has parallels in other studies in the caribbean for internal migrants this regular crossing over into globalized spaces with distinct practices of gender sexuality and economy can have implications for their overall health and wellbeing we argue that with growing employment in the tourism industry tourism workers in the dominican republic and in other tourismdependent nations are increasingly exposed to social and economic environments that center on the consumption of alcohol illicit drugs and sexual intimacy with the informal tourism economy this synergy potentially leads to contextual influences on behavior that can contribute to syndemic conditions in nations such as the dominican republic where tourism composes a significant proportion of all sources of labor and where tourism zones are absorbing vast populations of unemployed and underemployed labor migrants we believe that more holistic research informed by syndemic theory is critical for understanding health vulnerabilities of the working population as a whole we suggest that alcohol illicit drug use and transactional sex are normative and necessary parts of the social and economic landscape in sosúa in part because of the function of these activities as means for establishing and maintaining valued social and material exchanges with tourists in the context of the tourismbased economy of sosúa many businesses and informal employees view the sale of alcohol andor illicit drugs as a precursor to the establishment of sexual or economic relationships with tourists which provide a large source of both formal and informal sector profits as a means of facilitating such transactions and increasing profits for both individual tourism entrepreneurs and tourism businesses our participants described business strategies aimed to foster overconsumption of alcohol by both tourists and locals the use of both alcohol and illicit drugs was often viewed by workers as inextricably linked to the transactional sex economy because each facilitated and reinforced the other alcohol and illicit drug use were understood as occupational requirements even as they were perceived as potentially dangerous vicios furthermore participants described the need to manage their emotional connections to tourists to avoid getting crazy or losing control over their feelings and sexual behavior which they believed could lead to dangerous or risky sexual practices with tourists even though alcohol and substance use were seen as necessary they also compromised participants ability to maintain affective and sexual control leading to sexual situations which participants viewed as treacherous finally we end by discussing the implications of these findings for syndemic theory as applied to the situations and social contexts encountered by the growing population of caribbean tourism workers methods and research design population sosúa the primary site for this research is a small town of approximately 45000 located in the puerto plata province on the north coast of the dominican republic with its thriving tourism economy sosúa is characterized by a dense cluster of alcoholserving venues a high concentration of formal and informal sites for transactional sex and a diverse population of permanent local residents expatriates primarily from north america and europe and both dominican and foreign tourists many local residents as well as migrants from other parts of the country work within the tourism sector and are employed by the various restaurants shops bars and hotels in the area additionally many are employed informally within the tourism economy as for example sex workers vendors artisans waiters waitresses hotel employees and taxi or motorcycle drivers recruitment strategy and sample characteristics we conducted ethnographic observations in alcoholserving venues in sosúa and semistructured interviews with 32 adults between the ages of 18 and 50 years by design interviewees were required to be current alcohol consumers although we did not encounter any potential participants who did not report current alcohol use because of our original research interest in the influence of social context and environment on sexual practices and alcohol use we employed a theoretical sampling approach in theoretical sampling the researcher aims to intentionally maximize the diversity of perspectives on a set of issues of interest by systematically recruiting participants theorized to represent the widest possible range of perspectives on these issues while keeping the sample small enough to conduct indepth qualitative analysis across cases the method is designed to balance the richness of a small number of indepth narratives with a systematic means of ensuring wide variation in the voices and perspectives included in the study in this way it balances a relatively small sample with an emphasis on high participant diversity increasing the breadth of representation in the qualitative sample the method requires researchers to define participant characteristics that can be used relatively easily in the field to recruit equal proportions of participants from different subject positions because our conceptual framework focused on the ways that the social context of sosúa shapes alcohol use illicit drug use and sexual risk practices among tourism industry employees we defined four criteria by which to selectively recruit participants using theoretical sampling the sampling framework was aimed to maximize participant diversity in four characteristics type of venue in which the participant was encountered type of tourism employment sex and selfreported history of transactional sex we used a sampling matrix to track our sampling in the field and to continuously adjust our recruitment to achieve maximal sample diversity along these theoretical criteria aiming to recruit a minimum of two participants per cell in our 16cell theoretical sampling matrix our goal was to conduct indepth interviews with a diversified theoretical sample of 32 tourism industry employees recruitment of semistructured interview participants unfolded in the course of conducting ethnographic observations in alcohol venues we conducted ethnographic observations between february and august 2009 in three neighborhoods of sosúa el batey los charamicos and sosúa abajo el batey is the neighborhood with the greatest tourism presence including many businesses catering largely to foreign tourists but which also attract large numbers of locals seeking entertainment informal sexual exchanges with foreigners or other work opportunities los charamicos adjacent to el batey is primarily composed of local dominican residents many of whom are employed in service work in el batey and contains several wellknown puntos known for drug trafficking sosúa abajo is a lowerclass barrio located farthest from the dense tourism area of el batey and has fewer alcoholserving venues than either of the other two neighborhoods to determine the overall spatial organization of alcohol venues in the area we began the ethnographic observations by conducting a complete walking survey of all alcoholserving businesses in each neighborhood and mapping their location on a city map this led to a detailed map of 134 alcohol venues then team membersincluding dominican research assistants originally from sosúa and very familiar with all neighborhoodsidentified a list of sites in each neighborhood at which to conduct more detailed observational visits during observational visits to the alcohol venues team members interacted informally with clients and employees while observing the environment and social context because of our focus on context we felt it was critical to familiarize ourselves with the realities of social interaction in sosúa the project team incorporated distinct subject positions including two north american men of hispanic descent two dominican men and two dominican women we believe the range of perspectives and experiences on our team and our group discussions of observations deepened our understanding of the larger social climate in sosúa and also improved the quality of our formal semistructured interviews the process of participant recruitment began naturally as a consequence of informal interaction during observations in the venues consistent with the methodological approach of ethnography we were cautious about the ethical dimensions of the research and the potentially vulnerable position of employees and thus avoided formally approaching potential participants if we felt it created suspicion or concern from managers supervisors or the authorities thus participants were not immediately approached about participation in the interviews but rather casual conversations and interactions preceded formal recruitment for example in the course of observations the researchers played pool with local men played dominoes outside establishments and spoke extensively with bartenders waiterswaitresses security personnel and clients in each venue local team members who were very familiar with the environment provided important input to determine the leastinvasive means and moments for approaching individuals for formal recruitment if an individual encountered in the venue appeared to satisfy our sampling requirements we found an appropriate moment to talk briefly in a private setting outside the venue on many occasions this occurred when the individual took a break from his or her work and then advised us he or she was available to speak once outside the venue we explained the research in detail if the individual expressed interest in participating a brief verbal screening was conducted to determine whether he or she met the participation criteria as our observational sessions and recruitment approach proceeded we used the sampling matrix described above to track the types of participants we were recruiting for individuals who were eligible and interested in participating an interview time was arranged a contact card with the appointment site and details was provided and the person was asked to provide a phone number for a reminder call through this strategy research staff recruited the target sample of 32 from 12 alcoholserving establishments in sosúa and one outdoor venue that was composed of a cluster of alcoholserving stands following informed consent each participant was interviewed twice during a period of approximately 2 months with each interview lasting approximately 15 hours the first interview focused on family history work history migration stories and relational context the second interview focused more specifically on transactional sex relationships with tourists sexual practices alcoholdrug use and perspectives on condom use and hivaids we conducted two separate interviews per participant for two primary reasons first this broadened the range of topics we could feasibly cover allowing us to gather more indepth information on the context of the participants lives and to cover a wide range of topical domains second conducting two interviews allowed time for the gradual development of familiarity and rapport which was especially critical for the more sensitive questions the most sensitive issuesregarding sexuality sexual risk behaviors and alcohol drug usewere discussed in the second interview as a means of reducing any apprehension participants might have felt about discussing such experiences during the initial research interaction and to broach these subjects more gradually after building a certain level of trust between the interviewer and interviewee our teams training in preparation for the interviews also included extensive discussion of techniques for broaching sensitive topics during qualitative interviews incorporated feedback from local team members on culturally appropriate ways of approaching these issues and provided opportunities for role playing we believe that all of these procedures allowed us to approach these topics with the greatest sensitivity and to mitigate many of the problems associated with discussing sensitive issues in interviews at the end of each interview participants were given a 10 incentive for their time a brief sociodemographic questionnaire was applied to each interview participant following the first interview of the 32 participants 7 were currently married 26 had children and 22 had migrated to sosúa from other parts of the dominican republic or haiti their average age was 31 years ranging from 21 to 59 seventytwo percent were single 22 were married 6 were divorced and 81 had children 53 reported a primary school education or less and only 19 had completed high school all semistructured interviews were recorded on digital audio recorders and later transcribed for analysis because of the large body of text to be analyzed en vivo coding and analytic summaries were conducted with each interview en vivo coding involves the use of short restatements of emerging themes emphasizing the words and phrases provided by participants themselves analytic summaries consisted of 1page overviews of the key findings or emerging themes in each participants narrative based on these procedures a provisional codebook was then created including definitions of codes and subcodes criteria for inclusion and exclusion and brief examples of narratives that would be appropriate for each code research staff received coding training using the atlasti computer software program and the codebook a small subset of the interviews was then coded by project staff to ensure viability of the codebook and consistency between coders followed by team discussion and reflection following this process modifications were made to the codebook and all interviews were then recoded by one of six coders following coding data were analyzed by examining the range of responses associated with particular themes of analytic interest to obtain information about the tendencies in experiences and perceptions across the sample this type of vertical analysis decontextualizes segments of textual data associated with themes of interest by removing them for the larger transcript for focused analysis permitting a closer examination of codespecific responses across the sample second in conjunction with the continual writing of analytic memos and the use of the analytic summaries subtle variations in perspective among individual participants were situated within the larger context of meaning experience and behavior of each person this horizontal analysis allowed us to recontextualize narratives within the larger context of a persons life to develop explanations for variations in experience across the sample results if alcohol doesnt sell there is no life the business of alcohol use in sosúa with the high number and concentration of alcoholserving establishments in the area of sosúa it is perhaps not surprising that many participants described drinking as their primary form of entertainment indeed nearly all participants mentioned the consumption of alcohol when asked an openended unprimed question about what they enjoyed doing for recreation we began the second interview session with a very openended questionwhat do you like to do for funto avoid directly framing the discussion around alcohol use and to explore how participants interpreted having fun nearly universally responses were either direct references to alcohol consumptionsuch as i go drinking with my friendsor were references to visiting alcoholserving establishmentssuch as i go to discoteca discotheque x in el batey even when participants described having fun as going to specific locations or businesses rather than alcohol consumption per se followup questions about what activities they enjoyed engaging in within these sites very commonly produced descriptions of alcohol consumption or illicit drug use without direct questioning about these activities from the interviewers although this might reflect a cultural script associating fun with alcohol it also reflects the pervasive and ubiquitous presence of alcohol within the lives of all sosúans jonathon 1 a 35yearold man who reported working in a wide range of informal jobs within the tourism sectorincluding teaching spanish classes selling illicit drugs having romantic or sexual relationships with foreign women in exchange for gifts and brokering sexual exchanges between tourists and localsnoted that here we live alcohol here it is difficult to find a person who doesnt drink to say i do not drink alcohol very difficult i know one person who drinks rarely but he still drinks this perception of the pervasiveness of drinking was attributed largely to the influence of tourism because the industry depends on what josé a 33yearold security guard described as the vice of drinking and the vice of drugs binge drinking by tourists was described as having a profound impact on alcohol and illicit drug use among local residents and especially those employed by businesses catering to foreigners these environments normalized excessive drinking and made it nearly impossible to conceive of a life without alcohol particularly in interactions or exchanges with tourists or in tourism businesses thus even though alcohol was associated with fun participants also mentioned the consequences of excessive alcohol consumption which were often described with morally laden terms such as vicio 1 all names used in the article are pseudonyms drinking while working in the tourism industry was a common practice marcos a 38yearold man who worked renting chairs and umbrellas on the beach observed that alcohol functioned as a way to maintain the ambiente youre not obligated to drink … but the majority easily drink alcohol to create the atmosphere atmosphere was composed of rest relaxation and the kind of abandon that was facilitated by alcohol whereas marcos stressed that his job did not obligate him to drink other participants felt explicit pressure to drink as a part of their job in the tourism industry david a 31yearold man who described himself as a hustler working informally in promotions within the tourist sector noted the dominican republic is a party … there are times when i try not to drink but at times it is impossible for me … at times its customary that i have to drink drinking with potential clients allowed david to foster friendships and trust enabling him to successfully offer services which included serving as an intermediary in the sale of sex and drugs to tourists in sosúa alcohol was also described by participants as an essential part of the economic stability of businesses in sosúa and of the local economy as a whole many expressed the belief that alcohol was in the words of one participant life itself because the economic vitality of the city and the hope for a better future depended so fundamentally on the sale of alcohol julio the 39yearold manager of a local bar located strategically along the main coastal highway observed that if alcohol doesnt sell there is no life … we say there is no life there is no future no money although this equation of alcohol with life is perhaps not surprising for a bar manager it describes a more general tendency to view alcohol consumption as a basic and fundamental component of all social and economic transactions in sosúa margarita a 32yearold bar employee reporting a history of transactional sex described a tension between the perceived imperative to consume alcohol in the course of her work and her responsibilities as a single mother with young children although margarita admitted to drinking beer regularly in tourism areas she also insisted repeatedly during the interview i do not like alcohol i do not like anything to do with alcohol she explained the apparent contradiction between her distaste for alcohol and her regular consumption as follows i live with my children im a mother and father at once i cannot get home drunk but they tourists always offer me drinks i drink if they offer it to me but i cannot buy drinks i do not have resources to buy beer because i have a newborn baby and my daughter i do not want to get drunk i sometimes drink out of necessity but not because i want to margaritas narrative was similar to those a number of the women participants who expressed gendered reasons to avoid alcohol such as obligations to family and children but who also described the necessity to consume alcohol routinely in the course of their work here she expressed this tension in the notion of drinking out of necessity making reference to the ways that drinking is integrated into the material and interpersonal exchanges that structure tourism labor leading to the perceived imperative to consume women had to balance this necessity against other gendered obligations such as being a responsible mother and provider to children this imperative was reinforced by business owners and managers who employed various techniques to encourage alcohol sales which were described in detail by participants many establishments offered regular drink specials such as discounts or promotional boletos providing incentives for clients to buy more alcohol or to patronize the establishment on a particular night angelia a 33yearold unemployed woman who reported a history of sex work also noted that some businesses offered employees an incentive system such that if they sell more they earn more when david the selfdescribed hustler mentioned above brought tourists to local businesses he was often rewarded with free drinks from the manager this incentive system encouraged both greater rewards for the employees as well as increasing alcohol consumption among both tourists and locals through such commissions and informal rewards businesses perpetuated as well as responded to a pervasive demand for alcohol that was such a defining feature of sosúa in turn this climate of consumption contributed to a major theme that emerged throughout the interviews the inseparable relationship between sexuality and the consumption of alcohol alcohol and sex as intertwined in sosúa participants consistently articulated a kind of conflation or persistent association between alcohol and sex such that one almost necessarily implied the other one illustration of this is the fact that several participants described the presence of chicas as a prerequisite for the sale of alcohol in sosúa essentially no alcoholserving venue was perceived as viable if it did not offer womens sexuality as a primary component of the alcoholconsumption experience miguel a 44yearold man employed by a bar catering to tourists observed that venue owners often sought ways to attract women to the business as a means of drawing in more young men both dominican and foreign who were perceived as the lucrative clients in local businesses with good chicas he said there always are people as such women were framed as prized erotic commodities they were basic capital needed to generate greater profits from alcohol sales at the club where josé worked the late shift the owner requires the female bartender to be sexy and always to be dancing with tourists … because it motivates them to spend their money … it allows his business to sell more recognizing the function of women as a stimulus to alcohol sales a number of establishments offered entrada gratis or free entry to young dominican women under the assumption that they would positively influence the sale of alcohol many of these young women were known or presumed to be sex workers but often were not formally employed by these businesses rather their presence created a kind of consumptive synergy young women obtained opportunities for informally negotiated transactional encounters with tourists and the businesses used their presence to attract clients to boost alcohol sales participants were therefore quite clear in their narratives that the value of women within sosúa was inextricably linked to the value of alcohol as a commodity because sexuality alcohol and illicit drugs were mutually reinforcing and often consumed together participants expressed the perception that sosúa was a town that sold vicios a commodity that was the central reason that tourists come from faraway countries to experience this small caribbean town a number of participants expressed an awareness that tourists come to sosúa in search of vicios including excessive drinking and drug use even though they rarely do so in their home countries cristina a 21yearold working as a waitress in a local bar with primarily foreign clientele described one particular customer as a good person and then added that in his country he doesnt drink alcohol meanwhile he comes here and even his passport goes crazy when he is in the dominican republic maria a 24yearold woman working as a salaried waitress within the tourist area of el batey similarly explained that this behavior was acceptable and tolerated while on vacation in sosúa because of the benefits of such decadence for the local tourism economy so they the tourists come to this country to have fun what they cannot do in their country they do here but also the contribution that they make is really good for the country because we depend completely on tourism marias final remark which reframes tourists hedonistic behavior as beneficial reflects a pattern in the interviews despite recognition of problematic behaviors among tourists such as excessive alcohol consumption and drug use few participants characterized the tourism industry as negative or in need of reform instead they focused on the need to accept such excesses because of the countrys utter dependence on the industry it might be that participants themselves relied so heavily on interaction with tourists for their own livelihoods that it was impossible to envision an alternative reality participant narratives also demonstrated the conceptual linkage between alcohol illicit drugs and sex in the linguistic associations between these activities often alcohol drugs and sex were all mentioned in a list of vices that were believed to drive the tourism industry in sosúa for example josefina a 23yearold woman who described herself as unemployed but occasionally engaged in transactional sex with foreign men commented that tourists come to have a good time they come to look for whores to drinkto drink a lot similarly 35yearold jonathon who supported himself through various informal jobs within the tourism industry noted that tourists in sosúa come for prostitutes and for drugs do not tell me that tourists come here to go surfing or come to snorkel because its not true the tourist that comes here comes to have sex with their women to snort their cocaine sex like alcohol consumption was described as another tourist behavior that was absolutely central to maintaining the industry like alcohol participants emphasized the economic importance of sexual exchanges with tourists for the vitality of the entire industry because the value of dominican bodies to tourists was one of the primary resources that guaranteed tourist arrivals josefina 23 who occasionally engaged in transactional sex with gringos for example was clear that sex work was essential for the flow of dollars to the dominican republic indeed echoing the statements made about alcohol described above she observed that without whores there is no life tourism is very good very important for this country it brings a lot of money here … and the whores are good the people talk badly about the whores but the whores make the gringos spend money they like the whores to go to the dance clubs because without whores there is no life without whores there are no gringos the gringo goes where the women go you see the dance club over there the drinks are free for the women who enter because if the women go the gringos go josefina described a script of sex and alcohol in sosúa that was articulated by a number of participants tourism is vital for the life of sosúa the consumption of vicios is what tourists most desire and what motivates their travel cueros provide the erotic services that maintain the demand for such vices and are therefore good indeed essential for sosúas survival this script emphasizes the inseparability of these vicios because it is their synergistic relationship to one another that creates the particular social environment of sosúa this is evident in the organization of tourism businesses participants described alcohol venues functioning as informal brothels and some having habitaciones on site for sexual exchanges a trend noted in previous studies furthermore participants noted that in many alcoholserving establishments in sosúa staff employed as bartenders waitresses and security personnel often served double roles as sex workers or as intermediaries between clientele and sex workers in essence alcohol venues were not viewed only as places to purchase drinks they also offered the joint commodities of eroticism and sex in josés words there are two things that theyre selling drinks and women so the guy who has his bar sells the drinks and the women its also the same when consuming alcohol the tourist pays for his drink and takes along his woman that is that you do both things at the same time getting crazy and sexual risk in sosúa as described previously the literature on tourism and health behaviors has tended to focus on tourists uncharacteristic or distinct behaviors as they travel to new environments with different normative systems and controls in the context of hivaids this is hypothesized to be associated with higher rates of touristreported risk behaviors but few studies have documented the effects of tourism environments on local tourism employees in this study participants were well aware of the potentially harmful consequences of escapism in tourism areas which they often described as particularly dangerous because of the overwhelming presence of illicit drugs and alcohol in addition to the close linkage between alcohol and sex work described above participants understood tourism areas as especially dangerous in the context of hiv aids many participants described decreased inhibitions and poor or atypical behaviors in sexual situations in sosúa which could result in ceding control in sexual situations laura a 32yearold bar employee who goes out with clients for money emphasized in her interview that she was very cautious about drinking when she met clients if you get drunk whats going to happen is that youre going to get crazy and anything could happen to you and this life is very dangerous in lauras case this life refers implicitly to sex work which is often referred to indirectly in the dominican context but which pervades nearly every aspect of life in sosúa alcohol and illicit drugs were understood by participants to facilitate getting crazy which was often described as a temporary loss of control that ultimately contributed to danger like laura cristina a 30yearold waitress noted that after drinking many women in sosúa do not know what theyre doing they do not know who they are going with and who they are sleeping with because the entire tourism environment fostered abandon and participation in vices the addition of alcohol and illicit drugs reduced personal control over ones sexuality for laura and cristina the perceived danger of contact with tourists was therefore associated with the temporary suspension of normative controls on behavior that have been described for tourism areas in general but which were exaggerated by the alcohol and substance use that typically accompanies tourist activities the idea of getting crazy in lauras narrative is similar to that of other interviewees who expressed similar notions of losing control over sexuality and explicitly linked this phenomenon to unsafe sex sara a 22yearold woman working in a local billiard hall noted the connection between alcohol consumption and condom use with tourists some tourists do not want to use a condom … because of the environment the drink the women when they have their rum in their head their vice implying drugs all they want is sex but they do not want to be careful they do not want to take care of themselves in saras narrative it is evident that getting crazy and losing control are inherent aspects of the industry and lack of condom use in sexual situations is simply one component of this larger pattern cecilia a 23yearold selfidentified sex worker described in her interview that even though she always tried to be careful in her workwhich for her involved avoiding alcohol and illicit drugsthe social environment of sosúa was dangerous for many of her peers because sometimes when they go with a man they do things under the influence of alcohol you know that they shouldnt do then the day after they rethink what they have done cecilia also described an association between alcohol consumption and the false trust that it can generate leading to dangerous choices with a relatively unknown partner there are people that when they are going to have sex they do not protect themselves because of the alcohol and trust and thats why you cannot trust anyone here cecilia connected the idea of getting crazy with a related notion that is the development of intimacy with clients and the resulting dangers that this intimacy could provoke particularly in decisions regarding condom use as the literature on dominican sex work has described much of sosúas commercial sex industry depends on the development of intimacy and romance between tourists and locals a phenomenon that has been described as romance tourism the concept is useful in that it draws attention to the fact that much of what is being transacted in tourism environments such as sosúa is intimacy affection and love rather than sex per se it is clear that such intimate relationships were valued among many of our participants and indeed many of the histories of transactional sex described by participants did not involve onetime or direct sexformoney exchanges but rather intimate relationships or friendships with tourists rosa a 28yearold unemployed woman explained that at the time of the interview she had foreign boyfriends with whom she had sexual relationships but that they are not clients but for love they give me money and i do it with love nevertheless some participants described affection or love as somewhat strategic that is they also noted the utility of affection as a means to obtain material support luis a 34yearold man working in security in the tourism area was in a longterm relationship with a dominican woman but also described pursuing an extended relationship with a canadian woman when asked why he endangered his longterm relationship by developing additional connections with foreigners he described this as a financial decision if you do not have a good economic position when you find a partner that is economically viable then you have their benefits for him establishing an affectionate relationship was more explicitly a means to an enda chance for gaining some economic stability at the same time that intimate connections with tourists were valued these relationships were sometimes complicated to manage and some participants again described getting crazy as the loss of control over ones emotional relationship with tourists the ability to appropriately manage emotional feelings with tourists was thus something that was valued among participants because it allowed them to effectively manage needed relationships to privileged foreigners while also avoiding the loss of control that might lead to negative consequences or disappointments maricela a 23yearold woman who had had foreign boyfriends in the past noted the fleeting nature of these relationships they give you lots of love but after three months they forget about you one day they no longer call you they do not write speaking of her exboyfriend a tourist from canada angelina noted that he was a good person responsible and because i never had help like that from a man with him i felt safe he helped me a lot he respected me because times were different not like now angelinas comment implies that tourists at the time of interview were less likely to help and protect dominican girlfriends than in the past suggesting a need for caution in establishing such relationships in fact clara a 34yearold bartender and sex worker proudly noted that with the exception of one american tourist she had never loved a client referring critically to this previous relationship as crazy these cases demonstrate that even though tourism areas like sosúa encourage the establishment of intimate or romantic relationships between tourists and locals they can be challenging to manage emotionally and interpersonally and require a measure of control to avoid certain dangers or doing something crazy one such danger is engaging in behaviors that can lead to hivaids miguel a 44yearold man working informally in a tourist establishment explained the need to maintain control over ones feelings there are a lot of young pretty girls and you see them and you fall in love and so when you take a drink and you do not know her there are many women who have hiv so then youre left infected because you are partially drunk and so is she here miguel connected the emotional attribute of being in love to the decision to engage in risky sexual behaviors suggesting that alcohol can influence ones ability to exercise both emotional control as well as sexual control there are times david the 31year old selfdescribed hustler said that the women fall in love with the gringos and it is not like a job … there is pleasure trust they open up to that person putting them at risk to have sex with these tourists without any protection sosúa was understood by participants as a space in which the ability to maintain protective controls on ones emotional and behavioral decisions is compromised and the presence of vices exacerbates this tendency discussion although the literature on research in the caribbean documents high rates of sexually risky practices alcohol consumption and illicit drug use these phenomena have been generally understood within a behavioral or issuespecific framework the goal of syndemic theory is to reconfigure these frameworks to focus on the broader societal and material context that drives the accumulation of negative health effects particularly in marginalized or disadvantaged populations based on the regional social science literature and our own analysis we believe that tourism industry employees in areas such as sosúa constitute a vulnerable population often facing syndemic conditions that have rarely been addressed by public health initiatives or public policy which has primarily centered on educational and behavioral prevention approaches aimed at targeting separate health outcomes such approaches do not address the broader social and economic conditions of life and work in caribbean tourism areas where a growing population of workers converges as they cope with dwindling options for productive activity with our qualitative research on the social context of alcohol illicit drugs and sexual practices in sosúa we aimed to understand how a diverse sample of tourism industry employees described their own social and economic environments and the influence of these environments on their daily lives and practices this allowed us to examine whether the theoretical assumptions of syndemic theory are reflected in firstperson narratives of the tourism workers themselves and if so the specific forms they take our analysis revealed several findings consistent with syndemic theory in sosúa the consumption of alcohol and illicit drugs is described by local tourism workers as basic elements of the social and economic climate of sosúa and central to tourist practices and desires indeed without these vices many participants believed there would be no life because tourists are primarily drawn to sosúa precisely because of their ability to temporarily and with a certain degree of abandon engage in behaviors that are not typical back home tourism workers perceived tourists to behave quite differently in sosúa than they do in their home countries where they were regarded as morally upstanding in contrast to their crazy behavior in sosúa the participants were often compelled by this general social climate of abandonwhich we refer to as touristic escapismto engage in what they perceived to be crazy practices partly as a consequence of their desire to establish friendships and intimacy with tourists business practices contributed to a social atmosphere in which alcohol drugs and sex were readily available and were marketed and consumed as a suite of tourist services not as separate or independent commodities this economic rationality combined with the escapist climate of sosúa functioned to diminish their perception of control over alcohol consumption and sex for example although participants described the desire to maintain some control over alcohol use as a protective strategy and a parental responsibility they also noted the necessity of drinking with tourists as a means of establishing intimate social and sexual relationships in margaritas words i drink out of necessity not because i want to tourism businesses in sosúa participated actively in generating this sense of obligatory alcohol consumption businesses that our participants frequented as part of their work were not only places to purchase alcohol and illicit drugs but also sites that functioned to link alcohol consumption to eroticism through specific marketing practices many bars and discos for example provided free drink tickets to young women as a means of supporting alcohol consumption and attracting clients seeking good chicas or rewarded local promoters and staff with free drinks thus the marketing of dominican sexuality was functionally inseparable from the sale and consumption of alcohol conversely the sale and use of alcohol provided an essential means of establishing and fostering erotic and sexual transactions this synergistic relationship created particular challenges for tourism employees as they navigated the potential dangers of sosúa individually both sex work and alcohol played a role in the sexual vulnerabilities of tourism employees in sosúa nevertheless it was the synergy between alcoholdrugs and transactional sex that likely contributed most to sexual scenarios that could transmit hiv or other sexually transmitted infections a number of participants in this study noted that alcohol contributes to getting crazy or losing control over ones sexuality and compromising ones ability capacity or desire to use condoms our results and the regional literature suggest that this can be more common among those who engage in transactional sex but either do not selfidentify as sex workers or perceive these sexual encounters as a component of an intimate or romantic relationship in the cases of such transacted intimacy the desire or the need to establish intimacyand the consumption of alcohol and illicit drugs as a means to achieving intimacycreated a situation in which selfprotective strategies were less likely to be used hiv interventions do not generally address such experiences of transacted intimacy because they do not fit within the normative frames of public health particularly the emphasis on interventions targeting formalized sex workers although prevention efforts targeting sex workers are a critical component of public health efforts they do not capture the range of informally transacted intimate exchanges that our participants described or that predominate in the caribbean social science literature approaches to health promotion among caribbean tourism workers such as those we interviewed in sosúa should incorporate a broader understanding of the social and economic conditions workers face in the course of their daily lives as a growing population of tourism workers migrates to tourism zones health programs and policies should aim to guarantee safer working conditions and acknowledge the syndemic potential of these areas for tourism workers this involves moving beyond traditional approaches to intervention that separately target health outcomes such as hiv alcoholism and drug use instead healthpromotion efforts should be focused on the design and implementation of new policies and safer work protections aimed at providing the social and economic conditions for achieving health and wellbeing among tourism workers more generally following the premises of syndemic theory and informed by our qualitative findings we conclude that there are at least three domains in which programs and policies should be focused first policy advocacy should be focused on providing greater guarantees for the occupational health of tourism workers with particular emphasis on ameliorating the synergistic relationships among alcohol illicit drugs and transactional sex this will involve incorporating the perspectives and challenges faced by workers themselves into appropriate initiatives such as their perceived necessity to consume alcohol as a requirement of tourism work or the perceived loss of control in intimate encounters with tourists interventions with this population should avoid the partitioning and targeting of separate health behaviors and instead develop industry standards programs and protections based on the multiple and intersecting challenges to health and wellbeing faced by tourism workers second healthpromotion initiatives in tourism areas should foster collaboration across the public and private sectors to generate awareness and dialogue about the multiple health vulnerabilities faced by tourism workers and develop joint policies to ameliorate them business owners and managers are likely to be well aware of the synergies between alcohol consumption drug use and transactional sex and are critical partners in ensuring safer environments for employees based on workers expressed needs because our research demonstrates that local tourism workers in sosúa are already concerned about the dangers of losing control or getting crazy for example it is likely they would be responsive to workbased programs and opportunities for dialogue that would provide strategies and resources for avoiding such dangers in the course of their work finally programs for sexual health promotion which to date have largely avoided the tourism industry should be mandated and overseen by the state as a basic occupational health protection for all tourism industry employees such programs should not seek to target a formalized or stereotyped category of sex workers but rather address the pervasive presence of transacted intimacy alcohol consumption and substance use throughout tourism areas and incorporate broader hivprevention resources that are integrated into occupational health programs the fundamental goal of such programs should be to openly acknowledge the lived realities of transactional sex and its frequent combination with alcohol and drug use and then provide the skills and resources for reducing sexual health vulnerabilities it would be critical for such programs to avoid the stigmatization or penalization of these practices which would only serve to marginalize tourism workers and prevent positive changes in the conditions they encounter

the dominican republic has high rates of hiv infection and alcohol consumption unfortunately little research has been focused on the broader sources of the synergy between these two health outcomes we draw on syndemic theory to argue that alcohol consumption and sexual risk behavior are best analyzed within the context of culture and economy in caribbean tourism spaces which produce a synergy between apparently independent outcomes we sampled 32 men and women working in the tourism industry at alcoholserving establishments in sosúa dominican republic interviewees described alcohol consumption as an implicit requirement of tourism work tourism industry business practices that foster alcohol consumption and an intertwining relationship between alcohol and sexual commerce the need to establish relationships with tourists combined with the overconsumption of alcohol contributed to a perceived loss of sexual control which participants felt could impede condom use interventions should incorporate knowledge of the social context of tourism areas to mitigate the contextual factors that contribute to hiv infection and alcohol consumption among locals

appropriations act enacted in march 2020 allowed for reimbursement of home telehealth visits by video or telephone the goals of expanding telehealth coverage were to mitigate gaps and prevent surges in demand for patient care 12 expanded coverage led to rapid telehealth implementation allowing for inperson ambulatory visits to be replaced by telehealth visits 3 4 5 6 7 in efforts to decrease the transmission of the sarscov2 virus among patients and providers and conserve personal protective equipment 8 prior to the covid19 pandemic telehealth was primarily used in special situations particularly in rural areas and with military veterans to address health care needs in underserved populations 910 in these settings telehealth was effective and delivered similar outcomes to inperson care 11 while decreasing patient travel times 10 12 13 14 15 many believe that maintaining telehealth reimbursement in the post pandemic era will lead to improved health equity and outcomes by reducing geographic and other barriers to accessing care 1617 but data supporting this hypothesis is limited several studies have evaluated disparities in telehealth use during the early stages of the covid19 pandemic the most consistent finding was that older nonwhite patients who have medicaid or are uninsured and who live in rural areas were less likely to have a telehealth visit compared to white englishspeaking patients with commercial insurance living in nonrural areas 71218 a study conducted in new york city used zip code mapping and found disparities in telehealth use in underserved and minority communities 19 however a study conducted in the kaiser permanente system in southern california found that hispanic and lowincome patients had the largest increase in telehealth use following its introduction 6 these results suggest that telehealth may not be a ubiquitous solution to health care access barriers but benefit specific populations and models of health care delivery we aimed to evaluate socioeconomic factors and the geospatial distribution associated with access to care and telehealth use during the covid19 pandemic in a large population of rural and urban patients receiving care through a us academic health system we hypothesized that telemedicine would contribute to the efforts to maintain access to outpatient care including in remote areas which would have been otherwise negatively impacted by the covid19 pandemic however this access to care may be muted in patients from socioeconomic backgrounds known to face health care disparities methods study design and setting this retrospective crosssectional study included patients treated by primary care and speciality providers in clinics owned and operated by the university of nebraska medical center omaha nebraska in the united states unmc is a large midwestern academic tertiary health care centre in the united states with over a million outpatient visits annually telehealth was provided via a video platform embedded in the health systems electronic health record telephone visits were used when video visits were not feasible data and study timeline the study protocol was approved by the medical centres institutional review board we collected deidentified data from all inperson and telehealth ambulatory provider visits from the ehr system from march 16 2017 through march 15 2021 we used the oneyear covid19 period defined as march 16 2020 to march 15 2021 as the study period of interest covid19 period data were compared to a baseline precovid19 period from march 16 2019 to march 15 2020 to determine whether patients were established with a medical centre provider during these time periods we also identified corresponding establishment timeframes which ran for two years prior to the start of each period of interest patients who were seen during and were nondeceased at the end of an establishment timeframe were included in the established patient denominator for the subsequent period of interest study cohort we identified established and new patient cohorts for each period of interest patients with at least one ambulatory visit during the respective twoyear establishment period who had a provider visit during the period of interest were defined as established patients for that period of interest patients seen during the period of interest but who did not have an ambulatory visit in the twoyear establishment period were classified as new patients established patients could be in one or both periods of interest while new patients were only new in one period of interest variables dependent variables included the occurrence of overall ambulatory provider visits and by inperson vs telehealth delivery we created summary variables for counts of inperson and telehealth visits after which patients were categorized as having all inperson visits or one or more telehealth visit independent variables identified for each period of interest included demographic data and diagnosis of diabetes for established patients we based the patients age on the age at the beginning of the period of interest while we pulled other baseline characteristics from the patients last visit in the respective establishment period an exception was the diagnosis of diabetes which was based on having a documented icd10 code for type 1 or type 2 diabetes at any time during the respective establishment period for new patients we used baseline characteristics from their first visit in the period of interest due to the nature of the data warehouse patient residential zip codes were associated with a patients address at the time of the data extraction for data not available at the patient level we assigned patients the value associated with their zip code as a proxy using american community survey 2019 fiveyear estimates 20 statistical analyses for univariable statistics we used χ 2 tests and independent samples t tests or wilcoxon rank sum tests to assess the differences in categorical and continuous variables respectively between groups of interest when the two groups were independent we provide only descriptive statistics when groups were not independent no steps were made to impute missing data we thus calculated percentages for all descriptive statistics using the nonmissing data within each variable as the denominator we conducted multivariable regression analyses to identify 1 the odds of established patients having a visit during the covid19 period relative to the precovid19 period controlling for patient characteristics and 2 patient characteristics associated with having at least one telehealth visit vs all inperson visits during the covid19 period we used logistic regressions when patients only contributed a single observation for outcomes where a patient could contribute multiple observations we utilized generalized estimating equations to account for the correlation within patient for all models we presented adjusted odds ratios with 95 confidence intervals which were bonferroni adjusted based on the number of possible pairwise comparisons that could be made within each variable pvalues of less than 005 were considered to be statistically significant statistical analyses were performed using sas version 94 mapping we further summarized patientlevel data at the zip code level for each period of interest rates were calculated and the percentage of established patients who had a visit in the associated period of interest and the percentage of patients seen during covid19 with a telehealth visit for established and new patients separately zip codes with less than five patients in the denominator were excluded from mapping to avoid extreme percentages we associated summary statistics for each zip code with the centroid for that zip code and inverse distance weighting interpolation was used to generate an estimated surface of percentages across the entire state the mapping was done using arcgis pro software version 270 results a total of 128 598 out of 243 248 established patients seen and nondeceased at the end of each establishment timeframe had at least one ambulatory provider visit during the precovid19 period 125 855 out of 255 742 had at least one ambulatory provider visit during the covid19 period approximately 336 of all patients seen in the precovid19 period were new while only 300 of all patients seen in the covid19 period were new baseline characteristics of the patient cohorts are reported in table 1 established patients were similar between time periods with patients being on average 50 years of age predominately female commercially insured nonhispanic white and englishspeaking the majority in precovid19 and covid19 periods lived within 30 miles of the medical center and median internet access at the zip code level was high all baseline characteristics for new patients were statistically different between the precovid19 and covid19 periods except gender compared to new patients in the precovid19 period new patients in the covid period were slightly older more of them had medicaid coverage were of hispanic ethnicity and lived within 30 miles of the medical center in multivariable regression analyses established patients were less likely to have any ambulatory provider visit in the covid19 period compared to the precovid19 period controlling for demographic and clinical characteristics the spatial distribution of the proportions of established patients seen in the precovid19 and covid19 periods and the proportions of established and new patients having at least one telehealth visit in the covid19 period can be seen in figure 1 and figure 2 these maps represent percentages of patients in an area rather than overall counts the percentage of established patients with a visit in either period of interest is similar across the two time periods there were higher percentages around the medical centre and other larger cities in east central nebraska and lower percentages in more rural and western areas of the state further percentages shifted downward in the covid19 period indicating that fewer established patients were seen relative to just one year prior the percent of established patients with at least one telehealth visit increased from 04 in the precovid19 period to 411 in the covid19 period similarly 1 of new patients had a telehealth visit during the precovid19 period vs 235 of new patients during the covid19 period maps illustrating the percentage of patients who utilized telehealth at least once in the covid19 period highlighted a higher percentage of utilization in established patients in more rural and western parts of the state than in urban areas overall the percentage of telehealth usage among established patients was much higher than in new patients for new patients the percentage of those who used telehealth tended to increase with increasing distance from the medical center social determinants of health and telehealth visits in the covid19 period factors associated with having at least one telehealth use during the covid19 period in established patients are shown in figure 3 patients younger than 19 and older than 34 years were less likely have a telehealth visit while females were more likely to have a telehealth visit than males patients with medicare and medicaid had higher odds of having a telehealth visit compared to those with commercial insurance other social determinants of health associated with lower odds of having a telehealth visit include selfpay or other insurance type black or asian race nonenglish preferred languages and living in a higher income zipcode living in a rural area was not significantly associated with telehealth use compared to residing in an urban area within 30 miles of the medical centre however patients living in an urbanadjacent rural zip code had slightly higher odds of having a telehealth visit and living in an urban area more than 30 miles from the medical center was associated with lower odds of having a telehealth visit the likelihood of having a telehealth visit was positively associated with average internet access in the patients zip code of residence white star indicates main nebraska medicine campus we created the maps based on data summarized at the zip code level we used the centroids of zip codes for inverse distance weighting interpolation to generate estimated surfaces for maps of percentages we excluded zipcodes with denominators less than or equal to five to help avoid extreme percentages excluded zip codes are more common in the western part of the state which can result in large areas of extreme percentages where areas with missing data are estimated by the few nonmissing extreme percentage areas around it we created the maps based on data summarized at the zip code level we used the centroids of zip codes for inverse distance weighting interpolation to generate estimated surfaces for maps of percentages we excluded zipcodes with denominators less than or equal to five to help avoid extreme percentages excluded zip codes are more common in the western part of the state which can result in large areas of extreme percentages where areas with missing data are estimated by the few nonmissing extreme percentage areas around it factors associated with having at least one telehealth visit during the covid19 period for new patients are shown in figure 4 the association between demographic characteristics and having a telehealth visit for new patients mirrored those of established patients for age gender race spanish language and income selfpay patients and those with other insurance similarly had lower odds of having a telehealth visit than those with commercial insurance however new patients with medicare and medicaid were not more likely to have a telehealth visit as was seen in established patients unlike the established group new patients living in more rural areas had higher odds of telehealth use vs those living in an urban setting within 30 miles of the medical center discussion this study examined access to care and identified factors associated with ambulatory provider visits and telehealth use during the first year of the covid19 pandemic at a midwestern us academic medical center this represented a substantial shift in health care delivery due to lack of reimbursement models for inhome telehealth prior to the pandemic we report that as expected fewer established patients had a provider visit during the covid19 period vs the precovid19 baseline at the same time telehealth use increased substantially alleviating the pandemics impact on access to care specifically the proportion of established patients with at least one telehealth visit increased from 04 precovid19 to 412 during the covid19 period although new patient use of telehealth was lower at 234 overall we found that many patients with a telehealth visit also had at least one inperson visit during the covid19 period suggesting that telehealth is an option for care delivery but not a complete replacement for inperson visits inperson visits remain essential per need and patientprovider preferences dynamics that may have contributed to lower telehealth use by new patients the relationship between rurality provider visits and telehealth use provided us with useful insights relative to living within 30 miles of the medical center established patients living more than 30 miles away were less likely to have a health care provider visit during covid19 than during the precovid19 period however patients living in rural areas remote from the medical center may have opted to seek care at other health care facilities not affiliated with the university while patients from these further locales made up a smaller proportion of new patients during the covid19 period they were more likely to use telehealth a recent study reported that adults living in midwestern us and in nonmetropolitan areas have decreased odds of using telehealth 21 however the overall relationship between telehealth use and rurality in our study was mixed and our data suggest that telehealth may have helped rural patients access care at the medical centre during covid19 pandemic another notable finding regarding telehealth use during the covid19 period is that patients from zip codes with lower median incomes had higher odds of utilizing telehealth thus telehealth may benefit some patients with time andor transportation barriers to accessing care however patients of a minority raceethnicity older age uninsured status andor whose preferred language was not english were less likely to use telehealth these findings are generally consistent with the limited literature on telehealth use by social determinants of health 2223 and suggest that work is needed to educate and develop resources to make telehealth more accessible to diverse populations strengths and limitations the strength of this study is in its longitudinal analysis of health care provider access in a relatively stable population before and during the covid19 pandemic our inclusion criteria were broad and our population was largely representative of the diversity in the us 24 furthermore our medical centre has a large geographic and rural catchment area and it operates primary care and specialty clinics throughout the metropolitan area thus this study represents a breadth of settings and serves as a good model to study potential challenges to telehealth use one limitation of this study is its retrospective single center design we did not have access to data for the patients in our cohort who may have received additional care outside of the academic medical center to help understand overall health care access moreover income and internet access were not available in ehr systems and were obtained at a zip code level using acs data that predates the covid19 pandemic data analysed by medical subspecialty is not provided and we acknowledge that certain specialties are more amenable to telehealth than others in our study telehealth included both telephone and video visits evaluating these visit types separately may highlight further disparities studies have reported that despite interest in telemedicine navigating technology and internet connectivity required for video visits remains a challenge in certain patient populations 25 26 27 our study was not designed to assess specific technology barriers and further investigation is warranted finally we recognize that having access to internet is not equivalent to having access to broadband speeds required for telehealth visits by video conferencing future studies on longterm outcomes quality metrics effect on delays in preventative care consumer demands costeffectiveness and effects of access to covid19 vaccinations on telehealth use are needed conclusions the covid19 pandemic has transformed health care delivery in the us by increasing access to telehealth a model that is likely to remain in the postpandemic world as we move towards a health care model that includes both inperson and telehealth care our study highlights that solely changing reimbursement for telehealth is insufficient to expand access to care our data reinforces that access disparities existed despite the availability of inhome telehealth visits during the covid19 pandemic our study emphasizes the need for solutions targeting a improving digital literacy b interpretive language services and c access to stable highspeed internet these findings should prompt strategies and policy changes to allow for a more equitable health care system author contributions concept and design pd le and cmm data acquisition ks and aja analysis and interpretation of data ks aja pd le cmm and ad drafting and revision of manuscript pd le ks ad aja and cmm ethics statement this study was approved by the institutional review board at university of nebraska medical center omaha ne usa irb 090920ep a waiver of informed consent was granted due to retrospective nature of the study disclosure of interest the authors completed the icmje disclosure of interest form and disclose no relevant interests additional material online supplementary document

background during the covid19 pandemic health systems rapidly introduced inhome telehealth to maintain access to care evidence is evolving regarding telehealths impact on health disparities our objective was to evaluate associations between socioeconomic factors and rurality with access to ambulatory care and telehealth use during the covid19 pandemicwe conducted a retrospective study at an academic medical centre in midwestern united states we included established and new patients who received care during a oneyear covid19 period vs precovid19 baseline cohorts the primary outcome was the occurrence of inperson or telehealth visits during the pandemic multivariable analyses identified factors associated with having a health care provider visit during the covid19 vs precovid19 period as well as having at least one telehealth visit during the covid19 periodall patient visit types were lower during the covid19 vs the precovid19 period during the covid19 period 125 855 of 255 742 established patients and 53 973 new patients had at least one health care provider visit with 411 of established and 235 of new patients having at least one telehealth visit controlling for demographic and clinical characteristics established patients had 30 lower odds of having any health care provider visit during covid19 vs precovid19 adjusted odds ratio aor 071 95 confidence interval ci 0698071 period factors associated with lower odds of having a telehealth visit during covid19 period for established patients included older age selfpay or other insurance vs commercial insurance black or asian vs white race and nonenglish preferred languages female patients patients with medicare or medicaid coverage and those living in lower income zip codes were more likely to have a telehealth visit living in a zip code with higher average internet access was associated with telehealth use but living in a rural zip code was not factors affecting telehealth visit during the covid19 period for new patients were similar although new patients living in more rural areas had a higher odds of telehealth usehealthcare inequities existed during the covid19 pandemic despite the availability of inhome telehealth patientlevel solutions targeted at improving digital literacy interpretive services as well as increasing access to stable highspeed internet are needed to promote equitable health care access the united states us declared a public health emergency due to the covid19 pandemic on january 13 2020 subsequently the center for medicare and medicaid services cms followed by other insurance payers expanded access to and increased reimbursement for telehealth services specifically the 2020 coronavirus preparedness and response supplement

introduction we live in a world of data nowadays there are  billion of mobile phone subscribers worldwide with millions of new subscribers every day  more importantly the almost universal adoption of mobile phones and the exponential increase in the use of social media and other internet services is generating an enormous amount of data about human behaviors with a breadth and depth that was previously inconceivable as recently reviewed by blondel et al  the call detail records needed by the mobile phone operators for billing purposes can be exploited to extract mobility patterns  to model social interactions   citys structures  and epidemic spreading   to estimate population densities  and to predict socioeconomic indicators and outcomes of territories   similarly the emergence of social media provides further opportunities to researchers to study different aspects of human behavior such as peoples mobility  and social wellbeing of individuals and communities  in this context research challenges that provide access to a large number of research teams to the same dataset are becoming a valuable framework to advance the state of the art in the field and to sustain the process of reproducibility needed by the scientific community an example is the oranges data for development initiative   last year telecom italia with support from mit media lab northeastern university fondazione bruno kessler polytechnic university of milan university of trento eit ict labs trento rise and spazio dati organized the telecom italia big data challenge  providing a multisource georeferenced and anonymized dataset composed by telecommunications weather news twitter and electricity data from two italian areas the city of milan and the trentino province  more than  teams from more than  universities have participated to the telecom italia big data challenge the projects ranged from predicting energy consumption to exploring the impact on mobility of some specific events and comparing mobile phone calling patterns with economic demographic and wellbeing indicators the goal of the present thematic series is to showcase some of the most outstanding contributions submitted to the telecom italia big data challenge  and to provide a discussion venue about recent advances in the application of cdrs and social media data to the study of individual and collective behaviors with a particular attention devoted to the city dynamics contributions the first contribution by de domenico et al  investigates route assignments in smart multimodal systems   where individual daily trips follow recommendations based on personal and community constraints the proposed approach is of special interest for designing efficient cities where inhabitants could be automatically routed in order to reduce traffic and pollution a person might want to avoid routes with high traffic or areas with high criminality or to favorite routes across shopping and touristic areas however the individual choices of certain routes without accounting for the state of the whole urban system may lead to traffic congestion increasing pollution etc  in their paper the authors proposed to model the trips in an urban system as interacting particles with datadriven origindestination pairs the route choices of the interacting particles are based on a timevarying potential energy landscape that seeks to simultaneously satisfy individuals and communitys constraints specifically the proposed framework integrates multiple layers of constraints to favor certain routes and to study the effects of the proposed recommendations the obtained results showed that the synergy among the individual choices plays a fundamental role in designing an efficient and smart city only when all the individuals move according to the recommended routes the city traffic is closer to the most ideal mobility scenario interestingly the proposed method allows to monitor the traffic state of the city in real time automatically identifying areas that are experiencing a congestion and hence supporting urban authorities and policy makers in planning interventions the second paper contributed by douglass et al  used telecommunications activity data to create highresolution population estimates the traditional local census estimates are expensive contingent on participation and often suffer from several logistical issues as shown by  telecommunications data are a promising new source of realtime estimates of population in their paper douglass et al have shown that the correlation between call volume and population in a given area of milan is scale invariant above a certain population size then the authors by means of a random forest regression  provided a reliable estimate of population for populous areas the obtained results suggest that the method could be extended also to estimate population in less dense areas and to create estimates by gender age and ethnicity finally the authors evaluated models for predicting the percentage of foreign population in the third paper bajardi et al  studied urban spaces through the analysis of mobile phone records of users with strong international links eg migrants and visitors travelling to a city for tourism or for business more precisely the authors focused on mobile phone records collected in milan and used an entropy function to measure the level of country codes hetereogenity in the calling patterns of a citys neighborhood then they proposed a topological classification based on persistent homology and clustered the nationalities associated to the calls sources and destinations outside italy into two main groups the first group comprises lowincome countries whose topological spatial patterns show a strong cyclic spatial distribution the second group is formed by highincome countries whose spatial distribution is scattered in small areas over the city these results indicate that migrant communities from low income countries tend to aggregate in cohesive spatial structures and to live in the citys residential areas mainly around the city centre while communities associated with higher income countries tend to represent movement patterns of tourists andor highly specialized professionals in central and highentropy urban areas as pointed out by the authors the findings are in line with the ones predicted by the spatial assimilation theory  and confirm the empirical observation that different socioeconomic migrant conditions can show distinct spatial clustering patterns  moreover the authors demonstrated how mobile phone data can provide very specific spatial and temporal trajectories of visitors from a given country during a mass gathering event the fourth and last contribution by alshamsi et al  focuses on the relationship between urban communication and urban happiness specifically the authors analyzed geolocated tweets within milan to produce a detailed spatial map of urban sentiments then they used communication intensity data to build the directional network of urban areas where the weights of the edges represent the communication strength between the areas their results found that there is no correlation between the happiness level of urban areas and the amount of communication the areas receive or initiate instead happy urban areas tend to interact with other happy areas more than they interact with unhappy areas and similarly unhappy areas tend to interact with other unhappy areas more than they interact with happy areas interestingly the urban happiness homophily supports previous findings on individual happiness homophily  the obtained results may be relevant to guide policy makers in setting strategies that increase urban happiness conclusion the fourth papers in this series are excellent demonstrations of how mobile phone and social media data can contribute to many discoveries on daily life of individuals communities and cities telecom italia is currently running a second edition of the challenge  this year the data are released on  italian cities bari milan naples rome turin venice and palermo datasets include cdrs demographic data from telecom italia twitter data energy consumption data private mobility data and detailed italian companies information hence there are good reasons to continue with a second edition of this thematic series as follow up of the big data challenge  competing interests the authors declare that they have no competing interests

the goal of the present thematic series is to showcase some of the most relevant contributions submitted to the telecom italia big data challenge 2014 and to provide a discussion venue about recent advances in the appplication of mobile phone and social media data to the study of individual and collective behaviors particular attention is devoted to datadriven studies aimed at understanding city dynamics these studies include modeling individual and collective traffic patterns and automatically identifying areas with traffic congestion creating highresolution population estimates for milan inhabitants clustering urban dynamics of migrants and visitors traveling to a city for business or tourism and investigating the relationship between urban communication and urban happiness

introduction according to surveys the disabled population has continued to grow with 309 in 2000 459 in 2005 and 561 in 2011 1 a person with a disability often has no choice but to rely on hisher family supporting a family member with a disability is one of the most challenging experiences many preceding studies have reported that family caregivers of a person with a disability experience deterioration in mental and physical health due to stress 23 addressing familial burdens arising from an increasing population of the elderly and of patients with chronic diseases goodman and punoos 4 called family caregivers who care for a patient for a long period a second victim and the family of a person with a chronic disease a potential patient issues around the presence of disability within a family are not just limited to the person with the disability but they concern the whole family as the mental and financial burden are shared and care is provided as per the level of severity of the disability 5 some families build a closer relationship and successfully look after the member with a disability using a variety of resources while other families experience more tensions conflicts and frustrations between members 6 families who experience growing conflicts also experience sorrow desperation anger and lowered selfesteem internally and on the outside they experience physical burden lack of time owing to work and caregiving and financial challenges 7 if these feelings and emotions are left unresolved familial tensions and conflicts become chronic and extreme which occasionally leads the family to fall apart 5 at varying degrees majority of the families with a member with a disability show depression symptoms and feel stress over their caregiving responsibilities caregiving stress is in other words expressed in the form of familial tensions and pressure which is inevitably experienced owing to the imbalances between the caregiving responsibility and actual capability 8 families are put in a situation that is overwhelming and they experience mental and psychological confusion which acts as a threat to their physical and mental health therefore it is critical that the family members measure their level of stress and maintain their health depression influences ones behavior cognition and emotions and it significantly brings down the quality of care 9 depression is caused by the negative evaluation of 2 occupational therapy international oneself which makes it difficult to carry out daily routines as one feels fatigued and loses motivation it may also lead to physical pain and even suicidal behavior 10 hence it is important to seek solutions to relieve such symptoms and to improve the health of family caregivers of a person with a disability to protect their mental health and to ensure that they lead a healthy family life selfesteem is one of the characteristics that enable individuals to cope with hardships rosenberg 11 defined selfesteem as a subjective evaluation of oneself and he proposed that a strong selfesteem indicates that one accepts and respects oneself and believes that heshe is a valuable human being coopersmith 12 defined selfesteem as a level of selfevaluation that is created and maintained by oneself which is expressed either positively or negatively it makes the individual see oneself as capable important successful and valuable he argued that selfesteem serves as a critical component in building a healthy mindset and personality leading the individuals to selfrealization in other words selfesteem as a factor of selfconcept pertains to recognizing oneself as a valuable person selfesteem also mediates a variety of stressors experienced in daily life and serves as a social resource for a person with depression and as an internal resource that protects one from negative influences in a stressful environment 13 in reality however families who support a member with a disability experience the lowering of selfesteem due to the difficulties they face low selfesteem creates a vicious cycle in which one is reluctant to ask for help and narrows ones social network which in turn aggravate the burden of care a person with a strong selfesteem on the other hand experiences less stress as heshe can protect himselfherself from psychological challenges and is able to respond to situations more positively 7 therefore it is very important that we find ways to help the families improve selfesteem the studies that have been conducted on supporting a family member with a disability have largely focused on the difficulties and stress experienced by parents of a child with a disability very few studies have examined the stress depression and selfesteem of family caregivers of an adult with a disability therefore this study aimed to examine the above to analyze the correlations between the factors and to find ways to improve the quality of life of family members caring for an adult with a disability this study also sought to provide basic data necessary for designing interventions to mitigate depression and stress and to improve selfesteem methods 21 participants the study subjects were family members of adult persons with a disability who visited rehabilitation centers at hospital s and a in s city from june 1 2016 to july 5 2016 i briefed the subjects on the purpose and procedures of this study and requested their consent the 115 family members who consented to participation in the study were questioned regarding the level of caregivingrelated stress depression and selfesteem and 108 questionnaires excluding 7 invalid ones were used for analysis the unit and currency applied to the expression of the participants monthly caregiving expenses and their average monthly income were korean won instruments 221 caregivingrelated stress we used the tools used by kim to assess the burden of caregiving experienced by the family members which was based on the caregiver burden inventory developed by novak and guest 14 to measure the level of caregiving stress the tool contains 20 questions across the following 4 areas 5 questions on financial stress 5 on physical stress 5 on psychological stress and 5 on social stress financial stress refers to the stress pertaining to the expenditure related to treatment physical stress included the experience of chronic fatigue and physical conditions psychological stress pertains to the negative feelings experienced related to caregiving social stress concerns the stress arising from conflicting social roles a 5point likert scale is used with 1 representing not at all and 5 indicating very much so total scores range from 25 to 125 points with a higher score indicating a higher level of stress cronbachs 𝛼 of this tool reported in previous studies was 086 15 depression the level of depression was assessed using the korean depression scale developed by m s lee and m k lee 16 this scale comprises 30 questions with 5 questions for each of the following 6 areas negative thoughts about the future negative thoughts about oneself anxiety restlessness depressive feelings physical symptoms and loss of motivation each question is rated on a 5point likert scale with 0 representing not at all and 4 indicating very much so the gross score ranges from 0 to 120 with a higher score indicating a higher level of depression the tools cronbach 𝛼 was 088 16 i evaluated the total score of kds in this study 223 selfesteem rosenbergs selfesteem scale was used this scale is a selfreport tool that includes 10 questions with 5 positive and 5 negative statements responses are made on a 4point likert scale with 1 representing generally not and 4 indicating always negative statements are reverse scored and the total scores range from 10 to 40 with a higher score indicating a higher level of selfesteem the tools cronbach 𝛼 was 083 17 i evaluated the total score of rosenbergs selfesteem scale in this study analysis methods this study used the spss 180 statistics program for the analysis ttest and anova were carried out to evaluate associations of caregiving stress depression and selfesteem levels with demographic and personal characteristics of the subjects and the duncan group categorization was used as a post hoc test correlations between caregiving stress depression and selfesteem were examined using the pearson correlation coefficient and the variables affecting caregiving stress were examined using a multiple regression analysis the significance level is 𝛼 005 results general characteristics of the subjects general characteristics of the family caregivers the family caregivers showed the following characteristics the female group was larger than the male group was the distribution across age groups was as follows 60 years or older 50 to 59 years and 40 to 49 years the most commonly observed relationship with the person with a disability was spouse the largest group had no occupation the distribution according to academic qualifications was as follows bachelors degree high school graduate and middle school graduate or lower 815 of them were married the distribution of monthly expenses incurred on supporting the person with a disability was as follows 500000t to 1000000t and 1500000t to 2000000t 649 of the participants spent 10 hours or longer each day on caregiving and their monthly income distribution was as follows 2000000t to 3000000t 4000000t or more and 1000000t to 2000000t general characteristics of the persons with a disability the general characteristics of the adults with a disability were as follows the 70 years or older age group was the largest the most common type of disability was brain stroke followed by spinal cord injury traumatic brain injury and other bodily injuries the distribution as per the grade of the disability was as follows grade 1 grade 3 or higher and grade 2 and the distribution as per duration of disability was as follows less than 1 year 1 to 3 years and 10 years or longer correlation among caregiving stress depression and selfesteem the correlation between the caregiving stress depression and selfesteem experienced by the family caregivers was as follows there was a significant correlation between the total score on caregiving stress and depression additionally a significant correlation was observed with the subareas of stress financial stress physical stress and psychological stress no significance was observed for the correlation with social stress financial stress and psychological stress showed a significant negative correlation with selfesteem finally a significant negative correlation was observed between depression and selfesteem caregiving stress depression and selfesteem by the general characteristics of the subjects associations of demographic characteristics with study measures for caregivers associations of caregiving stress depression and selfesteem varied according to the general monthly income resulted in significant differences thus caregivers who were female were aged 60 years or higher were the care recipients spouse were single had no occupation were responsible for a high level of support expense or spent more time on caregiving showed a higher level of caregiving stress similarly among the female group those who incurred higher support expenses or had a lower monthly income showed a higher level of depression finally those who were younger had a higher educational level or had a higher monthly income showed a higher level of selfesteem associations of demographic characteristics with study measures for patients with a disability associations of caregiving stress depression and selfesteem experienced by the family caregivers varied according to the general characteristics of the person they cared for specifically caregiving stress differed significantly in terms of sex age grade of disability and duration of disability in terms of depression age type of disability grade of disability and duration of disability resulted in significant differences with reference to selfesteem grade of disability and duration of disability led to significant differences this indicated that among the caregivers who catered to a male care recipient a higher level of stress was shown when the latter was aged 40 to 49 years when the grade of disability was higher and when the duration of disability was longer a higher level of depression was displayed among family caregivers when the care recipient was 40 to 49 years the type of disability was stroke or spinal cord injury the grade of disability was higher or the duration of disability is less than a year when the grade of disability was higher or the duration of disability was longer the family members selfesteem was lower factors that influence caregiving stress to identify the factors that influence caregiving stress we conducted a multiple regression analysis with caregiving stress as the dependent variable and the total depression and selfesteem as the independent variables in addition i conducted a multiple regression analysis with age gender whether they are currently employed caregiving expenses time spent on caregiving and monthly income which can represent the general characteristics of caregivers as independent variables testing for multicollinearity between the independent variables showed that none of the variance inflation factors crossed 25 indicating no multicollinearity the variable that exerts the greatest influence on caregiving stress was the total depression score followed by selfesteem age among general characteristics time spent on caregiving and caregiving expenses discussion this study was designed to examine the relationships between the caregiving stress depression and selfesteem experienced by family caregivers of an adult patient with a disability and to understand the factors influencing caregiving stress to help relieve the burden on the caregivers the analysis of the correlations between caregiving stress depression and selfesteem revealed that caregiving stress had a positive correlation with depression and that financial and psychological stress showed a significant negative correlation with selfesteem further depression and selfesteem were negatively correlated this indicates that though family caregivers may have accepted the presence of a disability to a certain degree they continued to experience severe stress owing to the irrecoverable state of the disability and the care recipients continuous need for care this psychological burden led to loss of selfesteem finally resulting in depression 18 thus caregivers need to seek professional help to handle their stress but there are few programs or professionals who can help relieve 1920 regular participation in such programs will improve caregivers selfesteem and reduce depression the varying degrees of caregiving stress depression and selfesteem with reference to the general characteristics of the subjects showed that female caregivers who are older are the care recipients spouse have no occupation and spend more time and money on caregiving showed a higher level of stress additionally female caregivers who spent more on caregiving and earned a lower income showed a higher level of depression while caregivers who were younger had a higher educational level and had higher income showed a higher level of selfesteem sim and ans study 21 results also showed that a caregiver who incurs higher expenditure on caregiving and has a lower income showed a lower level of caregiving stress which is in line with this studys findings if a caregiver is financially vulnerable one has to spend most of the income on caregiving and cannot afford to save for the future or enjoy leisure and hisher quality of life will be hampered a female caregiver who has no occupation naturally experiences more difficulties because of having to make ends meet which could lead to depressive feelings these findings show that an aged spousal caregiver finds caregiving more stressful than others do as medical advances have continued to extend the life span of people with disabilities the strongest fear for a caregiver who becomes aged is that heshe herself is getting older 22 additionally an elderly caregiver would fear that when heshe dies there will be no one left to take care of the person with a disability 23 spousal conflict with a care recipient who is the caregivers husband is one of the factors that aggravates caregiving stress or depression the wife feels that her stress over caregiving is not appreciated by the other family members and becomes depressed she considers divorce but soon gives up because she is not financially independent and she goes back to caregiving this leads to a vicious cycle and the relationship deteriorates with no communication between the couple 24 such deepened divides between couples worsen the family atmosphere with reference to the general characteristics of the care recipient caregiving stress was strong when the care recipient was male was aged 40 to 49 years or had a higher grade of disability when the patient is aged 40 to 49 years a higher grade of disability led to a higher level of depression in the caregiver and having a disability owing to a spinal cord injury was related to a higher level of depression the more severe the disability was the stronger the caregiving stress was this may be because a person with a severe disability would have to rely more on the caregiver meaning that the caregiver will have less time to spend on oneself and would face more difficulties and stress any family member with a relative who had a physical disability may experience depression but it is notable that the caregivers of persons with spinal cord injury showed a high level of depression in a study on patients with spinal cord injury tatiana 25 found that 506 of the respondents reported that their spousal relationship deteriorated after the disability occurred indicating that the injury has a serious effect on the spousal relationship in particular loss of sexual functionality greatly undermines satisfaction with life and 60 of the persons with spinal cord injury said they had issues with sex life and that the sexual dysfunction may have caused high stress in their spouse 3 those who experienced spinal cord injury at a young age and those who suddenly lost a source of income with no time for preparation experienced great pressure both financially and mentally support programs for people with disabilities in korea are largely focused on individual support and services for people with a disability and no support is provided to their family 26 it is important that measures are taken to provide specific and realistic assistance to family members who are financially vulnerable additionally community service institutions for those with a disability should develop programs that invite people with a disability and their spouses together to help them build a good relationship however such programs should not be temporary and they need to be provided in a systematic manner offering psychological and social support depression was found to be a factor affecting caregiving stress depression causes caregivers to lose the will to live tire easily and feel physically heavy accompanied by physical pain 27 caregivers who take care of family members with occupational therapy international disabilities frequently complain of constant pain in limbs and back as they do not have time to take care of themselves 21 the physical pain triggers psychological burden and the symptom of depression leading to demotivation depression of caregivers eventually aggravates caregiving stress selfesteem was also identified as a factor that influences caregiving stress a caregiver with strong selfesteem that is one who sees oneself as valuable and positive is able to face the painful and challenging burden arising from caring for a person with a disability in a positive way which will lead to a lower level of stress therefore family caregivers need to be provided with psychological support to help them accept themselves as valuable and to help them deal with issues positively it is necessary to facilitate the realization of positive experiences that can be derived from caregiving in addition to the negative experiences 28 this may lessen the burden of support and help them accept the responsibility while having a positive image of themselves and feeling awarded as a more mature person 29 the factors exerting the greatest influence in caregiving stress out of general characteristics were age time spent on caregiving and caregiving expenses in that order older people are more prone to muscular skeletal disease symptom severity is likely to be worse for caregivers who provide physical care for family members with disabilities and could work as a factor aggravating caregiving stress the higher the proportion of caregiving expenses to total income is and the longer the time of caregiving is the harder it is to invest time and money in leisure for rest and recreation leisure enhances the level of satisfaction with life and ability to deal with stress thereby playing an important role in selfrealization and decent quality of life if leisure activities that are highly correlated with quality of life are cut off from the lives of caregivers because of the burden of caregiving expenses and increase in the time spent on caregiving it would result in more caregiving stress 30 south koreans are strongly family oriented and the responsibility of looking after a patient with a disability often falls upon the family in this sense a family can only be happy when they are considered physically and psychologically occupational therapy international stable for providing care for healthy families and the society practical policies need to be prepared to lend financial and emotional help not only to those with a disability but also to their family caregivers the limitation of this study was that the subjects were visitors of particular hospitals located in seoul and therefore they do not reflect the overall characteristics of family caregivers across all regions future studies should ensure that subjects cover a wider area and the findings are more representative of the general public conclusions this study sought to examine the relations between caregiving stress depression and selfesteem experienced by the family members of an adult patient with a disability and to identify the factors influencing caregiving stress caregivingrelated stress showed a significant correlation with depression and financial and psychological stress subitems of caregiving stress had a significant negative correlation with selfesteem caregiving stress was stronger among caregivers who were female older and the spouse of the care recipient had no occupation and spent more time and money on caregiving depression level was higher in those who were female and had a lower income caregiving stress was higher among those whose care recipient was male and aged 40 to 49 years while depression levels were higher among those whose care recipient suffered from spinal cord injury in order to reduce the levels of caregivers stress and depression and to improve their selfesteem continued and consistent support and help from professionals are needed a variety of intervention programs need to be planned and implemented for family caregivers at the national and municipal levels conflicts of interest the author declares no conflicts of interest submit your manuscripts at stem cells international hindawi

this study aimed to examine the relationships between caregiving stress depression and selfesteem of family caregivers of an adult person with a disability and to identify their effects on their caregiving burden the study was performed with 108 care providers of adult people with a disability who visited hospital rehabilitation centers caregiving stress showed a significant positive correlation with depression and with economic and psychological stress and it showed a significant negative correlation with selfesteem when the care provider was aged female and without a job and the caregiving cost and time were higher the caregiving stress was high when the care provider was female and had a lower income the depression index was high when the person with a disability was male and in the forties and the level of disability was higher the caregiving stress was high when the disability was related to spinal cord damage the care providers depression index was the highest to reduce caregiving stress and depression in the family caregivers and to improve their selfesteem continuous support and help from specialists are necessary additionally a variety of intervention programs need to be designed to motivate them to participate regularly at the community level

introduction e ven if age is a progressive process and therefore a relative trait many people have certain intuitive ideas as to which traits they can use to identify older people underlying images of old age may act as stereotypes influencing individual behaviour today mass media play a decisive role when it comes to shaping and staging images of aging the media select and emphasise certain age aspects this causes coherent portrayal and interpretation patterns that lead to polarising visual and other attributes with regard to the final phase of life public images of old age and aging are particularly important in countries that are undergoing significant demographic change as these portrayal patterns are part of social negotiation processes on how to deal with aging and the relationship between generations including the welfare state almost the whole of europe has an aging population but this is especially severe in the federal republic of germany in germany every second citizen is older than 45 and every fifth is older than 66 research into images of aging in the media has largely consisted of analysing media content and drawing conclusions on their effects so far there are hardly any findings on the question of which effects media portrayals of old age can have on recipients a variety of potential effects are conceivable that may be illustrated by a series of theories from sociopsychological attitude research these effects focus on the mutual interplay between the public and the selfimage of old age the public image of old age may be seen as a kind of external view of the final phase of life that contains supposedly typical characteristics as well as behaviour and role expectations the selfimage of old age mainly consists of the subjective experience of old age and a projection of personal aging into the future these theories especially project on older people as they may be expected to have a public and selfimage of old age according to terror management theory confrontation with an image of old age that includes frailty helplessness and mortality is perceived as threatening the internalisation hypothesis proposes that older people tend to internalise negative age stereotypes harming selfconcept and resilience the internalisation hypothesis is close to the ageism postulate which assumes a higher prevalence of mental and physical illness in old age and increased costs for the healthcare system due to public stereotyping of older people conversely positive images of old age may be assumed to support selfimage on the other hand resilience theory suggests that there is a certain barrier to transferring negative public images of old age to the selfimage as older people strive to protect their selfconcept the comparative hypothesis considers images of age as reference points for social comparison this entails developing selfesteemserving downward comparison with the negative oldage stereotype instead of integrating negative information into selfimage in this way the negative image of old age is instrumentalised to improve selfesteem the reinforcer hypothesis assumes that preconditions of selfimage strongly affect the way images of old age are received and experienced this demonstrates that resilience to negative images of old age relies on an intact selfimage accordingly older people with an intact selfimage perceive mainly positive aspects of public age stereotypes coming towards them and may also be able to draw a selfesteemserving upward comparison research interest the study to be presented is part of a multipart study series focusing on the following research topic how do older people react to media portrayals of old age how do media portrayals of old age affect attitudes towards old age and personal aging we used the framing approach as a basis for our research images of old age are operationalised as specific patterns of portrayal and interpretation emphasising certain aspects of old age therefore forcing a specific stereotype in the course of our study we selected older people as subjects as it can be assumed that they process media representations of age and aging in a specific way methods study design and setting so far studies on the effects that media images of age and aging can have are still lacking in 2020 a quasiexperimental written survey was conducted that aimed at analysing how older people react to impactful age portrayals for this purpose we used a prototypical age frame placed in the middle of the questionnaire among other things we measured how the stimulus affected central indicators of public and selfimage of old age the anonymous survey was conducted with support from a preliminary content analysis study in order to examine how far these quantitative results can be confirmed and to gain additional knowledge a qualitative study using semistandardised interviews was carried out in the autumn of 2021 again older people were confronted with the prototypical age frames that were derived in advance of the quantitative survey this article links the central findings of both studies with a focus on the qualitative study preliminary study for content analysis in 2020 qualitative content analysis was performed in order to identify common portrayal patterns of age and aging this step was necessary to obtain meaningful stimulus material for the questionnaire experiment articles in the germanlanguage news magazines spiegel stern and focus were analysed using the lexisnexis database access criteria were defined as follows release period from 1 january 1999 to 31 december 2019 article length of 500 words or more topic of the article focused on old age content analysis yielded a category system containing the framedefining indicators including topic activitypassiveness of older people number of older people the environment of older people gender of older people social class of older people oldyoung relationship oldold relationship the role of older people a second material review yielded the frames using the indicators stimulus material was then selected the first choice for the respective frame was the article with the most typical major indicators without competing frames the post was then adjusted according to the following criteria the stimulus material was pretested in advance of the quantitative study recruitment and implementation for the survey we recruited our study participants in the german federal states of north rhinewestphalia hesse and rhinelandpalatinate recruits were usually groups of older people recruited by contacting local and municipal pensioners and senior citizens associations a phone or email request was always made in advance to obtain general permission to visit the relevant senior citizens association recruit study participants and carry out the study the experimenter was the first author participants were informed about the study as well as our intention to publish anonymous data and asked for consent the study participants were instructed not to scroll forwards or backward when filling out the form we placed particular importance on not informing respondents of the research interest until after the survey had been completed and the questionnaires collected to prevent strategic response behaviour the survey involved three experimental groups of the same size and structure in terms of age and gender each of which received an age frame the interviewees for the qualitative study corresponded to a broad mix matching the sociodemographic breadth of the survey sample these interviewees were recruited from amongst distant acquaintances of the first author and interviewed facetoface between july and november 2021 interviewees were sent an explanation of the topic and declaration of consent to sign before the interview and additional information such as assurance of anonymisation all 36 interviews were conducted verbally and personally by the authors in turn between september and december 2021 the interviews were recorded on audio sampling a total of 910 survey participants completed the questionnaire in full respondents were aged between 60 and 94 the average age was 72 of the participants 47 were male and 53 female other characteristics of the total sample were • nationality 94 german 6 other • living situation 79 own apartment 12 retirement homecare home 9 other • number of people in the household 25 living alone 69 two people 6 more than two people • highest educational qualification 13 lower secondary 18 upper secondary 8 high school matriculation grade 28 university graduation 33 professional qualification the qualitative interviews were conducted with older people between the ages of 60 and 90 of the interviewees 17 were male and 19 female the sample comprised the following • nationality 30 german 6 other • living situation 26 own apartments 7 retirement home care homes 3 others • number of people in the household 13 living alone 21 two people 2 more than two people • highest educational qualification 6 lower secondary 7 upper secondary 5 high school matriculation grades 9 university graduation 9 professional qualifications research instruments the survey instrument was developed inductively and deductively since there was no comparable work on the subject under investigation the instrument had to be developed from scratch for this purpose a detailed literature analysis was first carried out when developing the questionnaire studies were consulted that deal with the potential effects of media representations of age the final survey comprises the following components sociodemographic characteristics the study was focused on selected indicators of public and selfimage of old age representing the dependent variable in the study these indicators were queried before and after a confrontation with the stimulus the stimulus included a prototypical age frame the received image of old age was also determined relating to the perception and assessment of age portrayal finally selected conditions of reception and sociodemographic characteristics were included as moderating variables the indicators of public and selfimage of old age were taken from the german aging survey in the course of the focused interviews each participant was confronted with a prototypical age frame the interview guidelines concentrated on the following points • general questions on public and selfimage of old age • received image of old age presentation of older people thoughts and feelings impression of the article plausibility of the portrayal and relationship with reality identification with the portrayal • querying how older people are portrayed in the media data analysis apart from descriptive analysis we used students ttest for dependent samples to determine significant differences within the experimental groups the difference in means was tested with significance assumed at p 0001 in the qualitative study there were indications of a theoretical saturation after 27 interviews the term theoretical saturation is used if the collection of additional data and its analysis would not promote any new aspects of a category and thus no new findings would come to light for the focused interviews the first author evaluated the transcripts prepared after data collection using qualitative content analysis according to mayring in preparation the written consultations were summarised with the essential information to gain an overview of the fundamental material the text was then extracted in individual sentences or paragraphs depending on importance and expressiveness with units to be used in analysis previously determined the most important core statements were isolated abstracted and summarised before forming categories the categorical system created was structured closely to the guidelines and repeatedly reviewed and modified as necessary during evaluation here we focused on forming logical categories from the various opinions and experiences we used the coreq guidelines as reporting statements as they cover the reporting of studies using interviews and focus groups results frame identification the appropriately adapted stimulus articles 13 in appendix 3 refer to the age frames shown we identified three recurring and polarising age frames characterised by connection to demographic change intergenerational relations and the welfare state as topics • frame 1age as declinemodels age as an allencompassing problem and unpleasant fate this article portrayed a phase of life of dire helplessness controlled by others especially in the example of elderly people housed in care homes according to this frame older people cannot fight against the injustice they are subjected to but are often left at the mercy of degrading everyday situations this is closely linked to the intense loneliness of old age • frame 2age as a powerportrays old age as a power factor reshaping the community politically economically and institutionally seniors are portrayed as an organised political group increasingly and stridently representing their own interests here older people are shown as a dominant influence and force gaining increasing power in politics and everyday life due to pure demographic development old people are portrayed as threatening the younger generation with demands for a better quality of life • frame 3age as a new dawnassigns an extremely positive image to old age the article portrays age as late freedom with happy fulfilled and prosperous seniors the focus is on how the advertising electronics and health industries reorient themselves towards wealthy best agers in control of their own lives mental fitness joy of life and physical vitality of older people are also portrayed the young at heart are seen to be rewriting traditional notions of age by imitating the consumer behaviour and lifestyle of their children and grandchildren results from typologising the interviewees reactions to the various frames are shown by comparison in table 2 the main findings will be discussed as follows emotional reaction and article assessment the interviewees reaction to the age as decline stimulus article was most homogenous interviewees perceived the article as plausible factual and convincing despite a few critical statements all those interviewed saw a high degree of authenticity the type of immediate reaction upon reception varied between simple approval of the matter covered and clear signs of consternation and emotional stress this is a very good article yes the article is right on the head it is exactly like that it hurts to read something like that in contrast interviewees regarded the second stimulus article age as a superpower as implausible exaggerated and provocative overall the article did not meet with interviewees approval some were visibly provoked and outraged by what they read some vehemently questioning the claims made of an older generation all living in prosperity while others remained rather distanced and did not seem to take the portrayal seriously some other comments showed an understanding of the situation of younger people and the social problems of demographic change this referred for example to the situation of statutory pension insurance in which a shrinking number of contributors is faced with a growing number of pension recipients its written a bit as if the old people ruled everything and that the old are greedy and entitled because they always want more money and power well i dont think thats believable there might be old people like that but i personally dont know anyone of that sort that thing about having lots of power is exaggerated and implausible some of its just plain ridiculous in contrast the third frame presenting age as a new dawn initially evoked mainly positive feelings the article received high approval ratings for plausibility but also for readability it was generally received with pleasure curiosity or fascination for the phenomenon of modern aging the article was seen as authentic especially regarding the change in old age by generational comparison the article was therefore confirmed in spontaneous reactions even so interviewees became clearly critical and sceptical about how aging was portrayed after reading the whole article and thinking more carefully about it interviewees saw the article in a negative light at one important point about the new different and positive aging process differed from its supposedly traditional form this involved many interviewees showing insecurity on noticing that they could not fulfil the requirements of modern aging as portrayed in the article traditional people like the granddad sitting at the fireplace with his slippers on smoking his pipe experienced a different time of youth professional life family life and so on compared to older people today its much more common today for someone active and fit to not really notice their age it says old age doesnt exist anymore and after that it says something like in the past thirty years ago age came together with waldi the dachshund so that means old people from back in the day were just narrowminded and stupid makes you feel stupid as an old person do i have to be like them now so hyperagile what if im not like that what if i have illnesses and limitations should that make me feel ashamed relationship between old and young after using the stimulus the interviewees were asked how they assessed the relationship between old and young in the respective article in the first article a pronounced relationship between dependency and powerlessness towards the younger generation was perceived with all the negative consequences that this entails i think these old people are like helpless babies only that babies are full of joy and treated lovingly by their parents but here this helpless baby is just old and nobody needs or loves it and thats how theyre treated the third frame was perceived in such a way that the relationship between older and younger people is cooperative and friendly because older people imitate the way of life of younger people these old folks may be old on paper but they seem so young like they have somehow lengthened their lives or as if they were starting all over again interviewees that had received the second frame judged noticeably differently from those in the other two groups the whole thing is very confrontational the old against the young the old repress everything its a horror vision that i cant understand for me its more of an attempt to put the old people down and attribute malicious motives to them identification despite the emotional dismay expressed after reading the first frame article interviewees did not relate with the older people portrayed in the article with personal aging often felt to be at odds with the portrayal of old age shown some interviewees stated unequivocally how well life was treating them as they aged okay im old as well and my health isnt the best but reading this makes me feel like an outsider looking at it all but not really affected by this horror it actually makes me realise how good life is for me do i have to feel bad now if i say that i am almost feeling better after reading this … because i realize that we are privileged old people the interviewees could not identify with the second frame which they mainly justified with the depicted intergenerational relationship neither those interviewed with nor without children could get used to the confrontational and dominating behaviour of the older generation as presented in the article many older people also have children and grandchildren the people here are strange to me because they dont seem like they have anything to do with the younger generations … this makes the article not credible in the case of the third frame it was noticeable that an initially positive assessment of the article was gradually revised on closer reflection in the further course of the conversation these interviewees showed doubt and scepticism the more i think about it the more i realize that while such an age may superficially be desirable and some long for it it is actually just a caricature of actual aging it almost looks childish as if the elderly are not able to arrive at this stage of life or they categorically refuse it is kind of awesome and horrible at the same time it is noticeable that this type of presentation caused feelings of guilt in around half of the interviewees who received this frame so now i feel worse than before i have the feeling that i dont meet modern requirements this is something that is generally always demonstrated in advertising and in public the super vital travelloving wealthy and educated grandparents always on the move reading this made me realise one thing i dont fit into this image of older people today i belong to the lame and lethargic ive probably left things undone a lot and done a selected survey results in the following the interview results are to be compared with the central findings of the quantitative study in the survey the emotional reactions and the assessment of the article largely corresponded to the interview results it could be hypothesised that frame 1 primarily triggers pity and depression among the subjects in contrast the third frame arouses mostly positive feelings at the same time a third of those surveyed stated that this type of extremely positive representation of old age made them feel ashamed that they did not meet the requirements of modern aging respondents found frame 1 to be credible factual and compelling frame 3 also received a high level of approval in terms of credibility but also clarity in contrast respondents considered frame 2 to be clearly implausible exaggerated and provocative after the use of the stimulus the subjects were asked how they assessed the relationship between old and young it turned out that after the reception of the second frame the interviewees increasingly had the feeling that older people and their needs were being neglected in addition respondents given this frame were more emphasising that older people have built the foundation of wealth that also benefits younger people these are indications that the intergenerational conflict staged in the article had an effect on the respondents one striking finding from the beforeafter comparison is that public image for the six repeated items showed significantly greater changes than selfimage in most cases public and selfimage indicators also diverged selfimage improved moderately for frame 1 while the public image for others saw considerable deterioration the third group showed the exact opposite trend importantly public image improved considerably in this case while selfimage deteriorated in two items medium to strong effect sizes were seen in some cases no changes to the same extent as in other groups were determined for frame 2 discussion the series of studies dealt with a question neglected up to now on the effects of media portrayals of age it was aimed at older people as respondents as the survey showed there is a striking divergence between public and selfimage indicators of old age in the beforeandafter comparison of using the stimulus selfimage improved moderately on negative portrayal of age whereas public image deteriorated significantly positive portrayal of age showed the reverse with public image improved while the selfimage deteriorated the focused interview findings support this and point in the same direction it was noticeable that the first frame article was perceived as depressing but the interviewees stated how well they were actually doing reactions to the third frame were exactly the opposite this type of presentation caused feelings of guilt in around half of the interviewees who received this frame these results lead to the conclusion that the theory of social comparison processes can be seen as an appropriate explanatory approach it proposes that media provide recipients with benchmarks for comparison the age as decline frame demonstrated that interviewees performed a downward social comparison confrontation with the drama of being old caused a revaluation in selfimage as study participants became aware of how well life was treating them compared to the older people portrayed the age as a new dawn frame caused a social upward comparison in the study participants the best agers frame reduced traditional age expectations to absurdity with the older peoples activity and fitness creating selfdoubt amongst the study participants various authors refer to the latent potential for discrimination inherent in glorified depictions of age another aspect is that the assessment of relationships between generations could vary depending on the frame stimulus frame 2 suggested fomenting a generational conflict emanating from older people staged in the media to provoke a counterreaction from older recipients in reference to services and claims from the welfare state but also allegedly neglectful behaviour from younger people overall the findings of the qualitative study confirm the quantitative results suggesting attitudechanging effects of media portrayal of age like the survey this study did not determine any substantial differences between age education gender groups or influence of intervening variables from the authors point of view this speaks for the overall potential effectiveness of mediamediated patterns of age portrayal this series of studies is compatible with the results of pinquart who confronted older people with negative age stereotypes pinquart also found that the general assessment of older people deteriorated while selfassessment improved in the experimental group receiving negative information about skills in old age the mares and cantor study is also worth mentioning the study found that older people deliberately draw upward and downward social comparisons with older characters on tv against this background the effect of oldage portrayal in the media varies depending on the individual characteristics motivation and mood of recipients limitations this series of studies should be understood as an exploratory approach to a largely unexplored area despite the large sample and the decisive results confirmed again the survey in particular has various weaknesses • these were textual frames • the study did not allow for the reception of naturally arising portrayals of age • the changes measured in older peoples and selfimage were shortterm effects this begs the question as to how media portrayal of age affects the longerterm reception process in everyday conditions • changes in public and selfimage of age were measured using a very small number of indicators • measuring changes in public and selfimage involved a comparison of means at the group level without any beforeandafter measurements at the individual level • the study also did not measure how easy it is to influence public or selfimage relative to subjectively existing preconceptions in relation to age and aging • no power analysis was performed to determine the appropriate sample size in advance this means that the sample may have been too large and the measured effects were overestimated the qualitative study was able to confirm the key findings of the quantitative study and therefore to compensate for some of its weaknesses with regard to the evaluation of the qualitative interviews it can be critically noted that a discourse analytic evaluation procedure would have been possible conclusion portrayals of age in the media are of great importance as they have a significant influence on societys perceptions and expectations of old age traditionally portrayals of aging in media products have been subject to content analysis and effects have been anticipated however the results of this study show media portrayals of age to be more ambivalent in their effect than the content might suggest negative portrayal of age seemed to lead older people to feel more easily confirmed in their supposed deviation from the old category whereas positive portrayals of age could make this distinction more difficult overall the findings are compatible with the theory of social comparison processes this proposes that media portrayal may be used for downward and upward comparison even if this study only determined shortterm effects the results should be seen as an indication that conclusions on possible effects should not be prematurely drawn from content analysis findings this would not do justice to the complexity of possible potential influences from portrayals of aging in the media which further empirical research should address future studies should take the complex relationship between the public and selfimage into account in the effect of the portrayal of age data availability all major data generated or analysed during this study are included in this published article additional information can be provided on request made to the corresponding author article humanities and social sciences communications competing interests the authors declare no competing interests ethical approval all methods were carried out in accordance with relevant guidelines and regulations the ethics commission responsible for our federal state informed us that approval by an ethics committee was not necessary informed consent written informed consent for participation was obtained from all participants before the start of the study the survey respondents received information about the purpose of the study and were informed that it was an anonymous survey in accordance with the existing data protection standards furthermore it was made clear that the data will only be used for scientific purposes interviewees were sent an explanation of the topic and declaration of consent to sign before the interview and additional information such as assurance of anonymisation additional information supplementary information the online version contains supplementary material available at correspondence and requests for materials should be addressed to julian wangler reprints and permission information is available at publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

mass media portrayal of old age plays a great role in social perceptions of aging however there are hardly any empirical findings on the effects on recipients or to what extent this can change attitudes especially amongst older people three types of media portrayals of old age in german news magazines were determined and used as stimulus material in 2020 910 participants from 60 years were confronted with different age frames in the course of a quasiexperimental survey in order to substantiate the results in 2022 36 focused interviews were conducted with older people each of whom was presented with an age frame this article links the central findings of both studies with a focus on the qualitative study the survey results showed that presenting a negative age frame led to an improvement in the selfimage of old age whereas the public image of old age deteriorated significantly after presenting a positive frame the public image improved greatly while the selfimage decreased the interviews confirm these results type of reaction upon reception of the negative age frame varied between approval and clear signs of consternation however interviewees did not relate with the older people portrayed with personal aging often felt to be at odds with the portrayal of age shown the positive frame was first received with pleasure and curiosity even so interviewees became unsettled about how modern aging is portrayed some of them showing insecurity that they could not fulfil the characteristics and requirements of modern aging media portrayal of age seems not to have the effects on older people as might be expected negative effects appear such as media portrayal making older recipients aware of their own age by presenting age in an exaggeratedly positive light in the best agers frame in view of these results the theory of social comparison processes may be used by which the media provides recipients with standards of comparison

although adolescents are considered to be the relatively healthy segment of the population they are vulnerable to illness in constrained situations such as food insecurity 1 2 3 food insecurity is associated with a range of poor health outcomes in adolescents adults and children it also affects both psychosocial and physical health outcomes 45 and leads to overall poorer health among members of foodinsecure households 1267 however gender inequalities in health have been consistently documented 38 because gender is a measure of socially constructed differences based on biological sex it is likely that health inequalities between male and female subjects reflect disparities in exposure to genderrelated factors biological behavioral and sociocultural mechanisms have been proposed for the gender differences in morbidity and mortality 9 biologically female subjects have an advantage for better health and longer survival because of the role of sex hormones in modulating lipid levels and increasing immune response 10 11 12 in addition the difference in morbidity and mortality between boys and girls is further related to individual lifestyle the use of health care and health and illness behaviors and practices 13 14 15 for example adolescent boys are more likely to smoke and have higher propensities of taking greater risks that expose them to injury 1316 although female subjects have biological and behavioral advantages established gender norms and values in developing countries contribute to the loss of the female advantage throughout the life cycle 16 while the effect of sociocultural factors is potentially less visible in societies with egalitarian attitudes toward gender women and girls have little decisionmaking power and enjoy less freedom and resources in constrained situations 117 we previously reported how in the ethiopian cultural milieu boys were more buffered from food insecurity than girls 1 the associations between food insecurity and child wellbeing to date have been based on household levels of food insecurity as reported by heads of the households 23 18 19 20 household measures however may not capture gender biases in intrahousehold buffering of children against food insecurity because parents may be unwilling or unable to report such biases to understand differences in morbidity among foodinsecure boys and girls it is essential to measure how adolescents experience the effect of food insecurity on their health 121 little if any research has been conducted to assess how adolescents experience food insecurity how this is associated with morbidity and the effect of gender in this process previously we reported how girls suffered from food insecurity more than boys and how food insecurity was associated with poorer health outcomes in ethiopia 1 in this article we document gender differences in health status among foodinsecure adolescents we hypothesized that the health consequences of food insecurity are more pronounced in girls than boys subjects and methods this report is based on data from 2084 adolescents enrolled in the first round of the 5year longitudinal study of adolescents in the jimma zone in southwest ethiopia the study area was stratified into urban semiurban and 6 rural communities adjacent to the towns and represents a range of ecological and developmental contexts a census was conducted to generate a list of all households in each site that produced a sampling frame of 5795 households a 2stage sampling plan was used to select a sample of 2100 adolescents of age as a first stage 3700 households comprising at least 1 male or 1 female adolescent were randomly selected from the list the sample size for each study site was allocated on the basis of probability proportional to size in the second stage 1 adolescent aged 13 to 17 years was randomly selected from each household in the sample using a kish table 22 this age group was selected for followup to capture life events that happened as boys and girls transitioned to adulthood this sampling plan produced a representative sample of households and adolescent boys and girls measurements structured household and adolescent questionnaires were used to collect data the household and adolescent interviews were completed in mid2005 to 2006 this timing corresponds to the rainy season and the spring season which is relatively better in terms of food security the questionnaires were interviewer administered and translated to the local languages and their consistency was checked by another person who spoke both languages both adolescent and household food insecurity were measured with items adapted from household foodinsecurity scales that were previously validated for use in developing countries 23 24 25 the details of the methods used to assess adolescent and household food insecurity are described elsewhere 1 food security is defined as the situation when all people at all times have physical and economic access to sufficient safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life 26 dietary diversity was assessed with a foodfrequency questionnaire containing 30 food items that are commonly consumed in the study area participants were asked to report the frequency of consumption of each food using the past 3 months as a reference 27 given the large variation of dietary habits in the local community over the days of the week the consumption of each food item per day 28 was not taken as a cutoff point for defining consumers adolescents were coded as a consumer of a food item if heshe had consumed the food item at least once per week 29 the food items were grouped according to the mypyramid classification 30 a dietarydiversity score was calculated as the sum of these food groups consumed over a week the means of the dietary diversity score were used to compare boys and girls height was measured to the nearest 01 cm using a stadiometer and weight was measured to the nearest 01 kg using digital scales ageand genderadjusted bmi z scores were calculated by using world health organization anthroplus software 31 adolescent selfreported morbidity was assessed using 3 questions adolescents were asked in the past 30 days how often has a feeling of tiredness or not having enough energy been a problem for you overall in the past 30 days how often have you had difficulties with school work or household activities because of poor health when was the last time you were sick with any illness the possible responses to the first 2 questions were very often sometimes rarely and never for this analysis we coded responses for both questions as very oftensometimes and rarelynever because the subjects who reported very often were few reponses to the last question were coded as yes for within the last 1 month and as no for both no illness or illness before last 1 month selfreported health status over a reference period of 4 weeks has been indicated to be a reliable measure of objective health 3233 the questionnaire was pretested on 200 adolescents selected from a community in jimma city that was not included in the main study and modified on the basis of the pretest observations the interviewers were given an intensive training for 1 week before the pretest and an additional training was given with the final version of the questionnaire for 1 week before the beginning of the actual interviews supervisors kept track of the field procedures and checked the completed questionnaires everyday to ensure accuracy of the data the research team supervised the datacollection team every week by physically going to the field site and checking questionnaires and discussing any problems that happened over the previous 5 days the study was cleared by the ethical review boards of both brown university and jimma university informed verbal consent was obtained both from the parents and each respondent before the interview or measurement the head of the household was interviewed by using the household questionnaire data analysis the data were double entered checked for missing values and outliers and analyzed using spss 161 first bivariate analyses were conducted and means and proportions were compared using the t and 2 tests after checking all the assumptions to identify the predictors of morbidity a multivariable logistic regression model was fitted for selfreported illness and other covariates variables that showed a significant association with illness difficulties in activities and feeling tiredness having low energy in the bivariate models were entered in the adjusted logistic model using the enter method for illness during the previous 1 month the model was constructed for the different scenarios including when both the household and adolescents are food secure when adolescents are food insecure and when both adolescents and households are food insecure for all scenarios illness and gender were first entered to find unadjusted effects and then other covariates were entered sequentially to find independent effects a similar procedure was followed to analyze the predictors of reporting difficulties with activities because of poor health and having a feeling of tirednesslow energy interaction between different variables was checked with the criteria for the significance of interaction term all tests were 2sided and p values of ͻ05 were considered statistically significant results of 2100 adolescents included in the study complete data were available for 2084 providing a response rate of 992 a total of 428 adolescents were classified as food insecure as presented in table 1 genderstratified bivariate analyses showed that a significantly higher proportion of foodinsecure girls reported illness during the previous 1 month whereas no significant difference in selfreported morbidity was observed between the foodsecure boys and girls household food insecurity was significantly associated with reporting having had an illness difficulties with activities because of poor health and feeling tirednesslow energy in girls but such a difference was not observed in boys the proportion of girls who reported an illness increased when the place of residence changed from urban to rural areas whereas this was not the case for boys openfield garbage disposal also was associated with reporting an illness having difficulties with activities and feeling tirednesslow energy only in girls for the multivariable analyses household and adolescent food insecurity increased the risk of morbidity significantly among girls than boys we adjusted for dietary diversity bmi place of residence cooking place and garbage disposal to isolate the effect of gender on illness there was no difference in the risk of illness among boys and girls when both households and adolescents were food secure as shown in fig 1 girls were twice as likely to report an illness when they were food insecure and 3 times more likely than boys to report an illness when they were food insecure and a member of a foodinsecure household the other predictors or selfreported illness in foodinsecure boys and girls were bmi rural residence and openfield garbage disposal food insecurity also was associated with the functionality of adolescents in the study area female gender adolescent food insecurity household food insecurity dietary diversity and openfield garbage disposal were independent predictors of reporting difficulties with activities because of poor health girls were 74 times more likely to report difficulties with activities because of poor health in the previous month compared with boys independent of other predictors the probability of reporting feeling tirednesshaving low energy was nearly 70 times higher in girls 20 times more in foodinsecure adolescents 13 times higher in adolescents who were members of foodinsecure households 13 times higher in households that dispose garbage in an open field and 071 times more in adolescents who consumed diet with higher diversity as shown in table 4 none of the interaction terms was significant in any of the models discussion we report that although both boys and girls are likely to report an illness in foodinsecure situations foodinsecure girls report higher frequencies of illnesses difficulties with their work because of poor health and feelings of tirednesslow energy compared with boys independent of their nutrition status dietary diversity and socioeconomic parameters there are several possible explanations for this gender disparity first studies have shown that female subjects report worse selfrated health compared with male subjects 3435 a common notion is that female subjects being less enduring of illnesses and more cautious of their health than men are likely to report mild illnesses 3536 although this explanation does not address why boys and girls reported differences in health conditions in our study it can potentially contribute to the gender a adjusted odds ratio from multivariable logistic regression models variables with p ͻ 05 in the bivariate models were included in the adjusted model girls boys figure 1 risk of selfreported morbidity within the previous 1 month among adolescents in southwest ethiopia according to foodsecurity status and gender a adjusted odds ratio as obtained from a logistic regression model variables with p ͻ 05 in the bivariate analyses were included in the adjusted model differences in selfrated health however our findings did not show a similar difference between foodsecure boys and girls who were members of foodsecure households this supports the argument that when resources are available and decisions do not have to be made over scarce resources a gender bias is not present sociocultural differences in how genders are treated could account for the disparities in the selfreported morbidity observed in our study in many societies of developing countries female subjects often find themselves in a subordinate position compared with men and are socially culturally and economically dependent having little or no decisionmaking power on resources and their health issues 1637 sons are perceived to have an economic social or religious utility whereas daughters often are felt to be an economic liability because of the social reasons 1638 more specifically there is a belief that male subjects are physically more productive and are better in defending the family from unfavorable circumstances compared with female subjects the ethiopian context also presents these characteristics 39 as a result differences are observed with regard to the allocation of household resources on the basis of power or position within the household mothers often favor their daughters whereas fathers give priority to their sons 40 in many of these settings women are disadvantaged because of cultural practices that value them less than men 41 this gender bias also may be reflected in the allocation of resources for children 42 and in their access to health 43 for instance boys were found to have an advantage in the allocation of nutrients in the philippines 44 in preferential buffering from food insecurity in ethiopia 1 and in the distribution of food resources in india 45 nepal 46 and guatemala 47 societal norms toward culturally specific gender roles and preferences put girls at a disadvantage with regard to health and health care 43 other studies 1643 show that gender inequalities have led to a systematic neglect of womens health the impact of factors such as education and income on health was reported to be considerably smaller than the social construct of gender 3 in the study area food insecurity is significantly higher among girls compared with boys which could be because of the selective availability of the limited food resources for boys than girls 1 the fact that a boy or a girl was sampled from each household did not allow for actual exploration of intrahousehold dynamics related to the treatment of boy and girl adolescents especially about intrahousehold allocation of food and other resources through pairwise comparisons the higher probability of reporting illness coupled with higher prevalence of food insecurity 1 among girls leads to decreased physical growth and a consequent reduction of potential for productivity and survival girls are likely to be trapped in the state of stunting 48 that resonates through generations because of the double burden of food insecurity 1 and morbidity lower bmi and rural residence were other predictors of selfreported illness in foodinsecure boys and girls observed in our study although low bmi is an indicator of malnutrition an increase in bmi may not always lead to better health 49 50 51 some reports have shown that a higher bmi in adolescents is associated with having poor healthrelated quality of life 4950 in our study area however the mean bmi is low and an increase in bmi was associated with lower probability of selfreported illness our analysis also shows a significant association between open field garbage disposal and selfreported morbidity having difficulties with work and feeling of tirednesshaving low energy which is similar to another study 52 garbage harbors infectious agents that can increase the frequency of illness dietary diversity might be associated with food insecurity which could introduce collinearity in the models the correlation coefficient between dietary diversity score and adolescent and household food security was 015 and 010 respectively and variance inflation factors in the models were generally low which indicates no substantial collinearity in our analysis similarly we cannot rule out that the gender of the respondent household head might have biased our findings with regard to the apparent foodsecurity status of the household in our sample 18 of the household heads were female subjects however when gender of the household head was introduced in the models it remained insignificant in all models which indicates that the bias was minor we used a foodfrequency questionnaire to assess the dietary intake this enabled us to capture the dietary intake of adolescents over a longer range of time and its association with health thereby reducing errors introduced by estimating usual intake from the daytoday variability in 24hour recalls 53 the use of a consumerbased definition of the quantities of food consumed is a limitation of our analysis this may have potentially lead to an over estimation of consumers and food consumed on the other hand people who might have consumed a food item more than once per week also were categorized with those who consumed only once per week which might underestimate the quantity consumed designing foodfrequency questionnaires that are valid in populations that consume from a common bowl or share food from the same plate is a challenge for dietary assessment 54 and requires additional research conclusions as in many other developing countries food insecurity is a chronic problem in ethiopia 55 and the size of the youth population is growing the study highlights that in foodinsecure situations girls suffer more frequently from adverse health consequences of food insecurity compared with boys this is an important result because it suggests that 1 way to reduce gender disparities is to remove resource constraints this might be somewhat easier than shifting populationlevel norms around gender interventions addressing food security should incorporate gender issues and pay special attention to girls to narrow the gap in health between boys and girls

the associations between food insecurity and child wellbeing have been well studied on the basis of household levels of food insecurity as reported by heads of households what this study adds household measures however may not capture gender biases in food insecurity and morbidity this study assessed adolescents own experience with food insecurity and how it was associated with morbidity and the effect of gender in this process

introduction given the ongoing economic and financial crisis involving western countries which affected also the characteristics of the labor market with the occurrence of temporary work and loss of income security there is a growing interest in linking precarious employment with adverse health outcomes 1 2 3 whereas traditional research focused predominantly on the differences between lowunskilled vs highskilled workers 4 more recent evidence suggests that other characteristics of the employment such as the effortreward imbalance 5 perceived insecurity 6 andor prospect of permanent employment 7 represent important predictors of health status especially temporary employment conditions have been reported as influencing significantly psychological health sickness leaves mortality and the use of healthcare resources 8 9 the correlation between obesity overweight and job insecurity has been controversially discussed in scientific have been in the same working position at least for 5 years at the time of the survey sociodemographic and health data and lifestyle information body mass index was calculated from selfreported body weight and height specified during the survey according to the world health organization definition persons with a bmi 185249 kgm 2 were considered to have a healthy weight those with a bmi 25299 kgm 2 were classified as overweight and those with a bmi ≥ 30 kgm 2 were categorized as obese 22 household mean bmi category was calculated from the respective data on members of the family of the participant worker excluding the worker himself and classified according to the who as above 22 data was also collected on gender age education smoking habits presence of chronic conditionsdrugs possibly attributable to overweightobesity leisure time physical activity was assessed by selfreport among all participants using an adapted version of the international physical activity questionnaire 23 according to the ipaq methodology ltpa has been categorized into low moderate and high data on dietary habits were also considered occupational data all respondents were asked about their occupation with particular interest in the type of contract freelance employee artisan and temporary employee a temporary employee was considered as a worker being occupied in at term work independently from literature 9 with papers reporting little or no effect 10 11 12 while others linking job insecurity to gain and even loss in weight 13 14 15 more recent studies report a direct association between overweight and obesity and selfperceived job insecurity 16 moreover job strain was reported to be associated with obesity in previous crosssectional studies 17 and job schedule including shiftwork has been recently associated with obesity 18 however the implementation of organizational intervention at work has given uncertain results 19 revealing that there is still room to improvement in our knowledge of the interaction between working conditions and obesity the main aim of this study was to describe the prevalence and risk factors of obesity among workers with different type of employment status including those with temporary contracts in a nationwide sample of the italian working population material and methods the study population consisted of participants of the national health survey health and use of health care services carried out by the italian national institute of statistics on a 5 year basis which aims at investigating a variety of aspects associated with the health status of the population eg the prevalence of chronic diseases the lifestyles and the patterns of health care use 20 a description of sampling strategy has been summarized elsewhere 21 each survey participant completed a selfadministered questionnaire and had a facetoface interview with istat data collectors the last edition carried out between december 2004 and september 2005 gathered data on 50 474 families and 128 040 individuals representative in terms of age and gender of the italian population for the present study a selection of people aged 1564 was considered as a representative of the occupationally active italian population subsequently those declaring to have been working during the previous week or to have not worked just for a temporary reason were included in the study moreover selected participants declared to classification of jobs in the 2nd model working category was transformed into a dummy variable by coding new variables considering the interaction of category with a number of working hoursweek exceeding 40 model validity was evaluated by using hosmer and lemeshow test and checking for collinearity significance level was set at α 005 all analyses were conducted using the stata version 90 software results a total of 80 661 persons were selected from the italian multipurpose survey database in the 1564 years old age range while a final sample of 36 814 people reported having been occupied in the same work for at least 5 years therefore they have been included in the analysis obesity was present in 931 of workers obesity was more frequent among males than women older age was associated with obesity with frequencies of the phenomenon increasing from 477 in the 1834 years old to 1431 in the 5565 years old group education as a risk factor was evident at bivariate analysis with 1214 of frequency of obesity in less educated workers poor ltpa was a risk factor for obesity together with being a former smoker some of participants practicing weight control were obese and this condition was associated with the use of drugs to treat some chronic diseases such as asthma hypertension depressionanxiety and thyroid disease other factors associated with obesity included overweight in the family of origin workers working 3639 hweek or 50 hweek artisans and sector of occupation such as agriculture energy the duration of the contract and the nature of occupation number of working hours a week was categorized as follows 35 h 3539 h 4049 h ≥ 50 h longworker has been defined as a person with 40 h of work a week according to the italian national institute of statistics industrial and occupational classification of jobs included the following categories agriculture energy manufacturing building commerce bar and catering transportation financial services real estate public administration teaching healthcare and other services the evaluation of occupational physical activity has been assessed by the following question your occupation is predominantly characterized by a physical activity which is a scarce the majority of time is spent in the sitting position b moderate majority of time is spent standing or walking c hard until sweating multivariable logistic regression models were built in order to assess variables associated with obesity in italian workers explanatory variables that were associated with the outcome at a significance of ≤ 02 in bivariate analysis were included as independent variables to adjust for the indirect effects of other variables association between the characteristics and obesity was expressed as odds ratios and 95 confidence intervals in particular the 1st model included the following variables workers sex age class family bmi category level of ltpa dietary habits presence of chronic conditions was considered as a dummy variable working hours per week type of working contract 3 freelance 4 artisan 5 temporary employee being occupied in shiftwork level of opa occupational fact while the interaction between working 40 hweek was associated with a higher risk of obesity in temporary workers this association was not found in entrepreneurs freelance artisans and permanently employed workers thus reinforcing the potential role of job insecurity and occupational changes during lifetime in weight gain the results are in line with a recent study from the literature that found significant associations between long work hours hostile work environments and obesity among a nationally representative sample of us workers however in italy we have found a lower prevalence of obesity in the working population with respect to the usa where 277 of workers are obese 24 the relevance of such findings has also to be considered with reference to modern labor market deregulation today flexibletemporary employments account for the large majority of newly created workplaces and it is increasingly difficult for new generations of workers to find permanent occupations according to official 2014 figures the rate of nonpermanent employments reaches 283 in poland and temporary contract rate was higher than 1 in 5 in spain portugal and the netherlands 25 in italy roughly 1 out of 7 employees works on a temporary basis 25 this phenomenon is in contrast with the traditional strict employment protection legislation adopted in italy with legal and normative regulations that make hiring and firing quite difficult these data in conjunction with those suggested by the growing literature on the linkage between type of job job insecurity and adverse health effects 26 such as that of obesity must set an alert on the future of new generations and the future expenditure for health care services in fact given the results of the above study we may hypothesize a positive effect of the italian employment policy historically based on permanent occupation on health and longevity moreover this hypothesis is also supported by the substantial equivalence of other known risk factors for disease and injury 27 all considered medications used to treat chronic conditions were associated with obesity thus useful in the adjusting process as expected former smokers were at high risk for obesity with or 126 workers employed ≥ 50 h have shown a high risk of obesity moreover temporaryemployed workers showed a higher risk relative to employed results considering the interaction between type of occupation and number of working hoursweek were similar but highlighting the role of temporary employment which was even more risky for workers working 40 hweek moreover shiftwork was confirmed as a risk factor for obesity in workers referring to different occupational groups some categories were associated with obesity in particular this phenomenon involved people employed in agriculture transportation and public administration on the other hand the inclusion of interaction between working contract and long work hours has evidenced a lower prevalence of obesity in workers occupied in industry construction commerce and bar and catering discussion our analysis in the italian context adds to the existing knowledge suggesting that obesity is significantly correlated with nonpermanenttemporary employments the association remains valid even after controlling for other important covariates such as education age gender family bmi category leisure time and occupational physical activity weight control habits smoking habit use of drugs moreover the impact of working hours per week has been more deeply investigated with the finding of a differential role of weekly working hours on obesity in human resource policies at company level with a negative effect of obesity on obtaining a permanent occupation given this potential dual nature of flexibilityobesity association further longitudinal studies are required to explain the causal pathways between the 2 investigated variables moreover since 1885 38 it has been recognized that workers may have a lower morbidity and mortality compared to the general population because relatively healthy individuals are more likely to become employed and continue being employed relative to severely ill and chronically disabled persons 3940 this phenomenon is known as the healthy worker effect and maybe linked to bias in epidemiological studies another possible limitation of the study may be linked to the lack of a direct evaluation of sleeping patterns of participants in a context of increasing evidence of a linkage between sleeping hours and overweightobesity 41 and the lack of information about the nutritional habits of the participants on the other hand public health impact of obesity at work has to be discussed in fact obese subjects are known to suffer higher levels of cancer and heart disease 42 as well as to being affected from some functional limitations including reduced flexibility limited range of movement and lower endurance 43 the balance between longterm cost of unhealthy obese workers and the shortterm benefit of working policies putting the workers at high risk for unhealthy conditions should therefore be evaluated from an economic perspective conclusions obesity and occupational injury are important concerns afflicting millions of workers in the world better understanding of factors that may lead to increased rates of illness and injury including both workplace factors as well as personal factors such as physical and mental health will be important in helping to control the burden of obesity as an occupational disease we have found significant associations between some kind of occupational sectors and obesity independent from other covariates in particular workers occupied in agriculture transportation and in the public administration have shown an increased risk of obesity these findings are in line with existing evidences from the literature in fact according to one study the normal weight group and the morbidly obese group differed in terms of gender socioeconomic status and also in terms of industrial classification of jobs they served 28 in particular the analysis by categories of subjects has put into evidence the high frequency of obesity among transportation workers a finding in line with a recently published study investigating obesity among professional drivers in italy 29 similarly an even higher prevalence of obesity in workers employed in public administration was also revealed in the study by luckhaupt et al 24 after adjusting for the interaction of working contract and 40 hweek however a number of categories showed a lower risk of obesity in particular this phenomenon was found in workers employed in manufacturing industry construction financial real estate commerce bar and catering services these alternate findings seem in accordance with the observations from a recent metaanalysis concluding that the link between longer working hours and type 2 diabetes was apparent only in individuals in the low socioeconomic status groups 30 and considering more specific findings linking working conditions with obesity it may be especially harmful to lowerincome workers 31 possible limitations of the study have to be considered studies in the economic sciences have found that obesity and overweight could influence employers decisions during the hiring process persisting stereotypes describe overweight and obese persons as lazy lacking in selfdiscipline and less competent 32 with absenteeism and costs attributable to that health condition 33 34 35 36 37 according to this interpretation the association found can be seen as the result of discriminating further studies are needed to support the design of evidencebased prevention programs aimed at health promotion and weight management in the workplace from a health policy perspective the european trends in increasing utilization of temporary contracts sustain the relevance of the above findings suggesting the need of immediate action addressing these types of workers in this sense our study contributes to the debate on the implementation of flexicurity policies by suggesting that policy makers should take into consideration the health consequences of such policies when assessing costs and benefits of possible welfare reforms the findings will also be of interest to employee advocacy groups and employer representative organizations in order to stimulate their counterparts to implement less myopic policies in fact if it is generally recognized that prevention fails when there is an economic and financial crisis 44 45 46 decision makers should transform this apparent limitation into an opportunity to necessarily select costeffective interventions maybe the way out of this pathway to obesity in the near future might be working better choosing organizational flexibility not fixed term

objectives to investigate the prevalence of obesity among different types of employment status in the italian working population and to examine associated risk factors material and methods crosssectional survey of 36 814 people that declared to have been occupied with the same type of contract for at least 5 years was analyzed multivariable logistic regression models were built considering workers sex age education family body mass index bmi category leisure time and occupational physical activity weight control habits smoking habit use of drugs number of working hours per week and type of working contract results after adjusting for covariates the importance of temporaryemployment was confirmed by multivariate analysis with odds ratio or 132 for obesity 95 confidence interval ci 107163 with respect to employed persons the association was even more important in workers occupied for more than 40 hweek or 169 95 ci 107266 moreover shiftwork was confirmed as a risk factor for obesity in workers or 106 95 ci 09412 dealing with different occupational group some categories were associated with obesity in particular this phenomenon involved people employed in agriculture or 144 95 ci 12217 transportation or 153 95 ci 126185 and public administration or 131 95 ci 11155 conclusions our analysis suggest that obesity is strongly correlated with temporary employment maybe the way out this pathway to obesity in the future might be working better choosing organizational flexibility rather than fixed term

introduction the 1988 november issue of the american psychologist was dedicated to what was then the emerging hiv epidemic in the united states in that issue stephen morin of the university of california at san francisco described three separate but linked epidemics morin distinguished the hiv epidemic from the subsequent aids epidemic foreseeing the ultimate convergence of preventing the spread of the virus and managing the disease it causes morin also discussed a third epidemic the social cultural economic and political reaction to the hiv and aids epidemics he went on to say that this third epidemic of reaction which is just beginning is as much a part of the pathology of aids as the virus itself twentyfive years later morins prescient analysis has been confirmed the three epidemics he foresaw are no less relevant today and the impact of the social context on the course and distribution of hiv infection shines a glaring light on the inequalities of these epidemics the centers for disease control and prevention estimates that in 2008 over one million americans were living with hiv infection and over one million americans have now been diagnosed with aids in contrast to the generalized epidemics of subsaharan africa the us hiv epidemic is concentrated in distinct geographical regions with most affected americans either living in urban centers of the east and west coasts or in major cities and small towns throughout the south within the cities hit hardest by hiv infection impoverished neighborhoods are far more affected than are more affluent areas overall the us hiv epidemic is characterized by low hiv prevalence in the general population with cases densely concentrated in local hotspots that primarily impact the most socially disenfranchised and marginalized populations hiv transmission is a biological event that is entirely dependent on social context and behavioral practices it has long been known that hiv transmission is a function of four concomitant interrelated factors local hiv prevalence individual behaviors biological factors and social conditions previous authors have conceptualized the complex factors that make up hiv epidemics as interlocking gears where changes in one cog invariably shift the next figure 1 illustrates our adaptation of this concept for the purpose of this discussion the spread of hiv requires a minimal prevalence in a population to maintain sufficient exposure for transmission the most relevant portion of local hiv prevalence occurs at the social network level for hiv transmission to occur the virus must have direct contact with cells that are susceptible to infection namely those cells that carry the specific surface membrane molecules to which the virus attaches and thereby infects the host cell the degree of risk for hiv transmission conferred by a given behavior is determined by the extent that both the virus and infectable cells are immediately present because hiv transmission is a biological event multiple factors can facilitate or impede hiv transmission hiv infected persons vary in their infectiousness depending on stage of disease and health status specifically the amount of virus in blood plasma or viral load is highest in the first days of acute infection and again at the end stages of aids in addition to stage of disease concentrations of infectable cells present when exposure to the virus occurs also influences the likelihood of transmission cooccurring sexually transmitted infections especially those that degrade mucous linings and cause genital ulcers are also critical determinants of both hiv infectiousness and susceptibility studies show that the probability of hiv transmission during a single act of vaginal intercourse increases more than five times when there is a cooccurring genital ulcer disease conversely male circumcision removes infectable cells in the penile foreskin and reduces hiv transmission by as much as half poverty discrimination inequality and other social conditions facilitate hiv transmission by influencing local hiv prevalence as well as an individuals risk behaviors for example substance use can both reduce the likelihood that a person will take protective actions such as using condoms and substance use can stimulate hiv replication and therefore increases infectiousness relationship instability caused by economic stress stigma discrimination domestic violence migration and incarceration also contribute to sexual partner mixing patterns that foster hiv transmission access to health care offers the potential to alleviate multiple sources of hiv transmission risk by reducing infectiousness through antiretroviral therapy and decreasing susceptibility through mental health substance use and sti treatment each year since the late 1990s an estimated 56000 americans have become infected with hiv the us hiv epidemic disproportionately affects men who have sex with men and ethnic and racial minorities the group consistently at greatest risk for hiv infection represents the intersection of sexual orientation and racial disparities msm are by far the most hiv affected americans and african american msm are at six times the risk for hiv than white msm aids is the third leading cause of death among black men and women between ages 35 and 44 and the fourth leading cause of death among latinos of the same age group aids remains a mostly urban disease in the united states with nearly half of all people living with aids residing in ten metropolitan areas furthermore different ethnic groups account for the preponderance of aids cases in the ten metropolitan areas eg puerto ricans in new york city haitians in miami there are hiv infection subepidemics also occurring throughout southern suburban and rural america disparities are evident not only in the transmission of hiv but in treatment and course of disease while the successes of hiv treatments have significantly improved the health and life span of people living with hiv infection these benefits are not equally shared across segments of the us population death rates are declining in some places remaining unchanged in others and even increasing in others the health disparities in hiv and aids are quite striking and yet underresearched a health disparities framework for hiv infection health disparities in the us are now widely recognized with disease burden and mortality greatest among the poor and among racial and ethnic minorities within minority groups diseases are concentrated along socioeconomic lines those at the lowest rungs of the social ladder bear the greatest disease burden socioeconomic status and chronic diseases rather consistently fall on a gradient where those of relatively lower ses have poorer health and are more often afflicted by multiple diseases than those above them on the ses ladder for example although osteoarthritis cervical cancer cardiovascular disease and other chronic diseases affect individuals across all socioeconomic levels those at the lower end of ses have somewhat greater prevalence hiv infection however does not show a graded association across the ses range rather hiv infections are concentrated among the poor with very few people in the middle and upper social strata contracting hiv adler and stewart offered a framework to explain the major pathways by which ses can influence health the model is developmental illustrating individual social and structural influences on disease over the lifespan figure 2 shows their health disparities model originally proposed to explain disparities in cancer with only slight modifications to represent the us hiv epidemic in the current conceptual health framework there are both individual level factors and socialstructural level factors that influence hiv mortality starting at the left most side of the framework socialeconomic position and personal characteristics influence each other as well as moderate the relationship between environmental resources and constraints such as social capital minority stress and stigma and psychological influences including depression and trauma at the social structural level environmental resources and psychological influences affect other socialstructural and individuallevel factors namely access to care health behaviors and psychoimmunology we use this framework to guide our discussion of the individual social and structural factors that influence hivrelated health disparities in the us epidemic at the individual level the model highlights race gender and sexual orientation as well as their intersections in the words of link and phelan these constitute the fundamental causes of health inequality that apply just as well to hiv infection since they shape exposure to discrimination and limit economic opportunity also at the individual level these personal characteristics moderate the influence of psychological factors such as negative affect trauma and resilience psychological factors in turn influence health behaviors and physical processes that directly impact hiv infection trajectories and health outcomes socialeconomic position race gender and sexual orientation unlike other chronic diseases that fall on the seshealth disparities gradient hiv infection nearly exclusively impacts those who face economic adversityb the cdc reports that hiv prevalence is highest among people who are at or below the poverty level in addition to the singular factor of income education and employment also play important roles in the epidemic hiv is concentrated among individuals who have less than a high school education and those who are unemployed people with more advanced hiv infection and aids may qualify for disability benefits that cap their ability to earn additional income like so many other characteristics of people living with hiv poverty is frequently a premorbid condition that is only exacerbated by an hiv diagnosis in 2009 african americans accounted for 44 of all new hiv infections while making up only 14 of the us population in one southern us state georgia 78 of hiv infections occur among african americans while african americans comprise only 30 of the overall population additionally a disproportionately greater number of latinos are becoming hiv infected hall et al found continued disparate incidence rates of hiv infection among blacks as well as latinos as compared to whites african americans are also less likely to be aware of their hiv status and therefore less likely to be engaged in hivrelated care in one of the largest studies to target hiv testing among msm 91 of african american msm and 60 of white msm who tested hivpositive were unaware of their hiv infection the tangled implications of ses and ethnicity and race evident in the hiv epidemic mirror relationships found in other health conditions the differential rates of infection based on raceethnicity within ses groups signal that there is an underlying mechanism driving these relationships within the hiv epidemic the major underlying mechanism for this phenomenon occurs at the level of sexual networks as stated before hiv is transmitted through populations via sexual activity or injection drug use however studies have shown that at least for african american msm these sexual networks are mostly closed such that if hiv is introduced it is more likely to be transmitted to other african americans than to outside groups hiv transmission within close knit sexual networks helps explain the differential rates of infection despite similar levels of socioeconomic status in terms of gender hiv in the us has largely affected men in comparison to women men comprise 78 of all new us hiv infections the greatest portion of hiv infections in men occurs among msm the most severely affected group in the us hiv epidemic recent analyses show that hiv infection among msm is now increasing at a rate faster than that which occurred in the late 1990s in the state of georgia for example msm account for 48 of people living with hiv and 53 of incident hiv infections despite the fact that they comprise only 2 of the male population as such the rate of hiv diagnosis for msm is 44 times that of other men although women make up only 23 of all new hiv infections women of color are also disproportionately affected fiftyseven percent of new hiv infections among women occur in black women and sixteen percent among hispanic women environmental resources and constraints hiv in the us is overrepresented in places with wider income gaps and prevalence minority stress in washington dc for example the nations most wealthy and powerful live adjacent to neighborhoods with hiv infection rates that rival those seen only in southern africa similarly the financial districts of new york city and san francisco border neighborhoods ravaged by poverty and hiv in a county level analysis gant et al found a significant positive correlation between hiv infection rates and income inequality additionally studies in urban health have shown that vacant buildings broken windows and high crime rates are all associated with the amplification of hiv infection the poorest neighborhoods have the least social capital another characteristic that predicts hiv infections social capital is generally defined as the value of a groups social network usually expressed in terms of trust reciprocity and cooperation among network members who share common goals however there has been little research on social capital and hivaids in one study holtgrave and crosby conducted a statelevel analysis of poverty social capital and sti rates including hiv infections in this study social capital was measured in an index of 14 variables that represented community organizational life involvement in public affairs volunteerism informal sociability and social trust the results showed that low social capital was consistently associated with high rates hiv infection an association that was significant over and above the relationship between poverty and disease this analysis however does not account for the interrelatedness of incomepoverty and race it is possible that the association between social capital and rates hiv may be a byproduct of segregation and race related social conditions such as white privilege it is well known that minorities experience more discrimination and prejudice than do majority groups resulting in minority stress these instances include exposure to structural barriers associated with residential social displacement and segregation eg attending lower quality schools with less experienced teachers exclusion from social networks that support career advancement minorities are often concentrated in neighborhoods that have high crime rates and that lack stores for purchasing highquality food or opportunities for physical activity and relaxation many theorists have proposed that responses to racebased stressors range from sustained vigilance for threat to tremendous anxiety to internalizing negative stereotypes about racebased characteristics all of which have been posited to lead to poor mental and physical health additionally perceived racial privilege in favor of other races in the workplace has been associated with poorer health status among blacks although research is lacking demonstrating a direct relationship between minority stress alone to hiv contraction there is some evidence for other multiply stigmatized groups to be at a higher risk for contracting hiv for those already living with hiv infection hivrelated stigma negatively impacts individuals along multiple dimensions hiv stigma is associated with poorer mental health diminished social support and poorer health outcomes people living with hiv who have internalized the degrading messages of hivrelated stigma experience increased depression psychological distress shame anxiety and a loss of hope in addition to impacting the health of people living with hiv internalized stigma impacts an individuals social spheres for example internalized stigma impedes social integration and increases relationship conflicts internalized stigma has the potential to undermine vital dimensions of the social support of people living with hiv limiting resources that can often relieve the adverse effects of stress additionally a large percent of african americans have reported racial and ses based discrimination within health care settings given the striking parallels between the processes underlying hiv stigma and race ethnicity it is likely that the stress exposures experienced by some minority groups may exacerbate the impact of hiv stigma lee kochman and sikkema found that people recently diagnosed with hiv infection and characterized by having less supportive families had not attended hiv support groups knew fewer people living with hiv and had a more negative image of themselves as persons living with hiv in terms of health outcomes less internalized stigma among people living with hiv is associated with engagement in health care and treatment socially enacted stigma is discrimination which is also dependent on the social context additionally stigma is a predictor of poor mental health low selfesteem and a personal sense of shame of particular importance is the association between stigma discrimination delays in seeking care when testing positive and poor hiv treatment adherence living with hiv in an adverse social context therefore limits access to environmental resources and constrains opportunities for health improvement psychological influences affective disorders are among the most common mental health problems facing people living with hiv estimates of depression in individuals living with hiv range from 5 to 20 depending on demographic characteristics disease stage and diagnostic methods in a nationally representative sample of people receiving hiv treatment in the us one in three had major depression and one in four had a less severe type of depression importantly the chronic health problems seen in hiv infection do not account for higher depression in people living with hivaids for example a metaanalysis showed that depression in people living with hiv is not accounted for by their medical status depression rates among people living with hiv are consistent with those seen in populations at risk for hiv infection because depression is a reliable predictor of hiv risk it is expected that depression is also prevalent in people living with hiv hivpositive msm show similar rates of depression as hivnegative msm and both groups have higher rates of depression than observed in the general population similar rates of depression have also been found among hivpositive injection drug users and their uninfected counterparts additionally although racial disparities are present in hiv treatment adherence depression does not modify the relationship between suboptimal adherence and race indeed depression has long been known to be a premorbid condition in a majority of depressed people living with hiv studies have also demonstrated that premorbid trauma experiences influence hiv disease progression most of the attention in trauma research among people living with hiv has focused on histories of child sexual abuse in studies of hivpositive individuals rates of childhood sexual abuse range between 15 and 68 in a study of hivpositive men onefifth reported preadolescence sexual abuse in terms of adolescent and adult abuse kalichman sikkema difonzo luke and austin found that one in three men and two in three women with hiv reported sexual assault since age 15 these studies converge to show rates of childhood sexual abuse are much higher in people living with hiv than occurs in the general population it should be noted that the majority of these studies were conducted with multiple races however research concerning racialethnic differences in the study of prior history of sexual abuse andor assault for people living with hiv is lacking there are also longterm effects of childhood sexual abuse on later psychological functioning seen in people living with hiv including depression maladaptive coping and revictimization in adulthood early trauma experiences also predict health problems that overlap with the progression of hiv infection including but not limited to illicit drug use alcoholism and risks for cooccurring sti sexual abuse at any point in life is related to subsequent sexual risk behaviors and substance use once again because abuse experiences are reliable predictors of hiv infection histories of abuse are prevalent in people living with hiv research indicates that trauma severity also predicts mortality among patients with hiv disease leserman et al found that lifetime trauma experiences were associated with aidsrelated mortality individuals who experience multiple lifetime traumas are nearly three times more likely to die of allcauses as compared to those who reported fewer stressors evidence also suggests that trauma histories and posttraumatic stress symptoms are associated with poorer medication adherence and therefore disease progression this evidence is important within our disparities framework because low ses has been associated with greater risk of exposure to traumatic acts of violence untreated posttraumatic stress disorder a common outcome of violence has been associated with lower levels of employment and annual income additionally there are racialethnic differences in exposure to traumatic events and the development of ptsd exposure to household trauma such as child maltreatment and domestic violence has been shown to be highest among blacks however the relationship between ptsd trauma and hiv risk is complex within the context of racial disparities in hiv reisner falb and mimiaga found racialethnic minority males who reported childhood violent events have substantially lower odds of becoming hiv infected compared to white males who also reported exposure to violent events in childhood access to care hiv testing is the essential first step to engaging infected persons in hivrelated health care testing later during the course of hiv infection translates to entering care later and therefore potential delays in treatment delayed testing also has serious implications for hiv transmission risk examining lowincome individuals in 16 us cities shows that african americans and young adults are more likely to be tested later in hiv infection putting these populations at a greater disadvantage for receiving necessary treatment in 2008 one in three people diagnosed with hiv infection in the us were diagnosed with aids within 12months indeed an estimated 35 to 45 of people diagnosed with hiv infection are thought to have aids at the time they are tested as many as half of people diagnosed with hiv infection fail to receive hiv care in any given year an estimated one in four of those who are in care are not being treated for their hiv infection although they meet criteria for recommended treatment in addition adherence to treatment is often poor allowing hiv infection to progress although the overall literature seems to be inconclusive several studies have shown that both lower ses and lower education have been associated with poorer medication adherence additionally racial differences in hiv care are mixed in the literature a study done in the southeastern us showed that latinos were more likely to enter into hiv care later in the course of infection however sullivan et als 10 us city study found no relationship between delayed care and raceethnicity among individuals who test hiv positive their access to quality health care is impacted by psychological social and economic factors just as one would expect people with hiv who are more privileged and have health insurance as well as greater education also have better access to care because they are often poor and unemployed people living with hiv typically rely on public assistance for their health care although medicare has been associated with more hospitalizations than private insurance it does protect against suboptimal engagement in primary care shrinking budgets and health service cutbacks therefore have direct health implications for most people living with hiv white privilege may also play a role such that racialethnic minorities may be at an inherent disadvantage in obtaining quality care in a timely fashion simply because of their disadvantaged social status compared to whites in addition to primary hiv health care there is also a growing need for ongoing care for other chronic comorbidities there have been several estimations of psychiatric comorbidities within the hiv positive population frequently demonstrating to be significantly higher rates than observed in the general population specific to low income individuals soller et al found that 56 had comorbid posttrauma symptoms and acute stress disorders however adherence to psychiatric care for lowincome individuals living with hiv has been poor with only about half of patients with psychiatric comorbidity following up with recommended psychiatric service referrals untreated psychiatric comorbidities can have serious impacts on regular care such as poor medication adherence not surprisingly poor adherence to psychiatric medications is associated with nonadherence to antiretrovirals in people with comorbid conditions such as depression comorbid medical conditions in people with hiv also stem from more generally problematic health behaviors such as smoking and overeating behaviorally influenced diseases such as diabetes and hypertension are represented on an ses gradient with populations at the lowest level of ses being the most affected because people with hiv are concentrated in these lower ses groups the prevalence of these comorbid chronic conditions as well as the behaviors that influence them are high among people with hiv data from the us military hiv natural history study for example shows that 37 of people with hiv were overweight and 9 were obese although this is not much higher than the us population obesity among people living with hiv can complicate care the majority of patients followed between 1985 and 2004 had gained weight during the course of their hiv infection and weight gain was not accounted for by medication sideeffects in addition poorly controlled chronic comorbidities are likely the result of poor adherence to multiple treatments for example suboptimal hiv suppression is associated with poorly controlled diabetes and hypertension and poorly controlled diabetes has been associated with lower ses poor retention to care is especially problematic because of its direct link to adverse health outcomes studies have shown that missing three or more physician appointments is associated with a greater likelihood of not receiving antiretroviral medications furthermore half of individuals who did not return to the clinic after their first visit ever received treatment racial disparities also exist in terms of access to hivrelated health care and utilization the national health disparities report found that african americans living with hiv are less likely to receive standard hiv care including antiretroviral therapy outpatient appointments and monitoring of immune functioning as compared to white patients latinos also experience greater barriers to care turner for example found that latinos experience greater delays initiating care than african americans and whites although no studies have pinpointed the underlying cause for these discrepancies discrimination prejudice and privilege are all possible explanations gender differences also exist in access to quality hiv care studies show that women with hiv are more likely to attend outpatient appointments than are men conversely women living with hiv were found to be less likely to receive antiretroviral therapy this discrepancy may reflect men entering into care earlier in the hiv disease process and therefore being afforded more opportunities for early treatment the observed gender differences also intersect with race and ethnicity women of color suffer disproportionately from poverty in america with lower literacy and lack of economic opportunities manifesting in delayed entry to care and poorer adherence to health improving behaviors hiv treatments have the potential to reduce hiv transmission risks and therefore offering public health benefits beyond those of improved personal health several antiretroviral medications penetrate the genital compartment of the immune system and reduce concentrations of hiv in semen and vaginal secretions just as they do in peripheral blood the potential preventive benefits of hiv treatment are therefore also threatened by lack of access to health care and health disparities factors such as poor adherence and cooccurring sti are both influenced by access to health care and both significantly increase hiv infectiousness a review of studies examining the concordance between hiv in blood plasma and hiv in semen found the strongest correlation of 67 with most studies reporting correlations closer to 40 and some studies reporting virtually no association between the two compartments of the immune system thus at best only 45 of the variability in genital secretion viral load can be accounted for by blood plasma viral load the public health as well as personal health benefits of hiv treatments are therefore unrealized for many americans with hiv in poverty health behaviors substance use and drug addiction are a driving force in the spread of hiv infection however not all drugs are equally represented in the hiv epidemic most obvious is the role that injection drug use has played in the us hiv epidemic where a substantial number of hiv infections have been directly linked to sharing contaminated injection drug equipment noninjection drug use also promotes the spread of hiv insofar as it influences sexual transmission in addition noninjection drug users sexual networks often overlap with the networks of injection drug users a person who smokes crack cocaine for example does not risk hiv infection from the drug use itself but will be at elevated risk if they trade sex for drugs or have sex partners who inject drugs one study found that hiv incidence rates were higher among recently infected individuals who reported amphetamine use within the past year as compared to nonusers amphetamine and its derivative methamphetamine are in particular associated with highrisk sexual behaviors of great concern is the association between methamphetamine use and a rapid turnover of multiple sexual partners research suggests that the probability of hiv infection increases as the number of sexual partners increases particularly when sex partners are concurrent meaning overlapping in time having multiple sex partners increases risk of contracting a cooccurring sti as well as transmitting hiv methamphetamine use has increased among gay and bisexual men particularly in urban areas and is prevalent in circuit parties and commercial sex environments thus methamphetamine is believed to fuel the spread of hiv in sex networks of msm it is also common for methamphetamine users to engage in other substance abuse making the isolation of any one drug as an hiv risk factor exceedingly difficult there are other addictive behaviors that can have a significant impact on hiv risk and transmission research shows that lack of personal control over sexual impulses and sexual preoccupations are associated with sexual risks for hiv including multiple sex partners and infrequent condom use another addictive behavior alcoholism increases hiv risks beyond those posed by specific sex acts by increasing the likelihood of intersecting sex networks with varied hiv prevalence in addition to facilitating highrisk sexual activity some recreational drugs can also dangerously interact with antiretroviral medications in particular some antiretroviral medications most notably drugs in the class of protease inhibitors are metabolized through the same hepatic pathways as recreational drugs increasing the potential for hazardous interactions regardless of the specific medication regimen people who are coinfected with hiv and hepatitis c virus and take antiretrovirals drinking alcohol is a significant risk for life threatening liver complications another critical health behavior contributing to disparities in hiv infection progression is medication adherence close adherence to antiretroviral medications is necessary to achieve the life prolonging benefits of these drugs combination hiv treatments have had dramatic effects on reducing viral burden improving health and quality of life of people living with hiv and contributing directly to significant declines in hivrelated mortality unfortunately not everyone who is prescribed antiretroviral therapies realizes the potential benefits of these medications when efficacy of treatment is assessed in clinical samples viral load remains detectable and therapeutic effects are suboptimal in 30 to 70 of hiv infected patients although a number of factors contribute to hiv treatment failure inconsistent adherence is one of the most critical factors implicated in suboptimal response to therapy adherence of at least 85 doses taken is often discussed as necessary for most treatment regimens to reach acceptable population based hiv suppression however antiretroviral treatment adherence varies widely clinical studies report that 26 to 35 of hiv positive patients have difficulty maintaining even 80 adherence hiv infections are concentrated in the most socially disadvantaged populations and are compounded by factors that impede adherence that are also prevalent among the least well resourced for example limited literacy skills are associated with misunderstanding hiv disease processes and hiv treatment nonadherence the association between health literacy and antiretroviral adherence appears quite robust with health literacy significantly predicting treatment adherence after controlling for social support attitudes toward health care providers hiv symptoms income level substance use and even years of education studies find adverse health effects of poor treatment adherence in marginally literate people living with hiv particularly with regard to viral burden immune function and hivrelated symptoms psychoneuroimmunology psychological social and physical stressors can alter immune functioning and undermine health of particular importance is depression which has been linked to decrements in immune functioning that are relevant to persons with hiv most importantly greater depressive symptoms have been associated with a greater decline in cd4 cells the target of hiv these associations are also observed outside the us with greater depressive symptoms associated with lower number of cd4 cells among hivpositive individuals in rural uganda leserman et al found that depressive symptoms associated with faster progression to the later stages of hiv infection individuals with a previous history of depression had a fivefold increased risk of developing a depressive episode during the study depressive symptoms predicted increased risk of developing aidsdefining conditions whereas the opposite was not observed reducing depression has also been shown to enhance immunity in people with hiv for example a study of hivpositive women found successfully treating depression and improved immune function specifically natural killer cell activity stemming from the association between emotional distress and immune functioning stress management interventions have been extensively tested in people living with hiv a metaanalytic review integrated the results of 35 randomized controlled trials which tested the effects of 46 separate stressmanagement interventions for hiv positive adults the studies included over three thousand people living with hiv infection results showed that compared to control conditions stressmanagement interventions reduce anxiety depression distress and fatigue and improve quality of life however the interventions do not generally improve cd4 cell counts viral load or hormonal outcomes compared with various control groups the degree to which stress management and other stress reducing interventions are available to people living with hiv is limited and is more likely to decline than improve with shrinking health care resources hivrelated health outcomes along with inequalities of health care coverage disparities in health outcomes for people with hiv are apparent in a recent analysis unmet basic needs such as shelter and food were found to have the greatest impact on overall mental health and disease trajectories for hiv positive homeless and unstably housed women in fact unmet basic needs had a greater impact on overall health outcomes than medication nonadherence with respect to food security as many as half of all people with hiv in us innercities lack sufficient food food insecurity in people with hiv is related to low medication adherence and poor health outcomes in vancouver british columbia lacking adequate food and having a low bodymass index predicted mortality in people with hiv over and above medication adherence as discussed earlier many people living with hiv rely on public assistance for their health care however there is evidence that simply having medicaid may not lead to better health outcomes one study found that people living with hiv who received medicaid reported similar levels of health status as those who did not have any insurance efforts to increase quality and access to health care through public programs are vulnerable to economic downturns and shifts in public policy advances in hiv treatment have significantly improved and extended the lives of hiv positive persons hiv infection is now recognized as a controllable chronic disease a recent study however suggests that the introduction of antiretroviral therapy has also increased inequalities in aidsrelated mortality rubin found that the association between ses and aidsrelated mortality increased with the introduction of effective treatment as persons at the higher end of ses have increasingly positive health outcomes although overall mortality was reduced dramatically for all individuals receiving antiretroviral medications access to the latest treatments has not been equal advantages in accessing the best available treatment are likely due to resources such as knowledge money health insurance power and social connections that often accompany increases in ses cunningham et al found significantly greater risk of death for those with no accumulated financial assets and those with less than a high school education even when controlling for hiv treatment and clinical care these disparate health outcomes will only be alleviated through changes in factors at the individual social and structural levels conclusions the greatest overall illness burden across all diseases occurs at the lowest levels of ses these health disparities are exaggerated in people living with hiv who are primarily concentrated in the lowest ses strata among whom racial and ethnic minorities are overrepresented multiple comorbidities are further amplified by high prevalence rates of smoking obesity empty calorielow nutrient diets substance abuse and other poor health behaviors which are also overrepresented among the poor and disenfranchised the factors that promote hiv infection and those that impede access to health care therefore parallel those identified for other chronic illnesses models of health disparities such as the one that we have highlighted in this article are useful when translated to the hivaids epidemic addressing health disparities in hiv infection may however require different approaches than other chronic diseases hiv infection is so closely enmeshed in conditions of poverty that it is indeed a pandemic of the poor changes in health behaviors alone will have significant impacts on hiv epidemics biological factors that promote and impede infectiousness and susceptibility require universal access to testing and treatment a feat easier said than done substance abuse and mental health treatment should be considered direct strategies for both primary and secondary prevention in aids providing adequate food and housing are health interventions as well as humanitarian imperatives we must also acknowledge that expanding all kinds of access will mean nothing unless the barriers posed by racism homophobia stigmas and discrimination are lifted our best chance for reducing the health disparity that is hiv will be to address social and structural factors that underlie the hiv epidemic a health disparities framework for hivaids adapted from adler stewart

the us hiv epidemic has evolved over the past 30 years and is now concentrated in socially marginalized and disenfranchised communities the health disparities in this epidemic are striking with most hiv infections occurring in sexual minorities and communities of color while widely recognized the health disparities in hiv and aids are not often discussed in this paper we examine the factors underlying health disparities in the us hiv epidemic we first discuss the interlocking relationships between biological social and behavioral factors that drive hiv epidemics guided by a wellestablished conceptual model of health disparities we then describe the social positions of those most affected by hiv and aids particularly racial and gender groups structural and economic conditions including environmental resources constraints access to care and psychosocial influences are examined in relation to hiv disease trajectories greater attention to contextual factors and comorbidities is needed to reduce the health disparities in hiv infection

background health care is important for improving population health and reducing health disparities however health outcomes are also driven by factors beyond health care especially the social determinants of health such as socioeconomic status living environment and access to healthy food 12 accordingly efforts that link health care public health and social services are likely to improve population health and reduce health disparities research has demonstrated a link between crosssector collaboration and health and healthrelated outcomes including a reduction in deaths from cardiovascular disease diabetes and influenza 3 improvements in childrens asthma control 4 favorable trends in blood pressure control in patients with hypertension 5 and increases in hepatitis b knowledge testing vaccination and followup visits 6 while there have been many successes a persistent problem is that health oriented crosssector collaborative efforts are often fleeting failing to establish sustained systems change that endures and continues to improve lives after initial energy wanes 7 8 9 10 to address this problem the robert wood johnson foundation recently drew on its many years of experience in the field of healthoriented collaboration the growing body of research on crosssector collaboration and recent trends in practice around collective impact and accountable communities of health to develop the crosssector alignment theory of change the central idea of the crosssector alignment theory of change is that health care public health and social services might better meet the goals and needs of the people they serve over the longterm if they create collective change in four core areas shared purpose data governance and financing so long as those changes reflect the will of the community in question 11 yet while research on health collaboratives has been steadily growing 12 recent reviews in this field have identified a need for increased attention to community voice these reviews note that a key challenge in both practice and research is that there is little agreement in the literature on the definition of community voice or on the most important factors to consider when planning strategies for incorporating community voice in health collaboratives 1213 furthermore many of the community voice strategies discussed are rooted in a paradigm that focuses on shortlived collaboration rather than sustainability and ultimately systems change 14 in a time of greater recognition of the need for inclusiveness it is especially important to understand the factors driving different community voice strategies and the implications these strategies have for improving population wellbeing over the long term the purpose of this review is to build on early efforts to define community voice in the context of health collaboratives identify specific community voice engagement strategies for fig 1 the crosssector alignment theory of change this image was reprinted from landers g minyard k lanford d heishman h a theory of change for aligning health care public health and social services in a time of covid19 american journal of public health 110 s178s180 11 health collaboratives along a spectrum of empowerment 121516 and draw out the implications different community voice strategies have for sustainable crosssector alignment methods we conducted a scoping review for this study scoping reviews differ from cochranestyle systematic reviews in that while cochranestyle reviews focus on an established and narrow literature a welldefined question and the weight of evidence bearing on that question scoping reviews are optimal for synthesizing broad literatures addressing broad questions or laying foundations for future research in an emerging field 17 we employ the scoping review method specifically to summarize and disseminate prior research findings on community voice in healthoriented crosssector collaboratives to draw out common themes and to identify gaps that might be addressed in future research that subsequently helps shape practice 17 data collection data collection involved two phases in phase one we identified papers addressing healthoriented crosssector collaboration for a broader project on healthoriented crosssector collaboration authors forthcoming in phase two the set of papers was narrowed to those that also substantially addressed community voice specifically papers were read and manually excluded if community voice or a similar concept was not discussed or if community voice was identified as important but the paper did not elaborate on why it was important discuss how it might come to be assess what it might produce or examine what it might entail 12 phase one consisted of three steps first papers were collected through a systematic scan of academic search engines second we performed a systematic scan within journals commonly represented among the search engine results for the third step we conducted a purposive scan for relevant documents using general search engines website searches and professional networks the scan of academic search engines was conducted using academic search complete pubmed and the cochrane library each search used the following search terms and and health and and or and public health or and public health documents were included in phase one if the following criteria were met published within the last 10 years english text version available discussed at least two of the three sectors identified in the crosssector alignment theory of change health care public health and social services all documents were independently reviewed for inclusion by two researchers disagreements on which articles to include or exclude were reconciled as a team the second step involved a systematic scan of key journals based on their frequency of appearance in the academic search engine results frequently represented journals included health and social care in the community international journal of integrated care social work in public health and the journal of public health management and practice researchers used the same inclusion and exclusion criteria described above the third step involved a purposive scan for relevant research on healthoriented crosssector collaboration this involved gathering relevant papers forwarded by rwjf and other practitioners in the field conducting a systematic scan of the rwjf website for relevant work scanning for reports on websites of key organizations collecting documents identified through rwjfs and the authors professional contacts and searching on general search engines using the search terms identified above in phase two of data collection an additional inclusion criterion was added to the existing criteria addressed community voice or a similar concept and either elaborated on why it was important discussed how it might come to be assessed what it might produce or examined what it might entail this criterion narrowed the set of papers to those specifically addressing community voice or a similar concept in the context of health collaboratives phase two also involved a directed review of research on community voice outside of health collaboratives which helped provide the conceptual grounding for this study and helped situate the findings within the broader literature coding information for each document in the review was coded in nvivo initial codes were based on a preliminary reading of the documents and included defining community voice types of community voice strategies for including community voice in collaboration barriers to including community voice in collaboration and notable passages with community voice here representing a broad class of similar concepts such as community participation community agency and community engagement a first round of coding was manually completed using these initial codes the coders then met to identify common themes and a second round of coding was manually completed based around these themes the results below reflect these themes and the subthemes that emerged during the second round of coding and are organized into three sections conceptualizing community voice types of community voice strategies and sustained systems change and community voice results conceptualizing community voice community voice is conceptualized in the healthoriented crosssector collaboration literature in a variety of ways the documents we reviewed used several terms including community engagement community agency community participation and consumer participation the papers we reviewed did not generally denote or connote differences in meanings between these terms accordingly this study uses community voice as an allencompassing term for inclusion of community members in collaborative activities consistent with research on community involvement more broadly 18 many papers on community voice in fig 2 prisma diagram health collaboratives do not formally define community voice terms we found three exceptions one from the centers for disease control and prevention another from the national academies of sciences engineering and medicine and a third from calancie and colleagues recent review of health collaborative models the cdc defines community engagement as the process of working collaboratively with groups of people who are affiliated by geographic proximity special interests or similar situations with respect to issues affecting their wellbeing 19 nasem defines community agency as collective control connections capacities and opportunities including partnerships with shared decisionmaking and mutual accountability 20 calancie et al define community engagement as working with community members and community organizations to build awareness around an issue gain insight into an issue andor develop capacity within community members 12 additional definitions are available in the broader literature and could readily be applied in future studies to help organize the learnings 21 22 23 24 25 for example butterfosss definition of community participation is a process along a continuum that enables communities to maximize their potential and progress from individual action to collective social and political change there are potentially important differences between these definitions for example the cdc definition places emphasis on a shared commonality bringing communities together while the nasem definition emphasizes decisionmaking accountability and community agency calencies et als definition emphasizes awareness and capacity building and butterfosss definition emphasizes the idea of a process a spectrum and the goal of sociopolitical change such differences have implications for the implementation of community voice strategies for example by implicitly referring to different populations with different levels of power and capacity conveyed to the community in question while we do not expect a single definition of community voice will be more effective than all others in every situation this finding does underscore the need to explicate definitions when community voice terms are used in future practice and research while the papers we reviewed often used community voice terms interchangeably and did not always define those terms we were able to identify several distinct dimensions along which community voice is generally discussed these dimensions include the bounds used to define community versus consumer the population composing community voice and the depth of community voice strategies these dimensions are discussed below community and consumer voice community and consumer voice are generally used interchangeably however these terms have distinct implications making it problematic to use them interchangeably the term consumer tends to reference users of healthcare services 26 27 28 29 30 31 32 33 or those with lived experience 34 the term community tends to reference groups of people in a bounded geographical location health care consumers and other community groups should be distinguished clearly and identified distinctly to promote conceptual clarity the population composing community voice community voice is provided by many different populations community voice could come from individuals living in one specific geographical location or users of specific services as discussed above communitybased organizations themselves may serve as proxies for community voice 35 because different populations can provide community voice care must be taken to identify the specific population in question for example in some cases an organization leader may be relied upon to speak for the community while in other cases it is people being represented who are considered the voice of the community these different categories of people have different experiences and backgrounds and they may live in different communities accordingly the meaning of community voice is likely to vary depending on the population providing that voice and the population involved is likely to influence the systems changes promoted by a collaborative this finding reflects the broader literature on community voice which highlights the importance of explicitly recognizing community identity in terms of groups that reflect specific settings scales and social power structures 36 37 38 39 the depth of community voice strategies the depth of a collaboratives community voice approach is often described using terms like meaningful or authentic in such cases meaningful or authentic involvement is understood as the ideal form of community voice 203140 these qualifiers are most often used within the context of recommendations to organizations on how to include community members in collaborative work this language conveys the insight that community voice is often marginalized even when it is purportedly a central concern however as in the broader literature on community voice 18 these qualifiers often do not come with clear definitions leaving it unclear how we might understand or identify effective practices the qualifiers themselves are not inherently faulty and prior research on community voice more broadly is quite clear that some community voice strategies are more likely to be emancipatory than others 41 the point is that the frequent use of unexplained qualifiers underscores the need to identify and use measures that more specifically identify the degree to which and how community voice is engaged to summarize this section researchers and practitioners interested in community voice are likely to gain mutual benefit from using clear definitions and qualifiers which identify a precise set of community members in terms of groups that reflect specific settings scales and social power structures and specify the type of community voice under consideration types of community voice strategies passive community voice strategies our review suggests that community voice strategies tend to range across two types passive and active consistent with earlier research 1516 we found that passive forms of community voice tend to transfer less power to community members than active forms of community voice however we also found that passive community voice tended to place fewer resource requirements on community members on an individual basis passive strategies for community voice tend to take the form of collecting data from community members 42 in the studies reviewed three types of strategies for including passive community voice in collaborations were identified holding community forums measuring community intervention experiences and conducting community assessments community forums are used to share data with community members and to compare alreadyobtained data with community perceptions 43 the intent is to share data and information out to community members community members might for example take part in community roundtables or working groups 44 because some community members may face barriers to participating including limited resources or time there are several recommendations for making these forums more community friendly organizations can make meetings more accessible by holding them at convenient times assisting community members with travel childcare and translation services providing compensation for their time and providing multiple avenues for participation for example via the internet as well as inperson 3145 a second passive community voice strategy is measuring community intervention experience this is in some ways another type of community assessment however it focuses specifically on measuring community experience with current programming the intent is evaluation this may for example take the form of collecting customer satisfaction surveys 3146 another intervention measurement strategy is conducting formal and informal conversations with community groups to gain feedback and community perspective on programming 46 47 48 such conversations can be used to make programming more culturally appropriate 48 the third passive community voice strategy is to conduct community assessments community assessments are used to measure health and wellbeing within a community and raise issues collaboratives might address assessments can take many forms but often take the form of community health needs assessments the patient protection and affordable care act made chnas a requirement for taxexempt hospitals part of the requirement includes participation from community members in the chna process however the wording of the requirement is vague on the definition for community participation 31 this means that in practice chnas can be limited to community focus groups or community members helping gather data interaction with community members can be limited and while this strategy places less burden on community members time and resources than more active strategies it provides few opportunities for community members to make decisions about how the data is collected or used active community voice strategies active community voice strategies convey more power to community members when compared with passive strategies this power comes from having community members in decisionmaking roles active strategies position community members within collaboratives however while active community voice strategies often entail greater empowerment we also found that placing community members within the collaborative came with higher capacity requirements for community members examples of activities requiring higher capacity include time for trainings relationship building and attendance at collaborative activities five strategies for including active community voice in collaborations were identified prioritysetting participatory decisionmaking trainings employing community members and communityled coalitions the first strategy for engaging active community voice in collaboratives is priority setting 31404249 community members can help by identifying and collecting important data in their communities for example community members can work with collaboratives on designing health impact assessments hias are recognized as valuable for advocacy efforts and communities can make them more impactful by including their voices 40 this differs from other community assessment tools because priority setting is done in collaboration with the community whereas other tools like chnas in many instances can be limited to only gathering data from community members the second strategy is participatory decisionmaking there are three forms of participatory decisionmaking in the literature one form involves health consumers being active participants in their care provision and in the decisionmaking concerning their own care 303133465051 another form is community members holding seats on governing or advisory boards 313252 the intensity of involvement required for community members shifts between the former and the latter type of participatory decisionmaking the latter type of participatory decisionmaking moves beyond individuals making decisions about their own care to community members making decisions that affect the care of many this will require more of community members time and resources for participating in these types of activities examples include hospitalbased patient and family advisory councils community involvement in these two examples typically requires at least 50 membership by current or former patients or family members 31 the federal public health service act requires federally funded community health centers to have a consumer majority on their board of directors 31 and the national multisector health coordinating body has seats reserved for consumer participation 52 a third form of participatory decisionmaking is participatory budgeting participatory budgeting empowers communities to make funding allocation decisions 3153 this form of community voice gives communities power in deciding what needs to address and how those needs should be met notably complicated power dynamics are likely to remain even when community members are empowered for example community members can be discouraged from participation in decisionmaking processes by the use of technical language and jargon 2732 addressing such dynamics may require activities such as developing a shared language between collaborators and community members 20 another example involves powerknowledge values the knowledge gained from research or academic conferences can be valued more than knowledge gained from protests or grassroots organizing 54 it is important to recognize that these values impact who is allowed at the table to define community problems and solutions 54 a third type of active community voice strategy is training organizations can take the time to provide training to communities helping them develop skills that will enhance collaboration between the two entities trainings can for example address decisionmaking advocacy or how to work collaboratively 324044 specialized trainings on social determinants of health can also help 40 in many cases community members are not the only ones needing training and training collaborative members from across organizations can strengthen the collaborative capacity of all involved while helping to build communitycollaborative relationships 40 a fourth active community voice strategy is to hire community members into collaboratives for example in communityliaison roles such as community health workers and community care coordinators such positions help connect other community members to services and have been shown to improve community health outcomes 31 providing monetary compensation for the additional time and expertise community members are providing can aid in their ability and motivation to participate in collaboratives 45 embedding community members also helps organizations and communities build trust which has been cited many times in the literature as an important step in engaging community voice in collaborations more broadly 27324548 the fifth active community voice strategy is to create communityled coalitions though the papers we reviewed provided strategies for including or even embedding community voice in collaboratives leadership originating outside the community still tends to play the dominant role in such working arrangements however one paper highlighted an initiative where a community coalition itself led much of the collaborative intervention 55 in this intervention health consumers oversaw monitoring the performance of health providers in collaboration with government in this case there was legislation in place that mandated citizen participation in governing health and social sectors 55 this mandate pointed to community participation specifically in … planning supervision execution and administration of health programs that are key actions for guaranteeing the right to health 55 in this initiative community members made many of the decisions with guidance and support provided by government collaborators however even with this example program sustainability was affected by community volunteer turnover due to lack of pay for the intense level of involvement required by the initiative 55 sustained systems change and community voice one of the core purposes of the crosssector alignment theory of change is to help guide sectors and organizations as they transition from a focus on shortterm collaboration to sustained systems change we found that the strategies identified above lend themselves to sustained change to different degrees in this section challenges to longterm community voice strategies are identified along with potential solutions passive and active strategies and sustained systems change several of the strategies identified above are primarily oriented toward shortterm community contact these tend to be passive strategies leading us to observe an association between sustained systems change and the intensity of community voice strategies specific strategies oriented toward shortterm collaboration include data collection community forums or hearings and initiative evaluations these activities could be institutionalized and become regular occurrences and these strategies may be helpful in many situations however they tend to take the form of irregular or onetime contact inherently limiting their longterm potential other strategies for engaging community voice may be more appropriate where the intent is to create sustained connections one shortterm strategy identified above that does involve active community voice is responding to heeding community voice in the form of protest 54 protests largely originate within communities and outside collaborativeinitiating organizations but phipps and masuda argue that community origin alone should not disqualify protest from being considered a form of community voice 54 because protests come and go the other active strategies mentioned above are perhaps more amenable to collaboration in the longterm these involve power sharing community participation in standing committees and boards compensation for community participation and communityled decisionmaking all of these provide either psychological instrumental or financial incentives that are likely to help promote community member involvement and ultimately strengthen aligning efforts over the longrun challenges and potential solutions challenges in implementing community voice are discussed often and may even be inherent several studies note that engaging communities is difficult 2756 active community voice can be difficult to retain often requiring unexpected compromises in implementation strategies changes in research design shifts in priorities delays in anticipated schedules surrender of power to the community and ultimately a shift in expectations for both processes and objectives 275257 many organizations are not able to or are disinclined to make such accommodations 275258 such changes may challenge fundamental assumptions individuals have about their roles and the roles of the organizations in which they participate power is not merely intellectual it is instrumental and giving it away has material consequences hesitance to share power is a key factor in the devolution of many community voice activities into tokenism 41 not everyone is prepared to make changes in operations that alter power relations between themselves and community members 59 however given the emphasis in the literature on building trust 276061 being thoughtful about boundaries is likely to encourage productive relationships even where changes in processes and outcomes are expected to be relatively moderate finally given that many of the studies we reviewed discussed the need to turn away from ineffective solutions the need for change and the importance of change management 62 63 64 65 66 sustainable collaboration may require embracing change in terms of engaging community voice this suggests that aligning organizations themselves should carefully consider how collaborative and community resources can be allocated in the most productive ways discussion this review surfaced several definitions for terms linked to community and community voice though community voice terms tend to be used interchangeably the literature does offer jumpingoff points for the systematic use of standardized definitions this review also underscores the need for researchers and practitioners to be explicit about their definitions of community voice and identify the community in focus in relation to specific settings scales and social power structures 36 37 38 39 furthermore the possibility that community voice could involve different population groups implies that the term community voices may be the more precise term in some contexts where no single community is identified 1467 we also distinguished community voice strategies that varied along a continuum from passive to active reflecting the broader literature on community voice these two types of strategies tend to vary in the power that is shared with communities with more active strategies involving more power sharing however these strategies also tend to vary along the same spectrum in the intensity of involvement required by community members with more empowering strategies requiring greater resources on the part of individual community members while prior research has identified a link between active community voice and power 20274553 identified potential pitfalls with community voice strategies such as tokenism 18415268 and pointed out the need for time and capacitybuilding when working with community partners 274546525868 no prior study of which we are aware has noted that the requirements placed on community members tend to increase along with power sharing on the activepassive community voice spectrum it is critical that researchers and practitioners recognize that empowerment may pose fewer new requirements on those with resources to address the requirements of increased involvement but empowerment in the complex environment of a collaborative may impose greater burden on people in historically underresourced communities 68 the burdens placed on participating community members will have to be addressed if empowerment is going to take place and practitioners should strategically consider how those burdens may increase along with power sharing for example by planning resources for capacity transfer along with power transfer or by planning highimpact activities specially designed to have low burden for community members indeed practitioners may find that certain activities offer higher leverage for example in governance where community board members might be able to have a significant impact on operations and outcomes this is of particular importance to the crosssector alignment theory of change as it would have implications for how community voice is implemented in the development of shared purpose data financing and governance respectively in summary organizations should carefully consider how they facilitate more intense involvement from communities which may require training capacity building time for relationship building and fair compensation for community members time and efforts as community voice is brought to bear on the varied activities of a crosssector collaborative another key concern in the development of the crosssector alignment theory of change was to promote sustainable collaboration active community voice strategies may be more suited to promoting sustainability since they tend to extend beyond onetime activities however they do pose challenges in that they require time and resources from everyone involved and they may result in deviations from what aligning organizations or systems had originally expected in terms of processes and outcomes implementing community voice strategies aligning organizations may benefit greatly from community voice 3053 69 70 71 community members add a sense of urgency around issues that they experience firsthand as important for their own wellbeing 69 community voice adds intellectual and experiential capacity to aligning organizations 273070 community members can provide data on the community in the short term and by incorporating community members over the longterm for example as decisionmakers and paid employees aligning organizations can institutionalize community voice as a lasting knowledgeproducing solution responsiveness to community voice also signifies sincere concern for community goals and needs perhaps increasing the likelihood of financing from potential investors 7273 such advantages do not always come without costs and those engaged in crosssector alignment should prepare themselvesand community membersappropriately working with communities takes time which can be costly and increase exposure to uncertainties working with communities also takes resources both for organizations and individuals and financing arrangements will have to be made accordingly governance structures may also have to change as community members are empowered in budgeting and other decisionmaking roles aligning sectors and organizations may be confronted with the need to accept the legitimacy and importance of communityled coalitions that have their own governance structures despite the costs incorporating community voice in health collaboratives appears likely to promote the objectives of crosssector alignment including improved community wellbeing in the process engaging with community voice may also help build capacity in communities and ultimately empower community members to selfadvocate in pursuing positive community outcomes limitations the studies we reviewed are primarily exploratory or descriptive in nature similarly most of the studies we reviewed did not contain a theoretical analysis limiting the linkages that could be made with research on community voice in other contexts these limitations represent opportunities for future research future studies could productively incorporate strong theoretical foundations and incorporate methods that allow for causal analysis we have attempted to move in this direction by grounding our findings in the crosssector alignment theory of change the literature on health collaboratives and the broader literature on community voice this effort will also be greatly aided where practice is based on a theoreticallyinformed foundation and rigorous evaluation plans are conceived and implemented early in the project planning phase conclusion this review provides three important contributions to the field first we have characterized the literature on community voice in healthoriented collaborations providing a conceptual jumpingoff point for defining discussing and analyzing community voice as a concept in this literature second we have provided a theoretical basis for future research by differentiating passive and active community voice strategies and highlighting the relationship between the power dynamics and resource requirements that undergird these strategies finally we have situated the literature in respect to sustained systems change and the crosssector alignment theory of change thereby promoting the theoretical development of a prominent framework in the field there is evidence that healthoriented crosssector collaboration can have a positive impact on community health outcomes 3 4 5 6 this review elaborated on the differences between passive community voice strategies and active community voice strategies which tend to provide an enhanced level of decisionmaking and power to community members we expect that increased attention to the concept of active community voice will help practitioners achieve improved health outcomes and help researchers better understand the pathways to health improvement through collaboration and ultimately crosssector alignment abbreviations sdoh social determinants of health rwjf robert wood johnson foundation cdc centers for disease control and prevention nase m national academies of sciences engineering and medicine chna community health needs assessment aca affordable care act hia health impact assessment competing interests the authors declare that they have no competing interests

background health care access is an important driver of population health and factors beyond health care also drive health outcomes recognizing the importance of the social determinants of health sdoh different actors in the health care public health and social service sectors are increasingly collaborating to improve health outcomes in communities to support such collaboration the robert wood johnson foundation developed a crosssector alignment theory of change according to the crosssector alignment theory of change community voice is critical for helping collaboratives address community health needs yet research on health collaboratives offers mixed guidance on how community voice should be understood and which community voice strategies are most effective methods this study addresses a gap in the literature with a systematic scoping review of research on healthoriented crosssector collaboration and community voice by scanning key academic journals searching three academic databases and obtaining documents from across our professional networks we identified 36 documents that address community voice in health collaboratives results the review reveals several conceptions of community voice and a range of community voice strategies we find that community voice strategies fall on a spectrum between two broad types of approaches active and passive these vary not only in the level of power shared between communities and collaborators but also in the level of involvement required from the community and this in turn has important implications for community collaboration strategies we also find that while most strategies are discussed in the context of shortterm collaboration many also lend themselves to adoption in the context of sustainable collaboration and ultimately crosssector alignmentthis review provides a characterization and conceptualization of community voice in healthoriented collaborations that provides a new theoretical basis for future research passive and active community voice strategies can be studied in more detail for their expected impact on health outcomes and disparities increased attention to active community voice and the resources it requires can help practitioners achieve improved health outcomes and researchers understand the pathways to health improvement through collaboration

introduction reducing inequalities in health between socioeconomic groups within a country is one of the greatest challenges for public health even in the highly developed welfare states of europe 1 recognising this several countries have set quantitative targets for reducing these inequalities a target to reduce health inequalities by 25 was introduced by the world health organization in 1985 and renewed in 1998 2 several european countriessuch as england finland and lithuaniahave adopted national targets for the reduction of socioeconomic inequalities in mortality 3 since these targets were set reports have suggested that inequalities in mortality have widened instead of narrowed both in countries that have set targets and in many other high income countries 4 5 6 however our study of changes between 199094 and 20004 in a range of european countries suggested that although relative inequalities in mortality have universally increased trends in absolute inequalities have not 7 we now extend this work by including more recent data and by systematically assessing whether there has been progress and if so how much in reducing relative and absolute inequalities in mortality there is no agreement among researchers or policy makers on what measures to use for monitoring progress towards the reduction or elimination of health what is already known on this topic a few decades ago reducing inequalities in health between socioeconomic groups became a priority for health policy makers in many countries of studies analysing trends in mortality inequalities since then most were limited to one country a few looked at relative and absolute inequalities and no study has quantitatively compared progress in reducing inequalities between countries what this study adds since the early 1990s absolute inequalities in mortality have declined among men in many european countries relative inequalities in mortality have increased overall progress in reducing absolute inequalities was largest in spain scotland england and wales and italy but absent in finland and norway narrowing of absolute inequalities was driven by substantial progress in reducing mortality in lower socioeconomic groups from ischaemic heart disease smoking related causes and causes amenable to medical intervention however there were substantial setbacks for alcohol related mortality recent trends in inequalities in mortality in europe have been more encouraging than commonly thought although progress has varied between countries inequalities 8 and different measures reflect different normative standpoints 9 the approach we take explicitly acknowledges that in a context of declining mortality where baseline levels of mortality are higher in lower socioeconomic groups than in higher socioeconomic groups the only way to reduce inequalities in mortality is to achieve stronger reductions in lower socioeconomic groups than in higher socioeconomic groups 10 this objective is difficult for declines in mortality as measured on a relative scale because it requires greater reach or greater effectiveness of interventions among lower socioeconomic groups it is easier although still challenging to achieve larger absolute declines in lower socioeconomic groups because starting levels of mortality are higher in these groups we therefore distinguished three possible outcomes • larger absolute and larger relative declines in lower socioeconomic groups leading to a narrowing of absolute and relative inequalities in mortality • larger absolute but smaller relative declines in lower socioeconomic groups leading to a narrowing of absolute but widening of relative inequalities in mortality • smaller absolute and smaller relative declines in lower socioeconomic groups leading to a widening of absolute and relative inequalities in mortality while outcome 1 will generally be seen as the most desirable outcome 2 is still valuable because ultimately it is the absolute excess death rate in lower groups that affects peoples lives not the relative excess of a more and more infrequent event even outcome 3 has some value because a decline of mortality benefits lower socioeconomic groups regardless of whether inequalities increase or not methods data data came from sources with a population wide coverage in which mortality could be related to indicators of socioeconomic position as reported in a census web tables a1 and a2 give an overview of the main characteristics of these data sources for this analysis we selected all european countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010 data for spain and italy came from regional populations data for england and wales were only available together most data stem from a longitudinal mortality followup after a census in which socioeconomic information of the population at risk and of the deceased has been recorded in the census spain had socalled repeated cross sectional data in which socioeconomic information on the population at risk came from repeated censuses and information on people who had died came from death certificates lithuania had cross sectional data for years 198890 and 200002 and longitudinal data for 200105 and 200609 because lithuanias cross sectional data have been shown to overestimate inequalities in mortality 11 we adjusted lithuanias estimates of inequalities in mortality for 198890 downwards we used the differences between lithuanias cross sectional data and longitudinal data for observed inequality estimates to calculate the relative overestimation in the cross sectional estimates we then multiplied lithuanias cross sectionally observed inequality estimates for 198890 by the inverse of this value we used two indicators of socioeconomic position level of education 1997 categories 02 34 56 and occupational class for england and wales the low and mid educated had to be combined because of lack of detail in the 1991 census the strong decline between 199094 and 200509 in the proportion of low educated people seen in our data corresponds well with that seen in other data sources occupational class was not available for all populations covered by the analysis and classification of women by occupational class was difficult so we presented results for men by occupational class in web fig a2 and web tables a6 and a7 in the analysis we focused on four main groups of causes of death that together accounted for total mortality and on specific causes of death for which strong trends in mortality have occurred that are relatively well understood these causes included ischaemic heart disease road traffic injuries smoking related causes 12 alcohol related causes 13 and causes amenable to medical intervention 14 web table a3 provides the corresponding icd code numbers analysis mortality rates by educational level and occupational class were directly age standardised using the european standard population 15 all analyses for education were restricted to the age range 3579 years and those for occupation restricted to the age range 3564 years most countries classified person years and deaths by age at death but slovenia classified person years and deaths by age at baseline for slovenia an adjustment was applied which was a further refinement of a procedure developed and validated within the eurogbdse study 16 data were available per five year period changes in mortality by educational group or occupational class were determined by quantifying absolute change and percentage change between the approximate periods 199094 and 200509 we studied changes in the magnitude of both relative and absolute inequalities using the easily interpretable measures of the rate ratio and rate difference these measures were calculated from the age standardised mortality rates in the lowest and highest socioeconomic group we determined 95 confidence intervals using parametric bootstrapping for each age standardised rate we first calculated its distribution by drawing for each age group and in 1000 replicas numbers from a poisson distribution with the observed number of deaths as parameter these replicas of each age standardised rate were then used to calculate replicas of rate ratios and rate differences from which confidence intervals and p values were derived we plotted countries changes in rate ratios and rate differences in a two dimensional graph 17 we also calculated relative indices of inequality and slope indices of inequality by education but because results were generally in agreement with those on the basis of rate ratios and rate differences we reported these in web table a6 patient involvement no patients were involved in setting the research question or the outcome measures nor were they involved in developing plans for design or implementation of the study no patients were asked to advise on interpretation or writing up of results there are no plans to disseminate the results of the research to study participants or the relevant patient community results figures 1 and 2 and web fig a1 presents changes in all cause mortality among the low and high educated groups apart from lithuania the trend in all cause mortality has been clearly downward among both low and high educated absolute and relative declines have generally been larger among men than among women and while relative declines have almost always been larger among the high educated than the low educated absolute declines were often largest among the low educated particularly among men tables 1 and2 show how these changes in mortality have played out in terms of inequalities in mortality absolute inequalities in mortality among men fell in sweden scotland england and wales switzerland and spain but went up in lithuania changes in absolute inequalities in mortality were less favourable among women with increases observed in finland norway and again lithuania by contrast relative inequalities in all cause mortality mostly went up although these increases were not always significant similar patterns were found with relative indices of inequality and slope indices of inequality figure 3 presents a more comprehensive picture of progress of countries in reducing absolute and relative inequalities in mortality a countrys position in the lower left hand quadrant implies that owing to larger absolute and relative mortality declines in the lower socioeconomic groups both absolute and relative inequalities in mortality have decreased over time this optimal situation was only seen for women in spain although the reduction of relative inequalities was not significant for men most countries were in the upper left hand quadrant of fig 3 implying declining absolute inequalities in mortality in finland sweden norway scotland and england and wales ischaemic heart disease contributed substantially to declining absolute inequalities in mortality among both men and women smoking related causes contributed to declining absolute inequalities in mortality in many countries among men but only in a few countries among women causes of death amenable to medical intervention contributed to decreasing absolute inequalities in mortality in many countries but serious setbacks occurred for alcohol related mortality in finland england and wales and slovenia with mortality rising more among low educated groups than among high educated groups web fig a2 and web tables a6 and a7 present results for occupational class inequalities in mortality in general terms patterns were similar to those seen for educational inequalities absolute declines in mortality were larger among men with manual occupations than among men with nonmanual occupations in most countries with absolute inequalities decreasing as a result however relative declines were larger among men with nonmanual occupations than those with manual occupations with relative inequalities going up country by country however we saw some differences between educational and occupational class inequalities with absolute inequalities in finland being stable by education but narrowing by occupational class and those in italy narrowing for education but widening by occupational class cause specific patterns were also similar discussion main findings in this study we saw substantial reductions in mortality in lower socioeconomic groups in most european countries for which data on socioeconomic inequalities in mortality were available for the approximate period strengths and limitations to our knowledge this is the most comprehensive analysis of trends in inequalities in mortality ever conducted covering roughly two decades and at least 10 countries however its broad international scope inevitably raises issues of data comparability for spain and italy only urban and relatively prosperous populations could be included recent national level studies from spain 18 and italy 19 as well as older comparative studies including national level data from these countries 20 also found relatively small inequalities in spain and italy thus there is no reason to think that our study misrepresents the situation in these two countries furthermore because the lithuanian data did not include deaths between age 70 and 79 years we probably underestimated absolute inequalities in mortality in this country the length of time covered by our analysis also differed between countries the longest being in lithuania and shortest in france this could have contributed to the relatively poor results seen for france in england and wales the low educated group could not be distinguished from the mid educated group in the 1991 census although we had previously shown that this does not bias the comparison between england and wales and other countries of trends over time 7 results for england and wales should be treated with caution but the fact that changes of absolute inequalities by occupational class were also favourable lends support to our observation on inequalities by education certification and coding of causes of death vary between countries and a substantial underestimation of ischaemic heart disease in official mortality statistics had been reported for france 21 even if such underestimation does not differ between socioeconomic groups and does not affect estimates of relative inequalities in mortality it will affect estimates of absolute inequalities in mortality from ischaemic heart disease another strength of our paper is that we could include both education and occupational class as indicators of socioeconomic position at least for men although the results were broadly similar and confirmed a tendency for absolute inequalities among men to narrow for both education and occupational class we did observe some differences between countries these differences could have been due to problems in classification particularly for occupational class but there could have also been substantive explanations between the low and high educated was calculated as road traffic accident data were not available for scotland and slovenia over the two decades of this study there has been a strong decline in the size of the lower education and occupational class groups because a smaller size may imply a more extreme social positionwhich could in itself lead to a wider gap in mortalitywe also studied relative and slope indices of inequality that make adjustments for such changes 8 patterns of changes were similar to those reported in this paper with absolute inequalities in mortality narrowing in many countries among men and relative inequalities widening almost everywhere among both men and women but changes in relative and slope indices of inequality were often more favourable as a result of the decreasing proportion of the low educated groups in all populations furthermore results from finland indicated that trends in mortality inequality by incomefor which percentile groups can be used that help to circumvent distributional changecorresponded well with results obtained for education 22 however relative and slope indices of inequality do not adjust for changes in composition of lower and higher educated groupsfor example for the fact that lower educated groups are likely to have become more homogeneous with regard to various forms of personal and social disadvantage 23 these changes made it all the more noteworthy that we mostly found favourable mortality trends among low educated groups finally our study covered adult ages between 35 and 79 years implying that the many deaths occurring at higher ages were not included and neither were deaths at younger ages for which trends and contributing causes might partly be different 24 interpretation our results show that in a context of declining mortality a narrowing of relative inequalities is very rare but a narrowing of absolute inequalities in mortality is not policy makers are therefore more likely to achieve their quantitative targets if they aim to reduce absolute inequalities indeed over the past few decades spain scotland england and wales and italy have achieved a 2035 reduction of absolute inequalities in mortality among both men and women although the concurrent but modest rise in relative inequalities implies that closing the gap in a generation 1 might well be an elusive goal even in these countries it is a highly valuable achievement historical evidence on the reduction of inequalities in mortality from infectious diseases such as tuberculosis also supports the view that what we can hope for is a reduction of absolute not relative inequalities in mortality 25 how have these reductions been achieved several of the countries represented in this study have developed and implemented national programmes to tackle health inequalities during the study period foremost among these countries is england which has between 1997 and 2010 carried out an ambitious and comprehensive programme to reduce inequalities in health 26 england has been followed with some delay by other countries that have all developed and implemented national strategies to reduce health inequalities all the other countries in our study have shown far less commitment to reducing health inequalities 27 as seen in fig 3 countries with and without national strategies to reduce health inequalities do not systematically differ in their mortality inequality trends furthermore the narrowing of absolute inequalities in england and wales started long before 1997 and evaluations of the impact of the english programme to reduce health inequalities have not produced clear evidence for its effectiveness 28 our cause specific results also suggest that the reductions in absolute inequalities in mortality are a byproduct of population wide improvements in prevention and treatment absolute declines in mortality were almost always larger in lower socioeconomic groups than in higher socioeconomic groups for ischaemic heart disease smoking related causes and causes amenable to medical intervention for ischaemic heart disease these trends must be due to more favourable changes in either proximate determinants of ischaemic heart diseasesuch as health related behaviours or healthcare effectiveness or bothamong low educated groups compared with high educated groups a recent narrowing of absolute inequalities in cardiovascular disease mortality has been reported for both england and scotland and has been attributed to an even distribution of treatment benefits rather than to risk factor changes 29 30 recent evidence for other countries is missing absolute inequalities in smoking related mortality have also been decreasing among men in many european countries as we have shown above and report in more detail elsewhere 31 these reductions reflect long term declines in smoking prevalence which are probably due to the delayed effects of health education campaigns and other attempts to reduce smoking in the 1980s and 1990s although modern tobacco control efforts have done little to reduce inequalities in smoking 32 it is heartening that reductions in smoking prevalence are finally paying off in smaller inequalities in smoking related mortality among men one possible explanation for the less favourable trends of mortality inequalities among women is that the mortality impact of smoking and of smoking related inequalities is still increasing among women in many countries 33 the only countries where a downward effect in smoking related causes on inequalities in mortality is already seen among women are scotland and england and wales another encouraging finding is the decline of absolute inequalities in mortality from conditions amenable to medical intervention it is likely that this decline reflects substantial improvements among lower socioeconomic groups in prevention and treatment of these conditions which range from infectious diseases to cervical cancer and hodgkins disease and from cerebrovascular disease to perinatal mortality previous studies have found large socioeconomic inequalities in mortality from these conditions and attributed these differences to inequalities in access or quality of medical care 34 our findings suggest either that these inequalities in access or quality of medical care have diminished over time or that further improvements in medical care have reached all social strata of the population despite continuing inequalities in access or quality in both cases it is good news that medical care has contributed to a narrowing of inequalities in mortality in many european countries real setbacks have occurred for alcohol related mortality widening inequalities in mortality from alcohol related mortality as seen in the north and east of europe reflect stronger increases in mortality from these conditions in lower socioeconomic groups than in higher socioeconomic groups over the past half century alcohol control has become less strict in some countries in the north or europe but more strict in the south of europe 35 this difference in control could have contributed to rising inequalities in the northern but not the southern countries 13 increased affordability of alcoholic drinks might also have had a role 36 inequalities in mortality in lithuania have increased substantially during the study period which has been due to a combination of rising mortality among the low educated and stable mortality among the high educated it is likely that these unfavourable developments were caused by the economic crisis and the subsequent economic reforms that followed the collapse of the soviet union in the early 1990s lithuania experienced large declines in national income and large increases in unemployment rates more so than other eastern european countries that had not been part of the soviet union 37 our results point to an important contribution of mortality from smoking related alcohol related and amenable conditions to the widening gap in all cause mortality in lithuania these results suggest that behavioural factors as well as problems in access and quality of medical care have been key in mediating the widening of the gap in mortality it is good to see that absolute inequalities in mortality have narrowed in several countries but how could relative inequalities decrease as well one suggested approach to reducing health inequalities is proportionate universalism 38 defined as universal action with a proportionate element tailored to the level of disadvantage or need experienced by middle and lower socioeconomic groups 39 this approach could reduce inequality across the gradient instead of between top and bottom only however whether proportionate universalism will be sufficient to achieve larger reductions in relative mortality in lower socioeconomic groups than in higher socioeconomic groups will depend on how disadvantage or need is measured allocating resources proportional to the current levels of morbidity or mortality by socioeconomic group will be insufficient because outcomes of interventions are usually worse in lower socioeconomic groups 40 to reverse this it will be necessary to measure need in more radical termsthat is doing what is necessary to achieve larger declines in relative mortality in lower socioeconomic groups than in higher socioeconomic groups this approach would require a much larger redistribution of healthcare and other welfare resources from higher to lower socioeconomic groups than has been realised in even the most advanced european welfare states apart from lithuania all european countries in this analysis have had strong mortality declines in lower socioeconomic groups among both men and women this result is all the more remarkable as reports from the united states have shown less favourable developments with increasing mortality rates among lower educated white women and possibly reduced life expectancy among lower educated white men and women 41 it also remains to be seen whether the favourable developments seen in europe will continue during and after the economic crisis starting in 2008 from which the effects cannot yet be discerned in our data conclusions trends in inequalities in mortality have been more favourable than commonly assumed absolute inequalities have been reduced in several countries probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment than as an effect of policies explicitly aimed at reducing health inequalities contributors jpm conceptualised the study participated in the analysis and wrote the first and final drafts of the paper ba mb cb tc gc cd rk ol pm gm oo rp mrs and bhs prepared data and commented on the paper ik cwnl and rdg participated in the analysis and commented on the paper all authors approved the final version jpm acts as guarantor of the study funding supported by a grant from the european commission research and innovation directorate general as part of the developing methodologies to reduce inequalities in the determinants of health project the sponsor had no role in the study design in the collection analysis and interpretation of

to determine whether government efforts in reducing inequalities in health in european countries have actually made a difference to mortality inequalities by socioeconomic groupregister based studymortality data by level of education and occupational class in the period 19902010 usually collected in a census linked longitudinal study design we compared changes in mortality between the lowest and highest socioeconomic groups and calculated their effect on absolute and relative inequalities in mortality measured as rate differences and rate ratios respectively setting all european countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010 these included finland norway sweden scotland england and wales data applied to both together france switzerland spain barcelona italy turin slovenia and lithuania results substantial mortality declines occurred in lower socioeconomic groups in most european countries covered by this study relative inequalities in mortality widened almost universally because percentage declines were usually smaller in lower socioeconomic groups however as absolute declines were often smaller in higher socioeconomic groups absolute inequalities narrowed by up to 35 particularly among men narrowing was partly driven by ischaemic heart disease smoking related causes and causes amenable to medical intervention progress in reducing absolute inequalities was greatest in spain barcelona scotland england and wales and italy turin and absent in finland and norway more detailed studies preferably using individual level data are necessary to identify the causes of these variationsover the past two decades trends in inequalities in mortality have been more favourable in most european countries than is commonly assumed absolute inequalities have decreased in several countries probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment than as an effect of policies explicitly aimed at reducing health inequalities

background although ethiopia has advocated for all mothers to give birth in a health facility in an effort to combat high maternal mortality rates 1 the maternal mortality ratio in ethiopia remains one of the highest in subsaharan africa furthermore the ethiopian demographic and health survey has indicated no marked decline in recent years reporting an mmr of 673 maternal deaths per 100000 live births in 2005 and virtually the same rate 676 maternal deaths per 100000 live births in 2011 23 ethiopia is one of the least urbanized countries in the world with only 16 of the total population living in urban areas posing considerable access issues on the majority of the population 34 related disparities persist between rural and urban populationsfor example the likelihood of urban women giving birth in a health facility was 46 times that of rural women in 2011 signifying only a slightly lower discrepancy than in 2000 5 similarly ethiopia has a total fertility rate of 48 children per woman yet the tfr in rural areas is nearly three children per woman higher than in urban areas 3 in the southern nations nationalities and peoples region of ethiopia in which 90 of the population lives in a rural area only 14 of the 184 health facilities perform all seven basic signal functions of emergency obstetric and newborn care and closer proximity to these care facilities has been linked to lower estimates of neonatal mortality 6 moreover while the underfive mortality rate in ethiopia has declined by twothirds achieving millennium development goal 4 neonatal mortality which comprises roughly 50 of all infant deaths in ethiopia remains high at 37 deaths per 1000 live births without significant decline in the past ten years 237 it is well documented that infant and under five survival is highly correlated with child nutrition and other important child health care practices attributable to maternal involvement and prioritization of child health 8 9 10 for example early and exclusive breastfeeding a nutritional advantage only a mother can provide has been shown to substantially lower the risk of neonatal death 8 routine immunization another critical health care practice which mothers prioritize has similarly been associated with a reduced risk of infant mortality 10 associations between maternal death and long term child health and survival however are less understood a growing body of literature is exploring the catastrophic effects of maternal death loss of the primary caregiver on older children in addition to newborns and infants 11 12 13 14 15 16 the costs of maternal deaths on living children family and other dependents are widespread impacting future generations of individuals as well as overall wellbeing and economic progress at the country level to this effect evidence has shown that investing in the prevention of maternal mortality through the prioritization of the education empowerment and sexual and reproductive health and rights of women and girls is a cost effective intervention 17 saving the lives and promoting the livelihoods of mothers children and families 18 though the magnitude of maternal death in ethiopia has been documented 2 3 4 7 the true toll of maternal mortality is undervalued and longterm impacts on children families and communities have yet to be adequately explored in order to contribute to the growing body of literature aimed at documenting these impacts a four country mixed methods study including south africa malawi tanzania and ethiopia was undertaken this paper presents qualitative findings from the butajira ethiopia study site and demonstrates the extensive impact of maternal mortality on orphaned children methodology study site design and participants the data presented here documents the impact of maternal deaths on living children in one of the oldest demographic surveillance system sites butajira rural health program in butajira ethiopia butajira is a rural district situated in the former meskan and marko districts in the southern nations nationalities and peoples regional state approximately 130 kilometers from addis ababa the butajira rural health program was initiated in 1986 to collect longitudinal demographic and health data and covers a population of 74407 individuals comprising 12407 households 19 within nine rural and one urban kebeles 20 this study employed indepth qualitative research methods in five kebeles serviced by the brhp bati dirama misrak meskan dobena and butajira town k04 nine health posts provide most primary and preventive health services to the population though three health centers and two hospitals also service the area along with this qualitative study results from a quantitative analysis on the impact of maternal mortality using twentyfive years of brhp dss data have been published elsewhere 21 the inclusion criterion was defined as the death of a woman during pregnancy childbirth or 42 days following the termination of the pregnancy as per who standards 14 data collection occurred between august and october 2013 patient records from butajira zonal hospital were used to identify women who had died from maternal causes snowball sampling was then used to identify family members of these women among the 28 maternal deaths captured only one woman was divorced while 5 were in polygamous marriages and the rest were in monogamous marriages most women had either primary or secondary education and delivered at home fourteen women were aged between 3039 and nine left behind 35 children topics covered in interviews with family members included general socioeconomic characteristics of the family drivers of maternal mortality and the impacts on the children and family and availability and accessibility of services for maternal orphans if there was more than one child orphaned due to a maternal death the impacts of the mothers death on each child were discussed two sexstratified focus group discussions were conducted in each of five kebeles totaling 87 participants roughly eight people participated in each fgd fgd participants were identified using purposive sampling and included teachers traditional birth attendants religious leaders community health workers community leaders farmers and other community members topics covered in the fgds included differences between families who were and were not affected by maternal mortality impact of maternal deaths on living children from infancy through adolescence and resilience additionally thirteen stakeholder interviews were conducted focusing on policies and programs available for maternal orphans and challenges for implementing such programs and policies such as financial issues and political will data collection all data collection tools were prepared by the harvard school of public health in english and translated into amharic by a professional translator the interviews were conducted by four lecturers from addis ababa university all indepth interviews and fgds were conducted in a place selected by participants that provided optimum privacy each indepth interview and focus group took between 15 and two hours to complete family member and focus group participants also received 100 ethiopian birr for the time spent all interviews and focus group discussions were transcribed from the digital recording and translated into english by an experienced professional data analysis and interpretation all interviews were imported and coded using nvivo 10 qualitative analysis software 22 the interviews were coded independently using an inductive approach by two members of the research team and discussed for differences and emerging codes the findings were analyzed using phenomenological approach where meanings were assigned as per the informants representation of the phenomenon salient quotes were used to express the experiences and perceptions of the informants ethics statement study protocols were approved by the harvard school of public health institutional review board and by the addis ababa university college of health sciences institutional review board informed consent was read aloud verbatim by the research assistant or interviewers and all participants consented through either a signature or thumb print results household changes caregiving and poverty unlike in malawi south africa or tanzania 131516 we were not informed of any formal procedures regarding the care or placement of children with family members following a maternal death in butajira however according to study participants fathers rarely take on child care responsibilities following the death of a wife in butajira common roles for women include providing child care caring for the home cooking and generating supplemental income by selling handicrafts or agricultural products from their gardens while men primarily carry the responsibility of earning income in farming this gendered division of household duties leaves fathers unprepared to assume caregiving responsibilities and fulfill the needs of the family without support following a maternal death husbands reported that their capacity in handling their families was halved because of their wives deaths as one informant described i am hurt i had sold my land and i am renting the rest i only have this land am still in grief my late wife used to support me by taking care of the household chores and also she used to sell khat and cabbage… the effects of losing any supplemental income generated by their wives compounded by extensive funeral costs and time spent away from work for funeral ceremonies often transformed a familys economic outlook funeral costs rapidly deplete a familys available resources and force households to utilize reserves that have been saved up over time or sell valuable often incomeearning assets leaving families in substantially lower economic positions than they were prior to the maternal death 2324 as this informant shared it the reason why i stopped farming and am now renting my land is because of the condition of our life and the weather conditions were not good so the production became less and when we became short financially to afford the necessary things i rented the land out but before her death we used to support each other to fulfill our needs life is not as easy when you lead it alone as when you have a partner half of the family members interviewed described situations in which families were given support by family on the maternal or paternal side including taking childcare responsibilities on completely or providing housing cooking material goods such as clothing or school exercise books and money and eight described situations in which financial andor emotional support was offered by the surrounding community this support while often critical to the health and wellbeing of the family suffering a loss diminishes the supporting familys capacity to meet their own needs as this grandmother supporting her sons infant child explained i used to work in the market but i cannot go out of the house now as i have to take care of the newborn one of my daughters had also dropped out of school to help me remarriage following a maternal death came up in many interviews as a contested issue while remarriage is seen as an option for offsetting the burden of child and household care responsibilities that fathers and supporting family and community members feel following a mothers death participants explained that in practice bringing a new wife into the home often leads to family disputes regarding the division household labor both between children and their stepmothers and between husbands and their new wives some participants perceived stepmothers as likely to mistreat orphaned children especially if they have biological children of their own to care for only three participants relayed positive experiences or opinions regarding relationships with stepmothers whereas fifteen shared negative opinions or personal experiences of stepmothers refusing to provide care to children or more often of frequent arguments at home between stepmothers and step children as this father explained she stepmother was good but her behavior has changed since she had her own kid the children maternal orphans argue with her most of the time when i father try to mediate they say she is not fair she gives more food for her children than us i am planning to send the older one to addis he may lead a better life there as noted girl children are often forced to fill their mothers role in the home following a maternal death even at a young age and at the expense of an education because fathers do not tend to take on what are considered female responsibilities following a maternal death one father explained that because he had to attend to farming and there was no one to look after the house following his wifes death his daughter had to drop out of school to take on those responsibilities and got married three years later never returning to her studies one focus group participant described the household responsibilities that girl children take on as follows its obvious if she doesnt have a mother its she who will do everything everything that her mother used to do males they dont spend much time at home and they expect a lot from her its her who will discuss with the father on the subject of buying something for the house boiling coffe etc she is responsible for everything…if the daughter in the family is old enough to do some house works she will be the one in charge she will clean the house clothes dishes etc we also were informed on multiple occasions of older daughters dropping out of school in order to work and contribute to the familys income while this occurrence is not unique to families who have lost a mother participants felt that the impacts of these situations on children were worsened when they did not have a mother versus a father i know of man with similar cases for instance the mother is not alive so the father is raising the children and the older daughters are working as maids in this town and when we compare families who lost the mother with families who lost the father the one who lost the mother suffers more than the other one impact on neonatal survival while fourteen infants were born alive to the 28 women who died from maternal causes only 3 survived to 6 months according to key informants and fgd participants causes of neonatal deaths in the community were mainly lack of proper feeding especially breast feeding due to lack of a mother most family members interviewed indicated that formula was unaffordable and while health facilities provided the feeding supplement plumpy nut for free caretakers reported using it for primary rather than supplemental feeding and observed that as such it had a limited effect on child survival participants uniformly expressed that the growth and nutrition of children who were breastfed and cared for by their mothers was exponentially greater than that of orphaned children but in general whatever kind of good treatment he is receiving a kid who lost his mom and a kid who lives with his mom cannot be the same if his mother is alive the kid could grow with health receiving simply his moms breath breast feeding and her warmth participants reported using a mixture of infant feeding types such as cow and goats milk powdered milk formula and community members breast milk to feed maternal orphans six participants mentioned foods not suitable for infants such as cabbage tea and traditional dishes such as mitin which is comprised of sorghum peas teff flour and barley interestingly while participants generally felt that breastfeeding maternal orphans by grandmothers female relatives or other breastfeeding women in the community was a common and beneficial practice a few felt that using mixed breast milk to feed infants was harmful to infants causing ill health one family member specifically noted the danger of transmitting disease via breast milk while others attributed poor infant health generally to being fed by multiple women the reason why his body has swollen was because he breast fed by numerous women had he got his mothers breast milk that would have not been the case he was breastfed by many women just because they wanted to save his life and he was not felt well anyway being breastfed by numerous women is not goodhealthy health and health care seeking in addition to the financial and household related burdens felt by a family following a maternal death stakeholders family members and focus group participants described differences in child health and health care seeking for families who have and have not experienced a maternal death no one will bother and take a child to health institution at exact time for immunization so its day for immunization will be forgotten and pass unless a mother is alive a mother will wash feed and immunize her child in a timely manner which couldnt be true for any other person me myself if i had a child i will never leave him for a moment and give all necessary care every time but if i raise others child i will not bother as i do for my child as the focus group participant cited above notes even stepmothers and female care givers who step in to help a family following a maternal death will not prioritize the health of maternal orphans the same way they will for their own children several male caregivers explained that they often delay seeking health care for their children hoping that they will get better on their own and therefore will not need costly medical treatments which become more challenging to afford due to the loss of income generated and funeral ceremony costs incurred following a maternal death as one father explained a when his case worsens i take him to the hospital these days it is better q so you spent a lot for medical fees a yes a lot q did you have to sell anything to take the baby to the hospital a yes q what did you sell for example to provide milk etc… a yes we had an ox we sold it moreover prior negative experiences at the facility levelsuch as perceived inadequate care and multiple transfersas well as costs incurred paying for services and traveling to and from facilities led to further hesitations to seek care at the community level as one stakeholder explained to tell the truth there is nobody who hates comfort it is because of financial problem it is those who have financial problem that do not want to give birth at health facility though poverty affects the majority of families in the study area and while women are often unable to access maternal health care due to intersecting barriers of poverty distance to the health facility and lack of decision making power participants consistently explained that when mothers are alive they make every effort to get their children the health care that they need even if they are not the primary decision makers for the family as they often are not as this key informant stated a mother is everything for a family father may think for his family but not as mother does when a child gets sick she will notice and take him or her to the health institution or raise the idea to take him or her as prompt as possible with the father as reflected in this and other emerging themes related to migration and education of orphan children when children lose their mother they lose their primary advocate impacts on older children education early marriage and migration as previously described girl children were more likely to drop out of school following the death of a mother given cultural gender norms regarding men and womens roles however participants described additional circumstances that commonly necessitate school drop out for boy and girl children for example though school is free in rural ethiopia educational costs related to clothing exercise books pens etc prevented children from attending school while older girl children dropped out to care for younger siblings and take care of the house boy children were required to help their fathers or caretakers in manual labor such as farming which prevented them from studying and eventually led to drop out as this family member described had their mother been alive for example they would not be going to look after the cattle also they would have been studying after they came back from school they could get a better education too they are not learning as they are supposed to because of her absence again the theme of a mothers love and guidance permeated discussions of education participants explained that without a mother to provide encouragement or to prioritize childrens nutrition at home children lost motivation to attend school they come back from school and cant find food because their mother isnt around they cant learn and are hungry and thirsty and their morale is reduced i think…he could be a bright student but his mother is not there to tell him to study etc…for example i am ignorant but i come from an educated family my mother loved it when her children studied and she managed to do some trade and send them to school… migration to work in major cities in the region or in middle eastern countries was another common outcome for children following a maternal death for girls and boys in interviews with family members we heard of nine children who migrated out of butajira for work 3 of whom were male though specific jobs were not always disclosed working in food service or as a house maid was reportedly common participants described situations in which children asked to be sent by their families to work in the middle east in order to make money andor leave tenuous relationships with stepmothers behind as well as situations in which guardians made the decision to send their children because they couldnt afford to send them to school or felt that working abroad offered them the best financial outlook though migration for work is a common occurrence amongst poor youth in the region participants shared that losing a mother greatly contributed to a childs likelihood of migration had her mother been alive she could have been enjoying her mothers love here… also she wouldnt have gone abroad available support our findings indicated that there was no structured support system for maternal orphans stakeholder informants described that while various ngos offer support systems for children they are mostly directed to orphans from hiv and are neither well organized nor systematized as different ngos cover different geographic areas and take different approaches to their programming a stakeholder from one of the ministries indicated the lack of systematic response as follows though the country has adopted a child protection policy it is poorly implemented and there is no coordination among sectors child health and social protection programs and policies do not overlap as this stakeholder went on to explain while health extension workers have the capacity to conduct household assessments following a maternal death they face competing service delivery priorities and which limit their involvement with communities coordinated efforts between health facilities ngos ministries and communities cutting across health and social welfare are needed to prevent maternal orphans from slipping through the cracks in addition to this however several stakeholders also mentioned the need to improve quality at health facilities to prevent maternal deaths in the first place according to one stakeholder at the facility level what i want to say is that the government policy is good but the nurses and midwifes also other professionals have to get additional trainings in order to made them fit right now there is a problem of quality but not quantity a lot of things have to be done by the midwifes and by the nurses in order not to make mothers die we have to be able to refer the mothers immediately after detecting the risks when they are on antinatal care and this is done in every health facility so i believe that there is a quality problem on the professionals discussion this study has highlighted the burden which families and children face following a maternal death without a mother newborns and children face nutrition deficits impacting their survival and growth and older children drop out of school to care for younger siblings and contribute to household and farm labor which is often beyond their capacity and age and often choose early marriage or migration in search of better opportunities family fragmentation is common following maternal death leading to tenuous relationships within a household with the births and prioritization of additional children further stretching limited financial resources our finding regarding suboptimal infant feeding practices among maternal orphans supports existing literature from low resource settings 81125 moreover a recent communitybased nested case control study in rural east ethiopia found that children whose parents did not jointly decide on the treatment of a sick child mothers lack of facility access and nonexclusive breastfeeding were significantly more likely to experience wasting 26 considering that maternal mortality exacerbates each of the aforementioned predictors it is reasonable to hypothesize that maternal orphans face worse odds of malnutrition and wasting underpinning all themes uncovered in our analysis was the perception of mothers as the primary nurturers of and advocates for their children participants continually stated that the lives and opportunities for their children would have been greatly improved had their mothers lived these sentiments compliment research that has begun to more rigorously investigate the role that womens agency plays in child health a casecontrol study in butajira found low decision making capacity of women to be associated with three fold greater odds of underfive mortality in adjusted analyses 27 similarly a recent study on emonc access in the snnp region found differences in maternal autonomy to contribute to overall and socioeconomic inequalities in early neonatal mortality 6 we found that following a maternal death children may be separated placed with various relatives or remain under the care of their father and sometimes stepmother where to place children appears to be a complicated question depending upon multiple factors such as family size and connectedness economic status distance fathers marital status and the ages of the children left behind research from the amhara and oromia regions of ethiopia suggests that newborns are not valued until the 40 th day of life 28 which may be related to the lack of standard or formal decision making processes regarding the placement of children as well as to our finding of heightened neonatal mortality following a maternal death we also saw that men as a result of defined traditional gender roles are generally unable to assume household responsibilities in the absence of their wives as they have never been involved in chores or childcare and are consequently illequipped to incorporate these tasks into their daily routines as a result orphaned girls are the first line victims who drop out of school to substitute for their mothers in caring for their younger siblings and tending to household chores other studies similarly showed that young girls in the region including orphans are often forced to prioritize household labor and childcare over education impacting future economic opportunities 132930 though labor migration is not specific to maternal orphans key informants indicated that migration was often viewed as choice made by girls andor their families to escape the overwhelming household responsibilities put on them following a maternal death a study conducted to assess female international labor migration in ethiopia also cites the unfair division of domestic responsibilities and traditional gender roles as contributing factors for girls dropping out of school early and subsequently traveling to the middle east to find work in the informal labor market 29 while the ability to travel to arab countries to work is often perceived as an advantage because these countries are much wealthier than ethiopia and hold the promise of wellpaid opportunities the majority of the girls and women who migrate to the middle east do so through illegal channels and are exploited and abused upon reaching their destination 29 this reality is unknown to many ethiopian families who are misinformed and view this as a chance for girls and women to earn their own living and provide money to their families rather than a source of family fragmentation 29 this study is not without limitations qualitative study findings are not generalizable outside of the study population and our small sample size and study design eliminate our ability to examine questions of causality however these findings contribute to a growing literature that is documenting the impacts of maternal mortality in developing countries this is the first study of its kind in ethiopia and study findings are consistent with other emerging evidence 12 13 14 162131 solidifying their importance in shaping future development priorities after the millennium development goals conclusions in addition to the need to improve services aimed at mitigating impacts of maternal death on children such as enhancing systemic linkages between health and social welfare programs and strengthening social protection schemes to better address the needs of vulnerable children and families our findings support the need to redouble efforts to combat maternal deaths which are the root cause of the impacts on families and children documented here maternal mortality is a human tragedy that could be averted through widespread provision of emergency obstetric and neonatal care skilled birth attendance and increased use of contraceptive methods 3233 while interventions targeting safer pregnancy and childbirth have been evidenced in many resourcepoor countries including ethiopia 17 90 of women delivered at home in 2011 3 eliminating inequalities in womens access to fully equipped facilities 56 and improving womens perceptions of facility delivery through the promotion of respectful maternity care for example 34 35 36 are imperative to closing the gap in excess mortality globally among poor women of reproductive age until the value of women as irreplaceable pillars of families and communities is recognized we will continue to see the devastating ripple effects of their deaths play out in the lives of their children peer review reviewer reports for this article can be found in additional file 1 additional material additional file 1 competing interests the authors of this paper have no conflicts of interest to report

the consequences of maternal mortality on orphaned children and the family members who support them are dramatic especially in countries that have high maternal mortality like ethiopia as part of a four country mixedmethods study ethiopia malawi south africa and tanzania qualitative data were collected in butajira ethiopia with the aim of exploring the far reaching consequences of maternal deaths on families and children methods we conducted interviews with 28 adult family members of women who died from maternal causes as well as 13 stakeholders government officials civil society and a un agency and held 10 focus group discussions with 87 community members data were analyzed using nvivo10 software for qualitative analysis results we found that newborns and children whose mothers died from maternal causes face nutrition deficits and are less likely to access needed health care than children with living mothers older children drop out of school to care for younger siblings and contribute to household and farm labor which may be beyond their capacity and age and often choose migration in search of better opportunities family fragmentation is common following maternal death leading to tenuous relationships within a household with the births and prioritization of additional children further stretching limited financial resources currently there is no formal standardized support system for families caring for vulnerable children in ethiopia conclusions impacts of maternal mortality on children are farreaching and have the potential to last into adulthood coordinated multisectorial efforts towards mitigating the impacts on children and families following a maternal death are lacking in order to prevent impacts on children and families efforts targeting maternal mortality must address inequalities in access to care at the community facility and policy levels

introduction within organization and management theory visual framing efforts such as media campaigns product design and headquarter architecture represent an important yet broadly overlooked dimension in organizations attempts to construct meaning in and around their organizations a recent line of work has brought attention to our limited understanding of the role of visuals and points to visuals as exceptionally useful means to entice audiences and gain legitimacy visuals are widely used by activists and organizations in their framing efforts to evoke strong emotions in their audiences and mobilize support for their political agenda in relation to social issues this work on framing within the social movement literature suggests that visuals increase audience engagement and enhance the legitimacy of the message therefore visuals often play a central role in framing the socially situated process of meaning construction visuals and visual framing efforts may thus enhance the effect of organizations attempts to influence internal and external audiences understandings of social issues still organizational research exploring how visuals contribute to organizations framing efforts in relation to a social issue is limited in the social movement literature on framing researchers have started to explore the role that visuals may play in the mobilization diffusion and framing of issues to advance such insights researchers are proposing ways in which visuals and visual framing could be analyzed focusing on identity or mobilization or explicitly considering frames and framing currently however this literature includes little empirical research that probes into how issues may be framed through the use of visuals in organizational and institutional theory scholars have explored framing efforts contestation struggles over meaning and identity work in issue fields issue fields are constituted by the various actors engaged with a specific issue such as corporate environmentalism this work on issue fields has primarily focused on fieldlevel contestation comparing the framing and counterframing efforts of the various actors due to the field level emphasis this work has primarily focused on the content of different competing frames within an issue field and has payed less attention to the strategies used by the individual actors within the field still the study by lefsrud and meyer proposed that different verbal rhetorical legitimation strategies may be used to establish expert legitimacy within an issue field this work does not however consider the role that visuals may play in the framing of issues by focusing on a single organizations visual framing efforts in an issue field it is feasible to study and detail how visuals may contribute to the framing of an issue here i address the following research question how do visuals contribute to framing an issue and establishing a collective organization as an expert within an issue field a collective organization can be broadly defined as a type of umbrella or metaorganization with other organizations as members or supporters set up to tackle an issue of shared concern the empirical focus of this article is on issuebased industry collectives representing a unique form of collective organization ibics are founded and supported by an industry and focus exclusively on engaging with a specific social issue specifically this article presents a case study of the ibic drinkaware a ukbased independent trust supported by 61 alcoholindustry actors including major producers retailers supermarkets and trade associations generally organizations rely on a range of different tactics including campaigning and lobbying to gain influence within an issue field drinkaware qualifies as a critical case as their sole engagement with the issue of alcoholrelated harm is through their educational campaigns which employ visually based communication to a significantly high degree by studying drinkawares framing of the issue of alcoholrelated harm in its campaigns this article emphasizes the role that visuals play in the framing of an issue the study is based on an analysis of drinkawares campaign materials from 20072013 the data analysis was multimodal considering the combined stimuli of the campaign material including both the visual and verbal modes still the role of visuals was the primary focus as the analysis pertains to visual framing the findings show how drinkawares campaign material performs three overall visual framing functions normalizing alcohol consumption defining and delimiting the scope of the issue and the responsible parties and establishing the organizations identity as an expert the study makes three main contributions first it contributes to organizational and institutional theory by providing a systematic elaboration of the visual framing functions performed by an organizations campaign material second the study contributes to the literature on issues and issue fields by showing how the issue was defined and delimited in visuals through the subject and through the use of contrasting moralization and emotional activation third and relatedly the study contributes further to the issues literature by illustrating how visual framing contributed to establishing a collective organizations identity as an expert in an issue field the article proceeds as follows first a theoretical background for the study is provided second the research context and research design are described giving an overview of the issue field around alcoholrelated harm as the empirical context and drinkaware and its campaigns as its visual framing efforts in relation to the issue of alcoholrelated harm third the findings from the study are presented elaborating the role of visuals in issue framing by specifying the visual framing functions and components finally the article concludes with a discussion of the findings and the theoretical implications of this study for future research theoretical context theories of organizations have not yet fully dealt with the role that visuals play in an organizational context recently several calls have been made to pay closer attention to the visual aspect of discourse and meaning in the realm of institutional theory studies on framing have often focused on verbal language however visuals also play an important role in the construction of reality and the formation of public opinion and the visual aspect of communication has certain characteristics that may enhance mitigate or even override the meaning of a verbal text in practice activists and organizational collectives often use visuals in their framing efforts to mobilize support for their political agendas and shape issue fields thus it is important to gain better insights into how visuals contribute to the framing of issues below i outline the theoretical contexts and concepts utilized in this study namely issue fields and social issues framing and visual framing issue fields and social issues an issue field hence issue fields are generally contested as there are several actors attempting to construct and shape the meaning of the issue the aim of this article is to study one central collective organizations construction of an issue to accomplish this i draw on gusfields conceptualization of social issues in my analysis of drinkawares campaign material according to gusfield there are three important aspects to consider in relation to the structure of social issues ownership and two kinds of responsibility actors in an issue field may attempt to gain ownershipthe ability to create and influence the public definition of a problem owners have the legitimacy and authority to make claims and assertions about the issue in question furthermore others look to owners to define and formulate solutions to the social problemissue other groups of actors may attempt to avoid a possible obligation to become involved in solving a specific issue and thus they may deliberately attempt to resist claims that the issue is their responsibility in relation to responsibility gusfield distinguishes between causal and political responsibility the first focuses on the causal aspect of the issue why does this issue exist the latter is a matter of policy what should be done about the issue and who should do it gusfields concepts overlap partly with snow andbenfords diagnostic framing and prognostic framing however i find that gusfields concepts are more clearly centered on actors playing a role in relation to a particular issue both in relation to causing andor solving it which is a key element in drinkawares construction of the issue in its campaigns the aspect of ownership is also particularly useful in relation to this study as drinkawares campaign efforts contribute to establishing drinkaware as an expert in the issue field and potentially gaining some form of ownership of the issue of alcoholrelated harm researchers have proposed various rhetorical legitimation strategies which may be used to establish expert legitimacy such as authorization rationalization moralization or normalization jones et al recently suggested that any visual efforts to establish legitimacy might rely on similar strategies framing the concept of framing has been defined and used in many ways and in different literatures frames are packages of proposals and critiques that highlight certain aspects of a specific issue thereby representing a socially constructed guide to interpretation in the present article the term framing is used to describe the socially situated process of meaning construction with a focus on the specific function of framing efforts framing efforts have a performative and transformative role as they are intended to mobilize potential activists and shape institutional fields or in this case issue fields in an issue field there are always several actors attempting to frame the meaning of the issue consequently the subject of contestation has been a common theme in several studies meyer and höllerer show that different ways of framing an issue are closely related to specific local cultural and sociopolitical contexts moreover lefsrud and meyer explore professionals discursive construction of climate change focusing specifically on the framings and identity work performed by various actors in the issue field they emphasize how actors attempt to frame themselves as experts to attain a favorable position in the issue field and gain influence in this context it is important to note that work on framing tends to focus on frames as content or strategies the work on framing contests outline different frames or framings and thus they primarily address the content of various competing frames here the focus is on strategies more specifically on the function of the visual framing efforts of one organization visual framing work on visuals has suggested that visuals are particularly well suited for framing not only can they obscure issues but they may also appear factual according to meyer et al this is due to the specific way visuals construct reality they appear as iconic representations of reality rather than framed versions of it while work on visual framing is still in its infancy some social movement scholars have focused on the visual expression of social movements and have begun to address the role that visuals may play in mobilization and diffusion some theoretical progress has been made such as doerr and teunes proposed model for visual analysis of social movements this recommends a focus on different forms of expressionthat is of the body object image and graphic designin relation to framing identity or mobilization few studies have been performed however one paper by luhtakallio provides a visual frame analysis of activists contention representations on their websites in finland and france offering one methodological approach to studying visual materialin this case photos in communication and media studies it has also been suggested that visual framing is crucial when it comes to managing key audiences impressions gaining legitimacy and securing competitive positioning this suggests that visuals may also play an important role in issue framing work within this area is rare but in a recent study lefsrud graves phillips analyze a broad range of media ads created by different opponents in the contested issue fields around the alberta oil sands their study shows how actors in the field combine visuals and verbal text in their legitimation struggles to promote or undermine the oil sands industry still we need more work that explores visual framing and its specific underlying functions here i systematically explore how visuals may contribute to the framing of an issue and establishing a collective organizations identity as an expert within an issue field research context and design in this study i explore how the issue of alcoholrelated harm was constructed by the ibic drinkaware first i elaborate on the research context and the significance of the issue of alcoholrelated harm following this i outline my research design and methods research context the issue of alcoholrelated harm and drinkaware as of the mid1990s a new public health movement had emerged it was centered on the promotion of preventive measures to fight existing and developing health threats in order to improve populations quality of life 1 this movement brought with it an increased focus on the health challenges posed by alcohol consumption the concern about which has peaked over the last 10 to15 years figure 1 provides an illustration of this development drawing on the newsbank database this figure shows the keyword pairing of health and alcohol in articles from five top uk newspapers between 2000 and 2013 during this time the pairing of these words increased threefold insert figure 1 around here in tandem with this movement different actors in the alcohol industry have also started to engage with this issue in the context of individual company actions and industry associations as well as in supporting funding and partnering with nonprofit organizations focused explicitly on the issue of alcoholrelated harm since the 1980s the number of ibics dealing with the issue of alcoholrelated harm has increased today more than 30 such organizations operate across 27 countries the ibic drinkaware is an independent trust based in the uk that deals with the issue of alcoholrelated harm drinkaware was set up as a trust in 2007 following a memorandum of understanding between the industry and the government drinkaware was to fulfil the educational campaigning role envisaged in the governments alcohol harm reduction strategy for a fund voluntarily financed by the alcohol industry to tackle the issue of alcoholrelated harm the original aim was to 1 increase awareness of • why and how to drink safely and responsibly and • the impact of alcohol misuse on society and on the health and wellbeing of individuals their families and communities 2 improve attitudes towards • motivation and personal responsibility to drink safely and responsibly and • the unacceptability of binge drinking and drink related disorder 3 effect positive changes in behaviour related to alcohol consumption sic emphasis in original in 2014 drinkaware had 61 funders 2 who had donated £55 million the organization has a staff consisting of 18 employees an independent board of trustees and a medical advisory board the members of the board of trustees have a range of different backgrounds from civil society health and the alcohol industry the medical panel is in place to provide qualified advice that guides the organizations campaigns the large network of supporters enables drinkaware to undertake new and innovative campaign initiatives drinkawares campaigns have a substantial reach especially considering that all funders products carry a health warning label referring to drinkawares website the inclusion of the label is voluntary but it is recommended by the uk government as good practice the site is also prominent in all partners communication materials ie print advertisements websites packaging etc which amounts to around 3 billion marketing pieces annually drinkaware is an extreme case as educational campaigns represent the central means by which it engages with the issue field in fact it is explicitly restrained from engaging in policy lobbying thus visuals are especially significant in drinkawares framing of the issue of alcoholrelated harm and the case has provided me with a unique insight into how visuals contribute to the framing of an issue and establishing a collective organization as an expert in an issue field data collection this article presents findings from an inductive case study insert table 1 around here while the analysis focused on drinkawares campaign material additional data on drinkaware the uk alcohol industry and the issue field were also collected these data which included annual reports website content press releases organizational and campaign reviews and six interviews with key actors in the uk alcohol industry were used as background information to contextualize drinkaware and its campaigns in addition i drew on my knowledge from previous and ongoing research on the international alcohol industry analytical procedures i created an analytical framework that made it possible to analyze a larger set of visual materials with a qualitative emphasis as it builds on ideas from visual frame analysis and recent work in the field of organizational studies therefore when analyzing the campaign material i adopted the assumption that framing involves specific constructions of the issue and packages of proposals and critiques that are aligned to emphasize specific aspects of the issue in my analysis i drew on the literature on social movements and framing and to identify the visual framing of the issue in the campaign material i used ideas and concepts from social semiotics decoding advertisements and rhetoric in the form of aristotles classic modes of argument the modes were used to study how the campaign material visually constructs the issue through the use of logical reasoning persuasion via emotions and by establishing a credible source in my analysis i carried out the following three steps as outlined and defined in table 2 in step 1 the campaign pieces were analyzed as multimodal texts like advertisements the individual pieces are composite visualsthat is visuals that combine verbal visual and graphic elements hence they are multimodal as their meaning is realized via several semiotic codes i treated the different parts as interactive and affecting one another working as elements of an integrated text still the central element in the analysis focused on the specific role of the visual dimension in each of the campaign pieces in step 2 i coded the campaign materials individually according to their rhetorical construction of the issue of alcoholrelated harm in doing so i asked the following empirical questions what is alcohol what is the role of alcohol in society what is the proposed problemsolution who are the central actors i used ideas from rhetoric when studying the constructed modes of arguments and appeal ethos pathos and logos to understand how the meaning of the issue was constructed in the campaigns appeal was further analyzed using williamsons concepts of subject appellation differentiation absence and the identified condensing symbols in step 3 i performed coding across the campaign pieces and compared them exploring general themes and the various visual framing functions all steps were carried out manually insert table 2 findings based on the findings from the case study in this section i elaborate the role of visuals in framing the issue of alcoholrelated harm alcohol as normal excessive drinking problem youth problem parenting problem consistent association with signs of truth and science and performing the role of educator these were grouped into the three overall framing functions of the campaign material normalizing alcohol consumption defining and delimiting the issue and responsible parties and establishing identity as an expert the presentation of the findings is structured around these framing functions which are also outlined in table 4 this table summarizes the findings and a conceptualization of the visual framing components insert table 3 table 4 and figure 2 normalizing alcohol consumption the main rhetoric evident in all the campaign pieces upholds the idea of alcohol consumption as being an aspect of socializinga natural element in a normal life this sense of normalcy is signified in photos by the invocation of tradition and social occasions at which alcohol is often consumed such as at parties during christmas or when relaxing and unwinding on the couch photos depict normal people rather than models and the homes and neighborhoods shown are consistent with average middleclass homes hence as depicted in the visuals the framing of alcohol consumption begins with the signal that the consumption of alcohol is normal on specifically defined occasions the campaign pieces do not condemn alcohol consumption in general but only a certain aspect of itirresponsible drinking overall the main rhetoric is that alcohol consumption is normal but there is also an effort to construct a contrast between responsible and irresponsible drinking the campaign pieces construct a reality in which alcohol consumption is a normal part of socializing irresponsible drinking however is not considered socially acceptable behavior as depicted via both the visual and verbal elements still most of the campaign visuals do not provide a clear distinction between responsible and irresponsible behaviors and the subject must deduce what irresponsible drinking may be the component of contrasting is a central one it is key to drinkawares framing and delimiting of the issue as well as its construction of responsibility the aspect of contrasting will be elaborated further in the following sections defining and delimiting the scope of the issue and the responsible parties here the focus is on how causal and political responsibility are constructed through the campaigns and particularly the distinctive role that visuals play a central aspect of the visual framing is the subject and subject appellation as a sign replaces something for someone it can only mean if it has someone to mean to all signs in the campaign material depend on the individual as subject interpreter and meaning giver for the campaign pieces the subject is created as a specific type of subject by the message in the campaign piece via subject appellation individuals are called upon to identify with the message next i move deeper into how visual framing in the campaigns delimits the scope of the problem as it is defined as an excessive drinking youth or parenting problem respectively the excessive drinking problem many of the campaign materials define the issue of alcoholrelated harm as being a problem of excessive drinking the campaigns target the consumersthe excessive drinkersas the responsible parties the campaigns focus on occasions on which excessive drinking is commonly understood to occur andor tools that may be used by consumers to avoid intoxication before and while consuming alcohol that is water food and the why let the good times go bad mobile application excessive drinking is symbolized through visual cues such as the presence of many bottles empty or halfempty glasses and people who are either sick or sleeping in awkward positions or places signifying that the people have passed out from drinking too much the toolfocused materials feature bottles or glasses of water soft drinks food and even a wingman whose responsibility is to ensure that intoxication does not ruin ones chances with possible partners there is a contrast made between being in or outside a group due to excessive drinking thus the campaigns signal social disapproval and exclusion as the immediate consequences of excessive drinking an alternative reading of at least one of the pictures could also be that passing out carries with it an implicit status as one picture portrays a young man passed out in a bathtub and two young women who are taking pictures and laughing at him the campaigns are moralizing and appeal to emotions they are often humorous and framed more as advice or friendly guidance several of the social occasions that are represented appeal to emotions by drawing on the image of good times worth remembering that would be undermined by excessive drinking which would leave the subject feeling sick andor excluded from the fun the youth problem in the materials excessive drinking and the youth problem overlap on many occasions still this framing constructs and delimits the issue as a distinct youth problem the campaigns directly target young people conveying the message that the problem should be resolved by consumers in this case young individuals the youthproblem framing is marked by signs such as young people that have passed out are sick or have been left alone the campaigns fit the world of a young audience and its priorities each campaign piece has a composition that seems to level with young receivers and speak their language rather than speaking to them through logical reasoning alone the language and pictures used are informal for instance play it smooth with a break from the booze in addition the people and situations are illustrated in pictures that would be expected to resonate with the subject who is likely to identify with these people and situations several of the campaign pieces are brightly colored and convey a feelgood spirit a friendship aspect is also signified in several pieces one campaign series explicitly focuses on contrast emphasizing the distinction between having a good time and getting sick this is signified by two pictures of the same young person in similar settings in one picture the person is smiling and socializing with other people in the other the same person is portrayed as being sick and acting in a way that would most likely be perceived as embarrassing alternatively the person is depicted as being alone on a bathroom floor or at home the contrast situations are separated by the outline of either a wine glass or a bottle signifying the contrast between being responsible and being irresponsible moralizing and emotional appeal are also significant in the campaigns addressing youth drinking an emotional appeal is made as the youth drinking definition clearly distinguishes between social success and failure feeling good versus sick success versus failure with the opposite sex and being a good friend versus being a bad or annoying one the fear of being excluded from a community is likely to be especially salient among young people a smaller component of the 2009 version of why let the good times go bad draws on mens lockerroom humor humor that involves crude sexual and perhaps even sexist topics in one example the danger of drinking excessively is illustrated in terms of a picture of beer googles paired with verbal text signifying that the beer googles increase ones risk of pulling a moose which is slang for pairing with an unattractive woman together the guidelines and the strong pictures showing these contrasting situations also appeal to the mode of reason the parenting problem this framing of the problem stands out because the target subjects are not the young consumers of the product but rather their parents eg the contrasts in this framing of the issue as a parenting problem are more subtle playing on good versus bad parenting and a right and wrong way to teach ones children about alcohol the depiction of parents drinking does not necessarily signify bad parenting as parents are depicted as negligent or unaware that their children are observing them in these photos parents are not looking in the direction of the children thus it can be inferred that there is a right way to teach children about alcohol moralizing and emotional appeal are salient in the parentingproblem framing this is evident in the contrasts between right and wrong described above as well as when verbal campaign text suggests that parents talking to their children about alcohol is just as essential as their talking to them about sex using phrases like time for that talk about the bars and the beers reformulating the phrase the birds and the bees connoting the hesitance that is often associated with talking to ones children about human reproduction meanwhile this also suggests that drinking alcohol is just as normal and natural a part of human life as having sex the emotional appeal is quite strong as evidenced in the use of dark colors the mention of a e and the tagline talk now and avoid problems later go to drinkawarecouk these elements all serve to reinforce the message that parental inaction will harm children as without guidance children could end up in the emergency room or experience other types of serious trouble furthermore there is also a latent emotional appeal that centers on the subject as still being needed and remaining an important person in the childsteenagers life establishing identity as an expert a crucial step in the framing of the issue is establishing and legitimating the identity of the sender drinkaware as an expert an organization needs to be perceived as a credible source of information and education and gain some form of ownership of the issue to shape the field in part drinkawares identity as an expert is established in the campaign material via the two previously described functions in addition drinkawares identity is established with the consistent association with signs of truth and science and drinkaware performing the role of educator these aspects are elaborated below consistent association with signs of truth and science in the campaign materials i identified several signs that pointed toward the central referent systems of truthscience a referent system is a system of meaning to which a sign refers such as a wedding ring which connotes the referent system of marriage drinkawares consistent association with the facts connoting the referent system of truthscienceresults in the establishment of a connection that becomes what williamson refers to as an objective correlative this means that when two things are put side by side such that they coexist we tend not to question whether or not this makes sense therefore in the consistent pairing of drinkaware with signs that connote the referent systems of truth and science the meaning of these systems may be transferred to drinkaware the significant point here is the construction of drinkawares ethos and its identity as an expert through its campaign materials performing the role of educator drinkaware is the sender of the campaign messages and they are visually recognizable as information and educational campaigns they follow the format and composition typically used in information campaigns and appear in places that these campaigns would appear such as on the bus or in a bar hence their identity as a source of information and education is reinforced because they are performing this exact role this educational role is often performed by public authorities such as when they provide information about official government guidelines in relation to alcohol consumption this role is made even more salient in the campaigns in instances where an official government unit guideline label is included andor when they inform the receiver about the law the performance of the role of educator and the signaling of association with the law and official government guidelines suggest authority and proximity to the official authority namely the government and signals governmental approval of the campaign material discussion and conclusion recent work in the field of organizational studies has emphasized that visuals are widely used by organizations both internally and in relation to different audiences and stakeholders visuals have also been identified as being exceptionally useful framing devices due to their ability to abstruse issues and appear overtly factual yet the previous literature on framing in issue fields has primarily focused on verbal accounts and thus far only limited work has addressed the visual in addition work on issue fields has often addressed struggles and contestation in fields limited work has addressed how certain visual framing efforts may also contribute to establishing a collective organizations identity as an expert within an issue field because visual framing efforts may have an important role to play in this regard it is important to explore how visuals contribute existing research and my previous work have motivated the research question addressed here how do visuals contribute to framing an issue and establishing a collective organization as an expert within an issue field to address the research question i studied the case of the ibic drinkaware and its visual framing of the issue of alcoholrelated harm in its campaign material i examined the various framing functions performed by the campaigns that is normalizing alcohol consumption defining and delimiting the scope the issue and the responsible parties and establishing the organizations identity as an expert each function had several components first the main rhetoric in the campaign was centered on normalizing alcohol consumption the foundational visual framing components were normalizing and contrasting which served to construct the distinction between normal responsible drinking and irresponsible drinking second the function of defining and delimiting the issue and responsible parties was rooted in subject appellation contrasting and moralization and emotional activation finally establishing identity as an expert relied on the consistent association of signs and performing the role in this case that of educators through its campaigns drinkaware is framing the issue of alcoholrelated harm as a problem of irresponsible drinking individual consumers and parents have the primary responsibility to solve and prevent the problem the campaign pieces draw on a wider logic of liberal democracy in which people are free agents capable of making the right decisions given that they have access to complete and accurate information in the campaigns this is marked by the depiction of the subject as an individual and a free agent this is also common in the subject appeal of regular advertising it is particularly salient in all the signaling of contrasts as a matter of conscious choice in which all possible positive and negative outcomes are portrayed as evident to the subject at any given time and place from this standpoint the importance of information is crucial and linked to the proposal of carefully constructed campaigns targeted at specific groups of people in this regard it is worth considering alternative definitions and explanations for the issue that are invisible in drinkawares materials such as drinking during pregnancy alcoholism and perhaps even the industrys reach in terms of advertising or the availability of alcohol drinkawares issue framing differs from other framings put forward by other organizations in the issue field such as the who and the global alcohol policy alliance which argue that the wider public and especially some groups of people such as children and young people are not necessarily free agents capable of making good decisions that affect their health in the long term instead these organizations push for tighter legislation and higher taxes on alcohol products arguing that these are the only measures that will lead to behavioral change in the campaign material drinkawares framing of the issue is focalized on consumers irresponsible drinking and education a framing that excludes invisible alternative explanations and simultaneously constructs an image of a socially responsible alcohol industry which funds the organization and supports its information campaigns in this regard the construction of drinkawares identity as an expert is essential as it lends credibility to its specific framing of the issue based on the findings described in the article this study makes three central contributions first it contributes to organizational theory and institutional theory by elaborating on the visual framing functions performed by an organizations campaign material previous work that has empirically studied the role of visuals in institutionalization processes has shown that visuals may be used to bridge ideational differences as well as in the translation of global contexts interestingly this study showed that visuals can also be used to construct contrasts such as between responsible and irresponsible drinking the framing function component of contrasting is particularly salient in the drinkaware campaigns in this regard it is worth noting that cultural studies on alcohol have suggested that a proper and improper use of alcohol is socially defined and transmitted in almost every society influencing the general publics understanding of alcohol consumption and establishing the contrast between responsible and irresponsible drinking may be crucial in reframing the issue from being a problem of the product or regulators to a problem that is the responsibility of the consumers while the study clearly showed that the visuals contribute to the framing of the issue it did not provide insights into the inner workings of the collective organization thus we do not know how and to what degree the visual framing efforts contributed to the mobilization of allies and support for drinkaware an interesting future study could explore this link further investigating the factors that mobilize organizations to support or join a collective organization focusing explicitly on the role of visuals second and relatedly the study contributes to the literature on issue fields by showing how the issue was defined and delimited in visuals through the subject subjects were invited to identify with the message using visual cuesthat is young people bright colors and humorous messages the specific emotional appeal of visuals has been highlighted by others my findings extend this research by clarifying the component of moralization and emotional activation doing what is right and the use of humor andor fear of being in the outgroup or a bad parent in addition the findings specify how this emotional appeal may be used in the visual framing of issues thereby elaborating on one of the ways that responsibility for public issues may get pushed onto individuals through visual framing and its strong emotional appeal a limitation of this study is that it does not show how the subjectsaudiences for the individual campaignsreceived the message as the material was coded and analyzed by the author an interesting future research direction could be to explore how this study focused on an organizations construction of an identity as an expert in its campaign material and it did not consider whether stakeholders and other actors in the issue field perceived drinkaware as an expert in alcohol education by considering other actors within an issue field future studies could explore how an organizations visual framing efforts may contribute to its positioning in relation to an issue on this topic it would be particularly interesting to explore whether and how visual framing may enable collective organizations to attain a powerful position in a field visuals and visual framing efforts represent important dimensions in organizations attempts to influence and shape issue fields but they are also significant parts of their external environment in a more general sense visuals are constructed in the organizational environment and then they are processed mediated transformed or challenged by organizational audiences still visuals and especially visual framing are still underexplored areas in organizational studies this article showed how to systematically explore the use of visuals in issue framing the study of visuals complements our existing approaches in organizational theory in an important way and may allow us to explore different aspects of meaning construction there is a truth about alcohol but not everyone has access to information consumers lack the knowledge to make an informed decision modes of argument ethos confirming the audience belief that the consumption of alcohol is normal campaigns are nonjudgmental and provide advice or guidance like a friend campaigns use informal verbal and visual language appropriate for a young audience recommendations are based on researchthe facts parents talking to their children about alcohol is just as basic as parents talking to their children about sex education and information is based on truth and science build by association to information visuals are relevant to the target audience mode of argument pathos arguing that it is normal to drink or that drinking too much might lead to social exclusion appeal to emotions of remembering the good times and being part of the fun or feeling sick andor being excluded from the fun appeal to emotions of success failure and the feeling of being included in or excluded from a community arguing that their lack of action will harm their children following the truthfactscience will keep the consumer safe from any health risks not following informationeducation will make the consumer or their loved ones vulnerable andor sick mode of argument logos alcohol consumption has always been the norm giving advice that will help consumers to not drink to excess giving advice that is useful when consumers have less knowledge and experience with alcohol and drinking arguing consistent association signs association of the drinkaware logo and facts parenting material visually conveys facts through figures tables and charts performing the role of educator the campaign itself is educational and it is visually recognizable as such government guideline label stating an official boundary between the proper and improper amount of alcohol units consumed notes 1 alcoholrelated harm has always been an issue but this new wave of concern emerged in the 1970s and increased in salience throughout the 1990s and 2000s 2 drinkaware is funded by donations from the alcohol industry which is made up of 88 on trade 348 off trade 557 producers and 06 wholesalers figure 1 illustration of the increased pairing of alcohol and health in five top uk newspapers illustration notes based on a search in the database newsbank figure1 provides an illustration of the keyword pairing of health and alcohol in articles from five top uk newspapers from 2000 to 2013 daily mirrorsunday mirror the guardian the times the sun and daily telegraphthe sunday telegraph year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 condensing symbols visual and verbal elements that capture both cognitively and emotionally a range of meanings and convey a particular framing a powerful symbol lends credibility to an explicit argument by drawing on implicit assumption and common sense these symbols may even signal a moral absolute that is unquestionable number of articles by colors certain colors might carry certain meanings and different color saturations might also function as modality markers to symbolize varying degrees of credibility value for example the visual depiction of what is or what could be subject appellation totemism the subject as signified we are created as a particular type of subject by the products and messages in advertisements composition the composition of the visual as a whole the way in which the representational and interactive elements are made to relate to one another to create a meaningful whole differentiation differentiation and contrasting is typically used in advertising to create a difference between a product and others in its category absence in hermeneutics meaning is always absent as meaning does not reside in things however this is even more significant when there is an absence in the signifying surface the receiver is invited to participate in a discovery of meaning and to fill the absence modes of argument ethos ethical appeal establishing a credible source pathos emotional appeal persuasion via emotions logos logical appeal use of logical reasoning individual single piece coding framing of the issue what is alcohol and what role does it have in society packages of proposals and critique that go together and highlight certain aspects of a particular issue a schemata of interpretation who is responsible for the issue how should it be tackled and by whom coding across campaign pieces framing of the issue comparing and contrasting the different campaign pieces to establish common themes function of the visual mode what function does the visual mode have in the overall framing of the issue differentiating between proper and improper use of alcohol signifying normal normal drinking occasions such as christmas and parties average homes and neighborhoods signifying contrasts in composition two pictures responsible and irresponsible separated by the silhouette of a wine glass normalizing contrasting defining and delimiting the scope of the issue and responsible parties defining and delimiting through the subject consumersparents focus issue areas excessive drinking problem youth drinking problem parenting problem issueproblem is solved through education aided and informededucated by drinkaware subject appellation audience addressed ie young people subjects identify with the message due to visual cues contrasting successfulunsuccessful with the opposite sex popular alone or ridiculed feel goodfeel sick good parentbad parent and living rooma e moralization and emotional activation through humor morale fear subject appellation contrasting moralization and emotional activation establishing identity as an expert consistent association with signs of truth and science establish the identity of drinkaware as holders and mediators of the facts about alcohol educators consistent association of signs drinkaware is consistently paired with truth and science performing the role of educator drinkaware is the sender of the campaign and is visually recognizable as an information campaign building its legitimacy within the issue fields center of the visual the silhouette of a wine glass marks the boundary between the two images consistent association of signs performing the role right lower corner yellow message box with text why let the good times go bad the first part of the logo for the campaign then try to make every third drink a soft one and find out more text goodtimes to 87078 separate from the other text is the second part of the campaign logo for the facts…drinkawarecouk text on the right and left catching up and left behind in bold white letters with a shadow font separating them from the background composition the picture and text on the left signify social success the picture and text on the right signify social failure due to excessive drinking the yellow box in the lower right corner is a separate area that presents the solution to the problem the key is being the person on the left rather than the one on the right this box also represents the sender of the message as an expert on the topic of staying responsible providing tools for the subject like an advertisement the tool to being responsible is the one sold to the receiver of the message modes of argument ethos the campaign in and of itself is an ethos appeal providing such an information piece signals credibility so does the text for the facts…drinkawarecouk connoting the referent system of truth and science pathos social inclusion on the left exclusion on the right exclusion is further emphasized in the text left behind anchoring the intended meaning of the picture in text logos logical appeal is mostly evident in the text try to make every third drink a soft one and for the facts…drinkawarecouk logical appeal is also evident in the picture as the receiver is urged to be the girl on the left rather than the one on the right subject appellation the subject will most likely be drawn toward the picture of the popular girl and might therefore create herself as such because of the visual message differentiation constructing a contrast between responsible and irresponsible feeling liked and feeling alone absence absence the reader has to deduce that the girl in the picture on the right has been irresponsible in her consumption of alcohol this absence is also supported by the silhouette of a wine glass the reader must also deduce that the girls friends have left her behind because she was drunk and thus she is being punished by social exclusion condensing symbols bottles and the silhouette of a wine glass symbolize drinking makeup and hairstyling symbolize the girls having a good time socializing the empty room symbolizes that the girl is alone in her suffering goals and proposals the campaign piece explicitly urges individuals to act responsibly when consuming alcohol try to make every third drink a soft one and go the drinkaware website to get more information on how you the individual can be responsible in this way the campaign defines the problem as being the individuals irresponsible behavior and suggests that a possible solution is to become responsible by using their tool framing alcohol is a normal part of social life but excessive youth drinking should not be individuals need to take responsibility for their own actions the problem of irresponsible alcohol consumption can be solved be the individuals action and the right information which is available on the website

the editors of this special issue and three anonymous reviewers for their helpful insights and comments on previous versions of this paper a previous version of this paper was presented at the workshop giving visual and material form to ideas identity and imagination at wu vienna may 2014 a part of this research project has been conducted while the author was a scancor postdoc at stanford university

introduction in recent years over 43 million venezuelans left their country 1 in search for better opportunities or for escaping political instability they are part of a mixed migrant flow caused by a combination of economic social and political reasons and are likely to remain in the receiving countries for relatively long periods sharing a two thousand kilometers border with venezuela colombia is the largest recipient of this flow the number of venezuelan immigrants in colombia significantly increased after 2017 totaling more than 14 million in 2019 666000 of whom were undocumented the remaining migrants were regular mainly holding a special residence permit issued by the colombian government in response to the situation national records also show that 48 of venezuelan migrants were women most of them of reproductive age 2 corroborating trends of feminization of international migration 3 healthcare in colombia is fragmented providing care according to employment status and income for different populations as observed in other countries financial limitations translate into infrastructure personnel and medication deficiencies that combined with fragmentation result in disparities in access and ineffective health coverage even for the national population 4 5 6 in response to the increasing venezuelan mixedmigration flows the ministry of health established that immigrants are entitled to emergency care and public health actions 7 later on access to prenatal care and other reproductive health services was also granted for undocumented migrants in an attempt to provide healthcare access tantamount to that received by the colombian population venezuelans holding a special residence permit can affiliate to an insurance program through their places of employment or be covered by the social assistance program for lower income or vulnerable populations despite governmental actions a recent article reported that 424 of undocumented pregnant venezuelan migrants who had arrived to colombia before the first trimester of pregnancy received no prenatal care as for those who got pregnant in colombia only 221 received prenatal care during the first trimester 8 another study shows that 768 of the 8209 undocumented pregnant venezuelan migrants registered in 2018 received no form of prenatal care 9 although international recommendations estipulate that migrants should have access to health services on equal terms with local populations 1011 this is rarely the case especially for irregular migrants who have fewer resources to claim their rights more enrollment constraints and less knowledge of access routes as compared to regular migrants 12 13 14 15 the former are also more vulnerable to job insecurity and difficulties in accessing social protection systems 16 which translates into enhanced health risks given the above understanding the difficulties encountered by immigrants in accessing prenatal care in receiving countries and how they manage to navigate healthcare services is crucial although often explored in the context of migration from less developed regions to highincome countries such issue has gained increasing prominence in the context of southsouth mobilities constituting a new panorama where people move out from their countries of origin due to factors associated with economic political violencerelated or climate change reasons to lowand middleincome countries with limited health systems the migration of venezuelans to colombia illustrates one such case providing an interesting example on how pregnant immigrant women fare in this context when studying migrant health one must consider that migrants are not simply a vulnerable population but that they are capable of mobilizing resources to seek for healthcare 17 in this scenario studies must document how migrants exercise their capacity for action and the elements employed by them for navigating the health system without disregarding the barriers to access imposed by health systems and immigration regulations to access services people mobilize resources that constitute their economic and social capital 1819 and their cultural health capital 20 this paper uses these concepts as a theoretical framework for exploring how undocumented migrants use their capitals to access services aiming to 1 explore the experience of irregular venezuelan female migrants in search for access to prenatal care in colombia and 2 examine what resources they mobilize to gain access to services methods data used in this study were retrieved from a multimethod project some quantitative results have been previously reported elsewhere 8 our analysis is limited to the results of qualitative interviews conducted between 2018 and 2019 with 15 pregnant women in barranquilla one of the colombian cities with the highest number of venezuelan immigrants 2 venezuelan undocumented pregnant migrants who were in colombia for at least two months were included in the study through purposive sampling 21 participants were located in public hospitals and areas with a high concentration of venezuelans interviews were conducted in university offices for one hour on average recorded and transcribed for analysis the following information were collected living conditions health problems nutritional health and food safety depressive symptoms accessibility quality and satisfaction with colombian health services and careseeking trajectories table 1 shows participants characteristics for contextualizing interview results policy documents issued by the colombian ministry of health and social protection in response to the migration crisis were reviewed all procedures involving human subjects were reviewed and approved by the institutional review board of the comité de ética en investigación of the división ciencias de la salud of the universidad del norte to assure they were in accordance with ethical standards all participants agreed to participate by an informed verbal consent and the project covered for the expenses related to meal and transportation to the interview site transcribed data underwent a deductive content analysis a research method for analysis and interpretation of qualitative material through the systematic process of coding and identifying patterns across cases 2223 according to the following steps 24 early analysis for prior codes and categories data coding codes and categories review comparison of emergent themes across cases and conclusions using atlasti 8 and atlasti cloud three researchers adjusted the initial coding scheme defined each code and individually coded the interviews researchers held regular meetings to discuss the analysis process revise and group the codes into categories and identify emergent themes after revising and coding all interviews they discussed emergent themes and their relevance across cases and finally determined a final set of relevant aspects and conclusions that responded the research questions results limited economic capital and material resources the context of migration and pregnancy pregnancy and migration were interconnected in participants experience some individuals reported having migrated due to the difficulties of accessing basic products for medical and maternal healthcare in venezuela this finding is in line with the increase in maternal mortality in venezuela due to the precariousness of maternal and child care 25 above all i came for the medical attention decreasing even further when pregnancy restricted their capacity to meet work exigencies some participants reported migrating due to economic reasons as pregnancy directly impacted their working goals according to some authors this situation can increase both pregnancyand migrationrelated stress 26 inability to work and the consequent economic constraints recurrently appeared as a source of psychological distress in the narratives some participants expressed concern about living in houses considered unsuitable for a pregnant woman mentioning inadequate infrastructure and basic services the most frequently reported problem in terms of housing was overcrowding which hampered womens resting and constituted a source of stress due to conflicts among inhabitants i took a pregnancy test and well i cried i really didnt want to have the child due to the situation in here i mean here we have to cook with wood and the smell of charcoal gets everywhere in the house there is no water no gas because this house is sort of deemed as of high risk even though i was pregnant and didnt feel well i used to get up at four oclock then id sit down for a while make some tamales sit down again and make some more tamales and so on my god i dont know how my baby will survive with so much stress i would like to be relaxed in a context of limited economic capital public services constituted the main source of maternal healthcare below we describe how access to healthcare depended on the changes introduced by the ministry of health and social protection in response to venezuelan immigration and how participants mobilized their capitals for navigating the system navigating a changing health system social and cultural health capital in colombia only regular immigrants are entitled to enroll in the general system for health social security insurance scheme in 2018 the ministry of health and social protection granted the right for undocumented immigrants to receive emergency care and participate in public health actions such as prenatal checkups and childbirth and postnatal care 7 venezuelans migrants had to obtain a residence permit and affiliate to the sgsss to obtain access to maternal healthcare or follow the special administrative procedures at the local level to comply with the ministrys resolution during the period of this research these administrative procedures underwent numerous changes in barranquilla pregnant women had to bring a pregnancy test result and their identity document to the city hall to receive authorization for accessing prenatal care at the local public hospital for each medical procedure a new authorization had to be requested so that women could be required to go to the city hall multiple times during pregnancy at first only 25 authorizations were issued daily and some participants reported spending the night at the place and leaving without an authorization in response to this problem the government created a telephone line for appointments but quotas remained insufficient so that many respondents were unable to access prenatal checkups timely the first time i spent two days ringing continuously and they only answered at about half past three in the afternoon of the second day after i had called about 40 times it was not as complicated at the second time i got through on about my fifth try however this time i have been calling every day and they have not answered me for a month even though i have called from monday to friday many participants reported that the procedures for regularizing their documents and affiliating to the sgsss were likewise unclear and burdensome as a result some migrants gave up on the process and relied on emergency services as source of medical attention most migrants using the country emergency services reported very few obstacles however others were refused care on the basis of their status as migrants which may have been due to the negligence or ignorance of health professionals regarding the new provisions participants coped with all these barriers by looking for strategies to access services including the mobilization of social capital both from personal support networks and community organizations with these resources participants managed to access medical care or medications more easily as stated by one of them here you see what you can do on a daybyday basis the collective influence of migrant organizations not only influence authority decisions but also support their female participants in overcoming problems related to healthcare access due to a pregnant women meeting that we organized word spread and the undersecretary of health became interested in the foundation migrants organization went to a meeting and saw our work she also mentioned it to some colleagues such as the registrar and told them it was a serious foundation that had existed for some time and already worked with several government agencies then she talked to us and said she could help us a bit and get these girls admitted more quickly than in the usual system to access healthcare participants also leveraged their cultural health capital which according to shim 20 includes information on the health system and incorporated knowledge on how to interact with health workers and other bureaucrats as for information given the changes in the administrative procedures and regulations concerning access respondents required up to date information to this end they resorted to both formal and informal sources including friends family and neighbors other pregnant venezuelans social networks meetings in the waiting rooms of hospitals and offices and health service workers among the latter those with knowledge of the access routes to services became especially important then i asked her if there was a social worker because they always tend to speed up the process or tell us what to do because another venezuelan at the hospital explained it to me that is the girl the woman who told me about the ultrasound scan told me when you get your ultrasound done you have to go to city hall there was a girl who had just given birth there who said thats not true you have to call to make an appointment i was told by another venezuelan woman who was there as for knowledge on how to interact with the system given that bureaucrats at various levels have a certain degree of discretion in their functions 27 participants used their interaction skills to negotiate their position by being either friendly or polite to the officials or by emphatically demanding attention the former attitude being more common than the latter as part of their knowledge of interaction modes the interviewees knew that getting attention from health workers outside the formal channels was yet another option for receiving access they told me they couldnt see me there because i didnt have an insurance card they couldnt help me but a nurse overheard me and told me to talk to the doctor privately so i did i talked to the doctor privately and explained my situation so she treated me she treated me there i so she gave you a sort of informal consultation p exactly yes and she told me well she gave me some recommendations she prescribed some injections i bought them and she gave me the injections but it wasnt a proper consultation in short participants managed to access the required prenatal care by mobilizing capitals however they still experienced several difficulties in accessing healthcare and most times it was not timely discussion in analyzing how migrants with limited economic and material resources managed to access health services we found that their access was based mainly in social capital and cultural health capital social capital defined as social relations based on trust reciprocity and cooperation 19 enabled them to navigate the health system thanks to networks inside and outside the migrant community in turn cultural health capital helped them to discover access routes and interact with providers in this sense our results highlight the agency of migrant women 17 and the possible effects of this agency on the health system 28 however the importance of these capitals for healthcare access reflects the limitations in care integration policies play an essential role in guaranteeing the rights and health of migrants 29 and the limitations inherent to these policies indicate structural problems in the health system despite the efforts exerted by the colombian state to guarantee effective access to care 4 the health system has limitations regarding timeliness and quality 6 and the complexity of bureaucratic procedures hamper access to care 28 especially regarding undocumented migrants 30 our results show that even after being legally recognized as a right the access to prenatal care is still limited due to bureaucratic procedures and insufficient information migration and health system characteristics are social determinants 3132 that either limit or increase decisionmaking and capacity for action among women in our study migrants operated within a restricted framework of possibilities requiring greater investments of resources for accessing services when compared to less vulnerable people such a need for investing a large amount and diversity of resources for meeting basic needs is a constant in the subsistence of vulnerable social groups 33 and comprises a social issue that should be solved within the framework of universal health coverage our study has some limitations first as our sample comprises a specific group of pregnant women within a limited geographical site and considering that the experiences of regular venezuelan migrants in other contexts or with better socioeconomic conditions may be different our results cannot by generalized however participants narratives achieved theoretical saturation with a relatively low number of interviews corroborating the results reported in other studies on undocumented migration and access to services 161726 suggesting that the results obtained in our study would apply to other groups of migrants further research should explore these issues in other southsouth migration contexts and include more diverse samples to improve generalizability although migrants can respond in creative ways to obtain access to healthcare authorities must keep promoting enrolment in insurance schemes on equal terms with the local population to guarantee these populations right to health as in colombia the main route for ensuring this equality is through regularization governmental authorities should adopt a migration policy that facilitates such process thus expediting access to health services moreover information on health services and the necessary steps for accessing them should be disseminated among both migrant communities and service providers actions aimed at improving access to maternal health services for migrant women can be used to review and improve the health system benefiting the entire population authors contributions vg designed the qualitative study conducted analysis cowrote the first version of the manuscript and reviewed and approved the submitted version rs conducted interviews conducted analysis cowrote the first version of the manuscript and reviewed and approved the submitted version jafn designed the parent study and reviewed and approved the submitted manuscript mlrb designed the parent study and reviewed and approved the submitted manuscript ib designed the qualitative study conducted analysis cowrote the first version of the manuscript and reviewed and approved the submitted version conflict of interests the authors declare no conflict of interest

to explore the experiences of irregular undocumented venezuelan migrants in accessing prenatal health services in colombia and to examine the economic social and cultural resources mobilized by them to gain access to caredata was retrieved from the qualitative component of a multimethod research conducted with pregnant immigrants in barranquilla colombia between 2018 and 2019 and triangulated with a review of regulations established by the ministry of health and social protectionhaving limited economic capital participants use social capital from personal networks and migrant organizations they obtain cultural health capital in the form of information on the health system and use their cultural competencies to interact with this systemmigrants exert their agency through the use of capitals although with certain constraints policies aimed at this social group should consider the strengths of migrants

introduction managerial practices in the healthcare sector are facing considerable challenges to improve the performance of medical staff in the evergrowing hospital market conditions in the opinion of reference 1 nurses among all healthcare practitioners are the frontline care of patients in providing timely quality health services in hospitals nurses also make up the largest human resource in healthcare organizations and nursing performance remains a longstanding determinate of the quality of patient care therefore the assessment of factors influencing the performance of nurses became essential for scholars and hospital management executives this study however is particularly interested in vietnamese hospital nurses previous studies explored a variety of factors affecting job performance such as working environment interpersonal relationships job satisfaction commitment leadership styles etc 2 3 4 this study focused on interpersonal relationships in the workplace and how these interactions affected the working manner and performance of employees the extant scholarship indicates that employees who are well informed through relationships at work report higher levels of job satisfaction and commitment 56 the higher the workplace interaction quality the better informed employees are and in turn the less uncertain they are about tasks and goals and the better the perceived performance 7 of particular interest the ways in which workplace relationships may influence the received information and resources were discussed through two primary sources of relationships with supervisors and colleagues prior studies showed evidence on the positive connections between these two relationship categories and the performance appraisal ratings of employees 8 9 10 in light of this employees can rely on their immediate leaders for an exchange of technical skills and resources and the highquality relationship with supervisors is associated with a higher level of trust respect obligation support and encouragement 11 otherwise coworker relationships provide employees the source of emotional and instrumental support as they have an understanding of the internal working environment 12 however the literature on coworker relationships appears inconsistent regarding the healthcare sector in which peer cohesion was less available between staff nurses who usually work on different rotating shifts 1314 most of the related research focused on european countries and the united states healthy workplace relationships receive a lot of interest since they are associated with the benefits of employees 15 and achieving the goals of the organization 16 in addition several previous studies also concentrated on examining the role of staff nurses participation in decisionmaking processes to improve the organizational process 17 and create a strong impact of health institution management models on clinical practice 18 as well as seeking clinical practice benchmarking to improve the quality of care 19 and identifying alternative models of effective funding systems in the national health service 20 to further investigate this stream of research caillier 21 investigated the impact of highquality workplace relationships on the overall performance of the organization through employee behaviors such as commitment social impact and job stressexhaustion however the significance of healthy interpersonal relationships at work in vietnam is of critical concern however it remains unexplored in research since current research possesses little evidence about the expected impact of relationships at work on employee working manner this paper aims to clarify the way in which healthy workplace interactions affect the working behaviors of staff nurses and performance ratings by examining two subcategories of relationships individually this study followed the same path as li and hung 22 who examined two subtypes of relationships separately and also grouped these types of relationships into one variable proposed by hansen 23 allowing the consideration of separate effects and a whole effect literature review highquality workplace relationships individuals are supposed to build and maintain positive relationships with others in the workplace 24 the socalled workplace relationship is defined as the information exchange between individuals and groups who want to complete their goals 25 research long found a beneficial impact of the quality of employees workplace relationships with their supervisors and peers on organizations the processing of information enhances the performance of an individual and the organization since wellinformed employees are less uncertain about the target goals and make better decisions 726 certainly some employees are better informed than others because the amount of information and resources received are likely affected to be by the quality of their relationships with their supervisors and coworkers the current study examined two primary categories of the highquality workplace relationship supervisorsubordinate and peer relationships doing so allows the consideration of separate effects in order to investigate an overall impact of the workplace relationship and to measure the extent to which each relationship subtype captures this construct the study follows the same path as reference 22 and also groups these relationships into one variable proposed by reference 23 the leadermember exchange lme theory the leadermember exchange is the most widely accepted theory regarding supervisorsubordinate relationships 27 it suggests that managers should encourage positive interactions between leaders and each of their employees through different exchange levels 28 in general these relationships vary with respect to quality and highquality workplace relationships rely on mutual trust respect obligation 2930 and internal motivation 21 between organizational members it follows that highquality lme employees are likely to receive more support and attention from their leaders than those in lowquality lme due to more frequent communication sias 11 pointed out the positive association between lme and employee information experiences providing some directions for examining how lme affects the quality of workplace relationships as a result the quality of lme is linked to a variety of important individual and organizational outcomes in the working environment where lme is of a high level staff who are provided with technical knowledge and are encouraged with respect and feedback 31 are likely to exhibit a sense of motivation and commitment 32 allen 5 indicated that wellinformed employees were more satisfied with their jobs and the higher the level of satisfaction the higher the degree of involvement 33 and lower intention to quit 534 there is a variety of previous studies showing that a highquality leadermember exchange maintains organizational commitment 35 36 37 38 39 azim and islam 40 stated that perceived social support which includes informational and instrumental support from others in networking is an antecedent of nurses commitment in saudi arabia however private nurses exhibited a higher level of commitment than nurses working in the public sector in addition according to reference 35 a highquality or positive lme refers to a great exchange of resources and information between participants members who perceive a positive lme relationship deliver superior performances as they receive valued resources opportunities and support from their supervisors 4142 to be more efficient and effective at work more specifically members of highquality lme relationships tend to contribute more than what is required from their formal duties and lowquality lme relationships make members perform the more routine tasks 28 in line with this reasoning high levels of lme are likely to provide employees with expectations about their ability in undertaking challenging task demands beyond their formal duties 43 hence the following three hypotheses were proposed hypothesis 1 the quality of the leadermember exchange has a significant and positive effect on highquality workplace relationship hypothesis 2 the quality of the leadermember exchange has a significant and positive effect on employee commitment hypothesis 3 the quality of the leadermember exchange has a significant and positive effect on job performance coworker relationships the second major category of highquality workplace relationships involves peer relationships which are described as equivalent relationships 44 between similar status peers in the organization these relationships provide significant attributes to a peaceful and productive work environment for several reasons the coworker relationship is referred to as a primary source of emotional support career development 45 and instrumental support 11 as coworkers may have a clear understanding of the working experiences and conditions as well as gossip about organizational information that cannot be obtained by external employees 46 however regarding the healthcare sector staff nurses working in hospitals typically work long hours in rotating shifts with few breaks to ensure 24hour patient care nurse working shifts may not follow traditional patterns of day and night and nurses are required to work extra hours in specialized units such as surgery or intensive care 47 in vietnam nurses are found to be involved in an onduty work schedule which means that staff nurses follow work hour regulations and ensures that 24 hours of continuous working is followed by a day off 48 after all staff nurses usually devote much of their free time to recover between shifts hence they have less time for interaction and resource exchange with their coworkers zedeck jackson and summers 49 indicated that night and rotating shift work when compared to day work was associated with adverse wellbeing outcomes specifically increased social isolation and lower levels of cohesion in addition coffey skipper and jung 13 and parkes 14 argued that peer cohesion was less available during rotating shifts between staff nurses of particular concern heath johanson and blake 50 demonstrated that the lack of effective communication collaboration and decisionmaking promotion adversely affected the quality of workplace relationships hypothesis 4 coworker relationships are proposed to be insignificantly related to highquality workplace relationships there are a large number of studies demonstrating the positive influence of peer interaction on job performance 22 however information and resource exchange through channels are found to be affected by different sectors regarding the healthcare industry staff nurses usually work directly with their supervisors or doctors in their department 51 for technical information such as updated work plans guidance and job training moreover staff nurses are in charge between different working shifts or are assigned to different tasks and care areas 52 these are some reasons why a lack of interaction between staff nurses is likely to be observed when considering the healthcare sector hence the lack of information exchange between peers happens to be insignificantly related to job performance hypothesis 5 coworker relationships are proposed to be insignificantly related to job performance highquality workplace relationship social impact and hospital commitment job satisfaction and organizational commitment were obviously long found to be positively linked to the quality of workplace relationships including supervisorsubordinate relationships 5 53 54 55 and coworker relationships 5657 specifically venkataramani et al 58 argued that encouragement support and respect by managers within a highquality workplace relationship organization facilitated the employees organizational attachment hackett and guion 59 and bass 35 proposed a positive interaction of coworkers on job satisfaction which further increased the organizational commitment 60 61 62 63 64 hypothesis 6 the presence of highquality relationships within the workplace will be associated with a higher level of organizational commitment among staff nurses in addition employees are considered to achieve an understanding about the purpose of their work or what they believe is achieved in their work through their interactions in the workplace 65 put differently relationships at work make employees aware of the significance of the tasks they are performing this line of reasoning is powered by the job design theories of jobs as a collection of relationships as well as a collection of tasks 66 in this sense a supportive working environment is proposed to contribute to the awareness of the differences that employees are making to others additionally the degree to which employees actions make a difference in the lives of other people the extent to which employees efforts protect promote or contribute to the welfare of others is regarded as perceived social impact 67 hypothesis 7 workplace relationships of high level are expected to be positively linked to a higher degree of realized social impact according to reference 68 in comparison with private employees public employees are more likely to have a higher degree of spirit and motivation since they have a desire to serve a socalled wish of creating benefits for others 69 apparently not all public staff are perceived at the same level of social impact 67 specifically regarding the healthcare sector society usually considers nursing as a paramedical or an undervalued profession whereby nurses simply follows doctors instructions public belief about nursing is partially created by the way the media portrays the healthcare sector which includes only two groups of professionals medical doctors and other health professionals serving doctors 70 in the minds of most people the role of staff nurses is restricted to medication giving handling technology and the measurement of vital signs 71 as a result staff nurses do not receive sufficient respect and recognition from society and hence may face stress hardship and bitterness when doing this profession however nurses still continue to stand firm in the workplace and live up to their own careers this can be possibly regarded as occupational commitment which is the tendency to remain working in the nursing sector and their loyalty to the nursing profession 72 explained by this kind of commitment nurses endorse the value of nursing as they believe in their professional goals of doing good for society making significant efforts in patient care and having a sense of pride in their career 7273 regardless of social valuation hypothesis 8 social impact is proposed to be not significant with commitment highquality workplace relationships social impact and job stressexhaustion individuals working in the healthcare industry are likely to face an extreme amount of stress including pain morality the inadequate number of nursing staff dealing with a large number of patients work overload decisionmaking based on insufficient information in emergencies etc 74 nguyen et al 48 stated that nearly 50 of nurses experienced a high degree of stress in vietnam additionally the ratio of nurses suffering from exhaustion in vietnam was found to be quite high in comparison with that of japan and finland 75 hence job stress logically became the main factor in reducing professional efficiency and the quality of patient care blair and littlewood 76 believed that the quality of workplace relationships was a potential contributor to employee stress for example employees working within highquality workplace relationships are powered by instrumental resources and encouragement needed from supervisors and emotional support from peers that contribute to improving psychological empowerment 77 cohen and wills 78 and searle et al 79 reported that interpersonal interactions at work reduced stress experiences among the staff this is also similar to the study by sveinsdottir et al 80 where evidence was provided showing that lack of support from supervisors and peers and less satisfaction with the head nurses generated stressful situations among nursing staff more evidence of the positive connection between workplace relationships and job stress was recorded by reference 81 who stated that the absence of support from the working environment scored higher for teaching hospitals and thus nurses in teaching hospitals reported a higher level of stress when compared to nurses in nonteaching hospitals hypothesis 9 nurses perceive that highquality workplace relationships are negatively related to job stressexhaustion levels since public staff perceive that they are doing good for others they tend to contribute more to gain social impact 67 which in turn helps eliminate stressexhaustion within the workplace environment in addition by creating a highquality workplace relationship managers who practice facets of transformational leadership ideally influence and inspire motivation whereby individualized consideration and intellectual stimulation are considered as a positive influential factor on employee performance 2282 it follows that meaningful tasks given by managers 8384 help develop a positive attitude and stress relief 83 the relationship between highquality workplace relationship and job stressexhaustion was found to be connected through social impact moreover when employees are getting stressfulexhausted they will not keep their commitment at workplace therefore the following hypotheses are proposed hypothesis 10 staff nurses perceive that job stress and exhaustion are connected by social impact hypothesis 11 staff nurses perceive that job stress and exhaustion have a negative impact on commitment job performance and commitment since employees who are more committed are less likely to be involved in withdrawal behaviors such as lateness absenteeism 85 turnover intention and are more willing to accept changes 86 it is evident that job performance would be potentially affected many studies paid attention to the relationship between commitment and job performance under different sample data the majority of them pointed out the positive impact of employee commitment on performance where committed individuals devote their time and energy to the pursuit of organizational goals and to delivering a superior performance 87 notably khan et al 88 concluded that a higher employee commitment emerged as a predictor of better performance considering the public sector of oil and gas in pakistan other studies by bakiev 89 and mansour et al 90 revealed the positive influence of organizational commitment on perceived performance among police officers in krygyzistan and human resource management practices in the tunisian financial services industry respectively especially regarding the public sector camilleri and van der heijden 91 reported the same result however the findings of the positive relationship between commitment and job performance are inconsistent in the literature for instance the studies of angle and lawson 92 steers 85 mathieu and zajacs 93 and more recently the study by biçer et al 94 all observed a negative insignificant or even weak relationships between the two concepts this variation can be explained by the inconsistency in measurements and constructs across the studies above all consistent with the current literature in the nursing profession nurse commitment is expected to be positively and significantly related to their performance in the vietnamese context hypothesis 12 nurses perceive that commitment is positively connected to their job performance based on the analysis above the research model was developed and is illustrated in figure 1 it includes seven components workplace relationship and job stressexhaustion was found to be connected through social impact moreover when employees are getting stressfulexhausted they will not keep their commitment at workplace therefore the following hypotheses are proposed hypothesis 10 staff nurses perceive that job stress and exhaustion are connected by social impact hypothesis 11 staff nurses perceive that job stress and exhaustion have a negative impact on commitment job performance and commitment since employees who are more committed are less likely to be involved in withdrawal behaviors such as lateness absenteeism 85 turnover intention and are more willing to accept changes 86 it is evident that job performance would be potentially affected many studies paid attention to the relationship between commitment and job performance under different sample data the majority of them pointed out the positive impact of employee commitment on performance where committed individuals devote their time and energy to the pursuit of organizational goals and to delivering a superior performance 87 notably khan et al 88 concluded that a higher employee commitment emerged as a predictor of better performance considering the public sector of oil and gas in pakistan other studies by bakiev 89 and mansour et al 90 revealed the positive influence of organizational commitment on perceived performance among police officers in krygyzistan and human resource management practices in the tunisian financial services industry respectively especially regarding the public sector camilleri and van der heijden 91 reported the same result however the findings of the positive relationship between commitment and job performance are inconsistent in the literature for instance the studies of angle and lawson 92 steers 85 mathieu and zajacs 93 and more recently the study by biçer et al 94 all observed a negative insignificant or even weak relationships between the two concepts this variation can be explained by the inconsistency in measurements and constructs across the studies above all consistent with the current literature in the nursing profession nurse commitment is expected to be positively and significantly related to their performance in the vietnamese context hypothesis 12 nurses perceive that commitment is positively connected to their job performance based on the analysis above the research model was developed and is illustrated in figure 1 it includes seven components methodology to test the research model and proposed hypotheses this paper adopted a quantitative method where data were gathered by means of largesample survey the measures sample and data collection and data analysis technique are presented below measures referring to an extensive literature review the study constructed a 33item measurement scale to examine the latent variables observed firstly the rate of the relationship with managers was assessed through the fiveitem scale from graen and uhlbiens 31 which measures lme secondly a threeitem scale was adopted from kram and isabella 95 and typology relationships 9697 to assess coworker relationships each item was used to describe each type of coworker relationship by sias 11 thirdly highquality workplace relationships were examined by the threeitem scale from hansen 23 fourthly the social impact was assessed by the sixitem scale following bullock et al 68 which included the definition of the social impact developed by grant 67 and the same items built by grant and campbell 98 fifthly instead of testing separately the two indicators of job stressexhaustion by steiber and pichler 99 the study combined two indicators to make a fiveitem scale to measure job stressexhaustion this was in accordance with the theory of the maslach burnout inventory developed by maslach and jackson 100 sixthly a sevenitem scale was applied by bullock et al 68 and allen and meyer 6 to examine the commitment finally job performance was investigated through the fouritem scale stated by colquitt et al 101 a fivepoint likert scale was used to evaluate the level of respondents agreement sample and data collection in the sampling process one of the most important questions is how many observations or respondents to use for the research sample deciding on the appropriate sample size is an important and complex issue which depends on the statistical estimating precision needed by the researcher and the number of variables 102 although larger sample sizes always provide better projection of the whole population it is supported that a range from 200 to 400 is considered to be critical for multiple regression and path analysis 103 green 104 and tabachmick and fidell 105 suggest a rule of thumb for determining the sample size accordingly sample size 50 because there were overall 33 items used for the measurement of the models constructs a total of 314 observations was considered to be effective sample size since the purpose of the study was clarified we contacted the department of health in both ho chi minh city and binh duong province vietnam to get references for the list of hospitals then we attempted to contact hospital managers to ask for help conducting the questionnaire survey this enabled the delivery of the majority of the questionnaires to be done in person and to utilize the managers personal contact with many nurses consequently researchers received the approval of hospital authorities from four hospitals in ho chi minh city and two hospitals in binh duong province vietnam to conduct the questionnaire survey in order to assure ethical requirements a cover letter was introduced in the first page of the questionnaire survey where the purpose of this study was clearly identified it also involved the authors names addresses and university of the authors with the perspective of increasing the confidence of the staff nurse employees and for them to be familiar with whom they were answering as mentioned by reference 106 researchers ensured that respondents information was kept confidential used only for academic purposes firstly the questionnaire was translated into vietnamese and it was checked and corrected by an english lecturer however the first vietnamese version was not easily understandable secondly researchers conducted a pilot test of facetoface interviews with 30 staff nurses in march 2018 the results of the pilot test enabled researchers to verify and modify the final questionnaire for easy understanding and improving the response rate under the vietnamese context with kind support from hospital managers researchers distributed 80 questionnaires in each hospital the managers assisted researchers in asking staff nurses to fill in the questionnaire researchers stopped by each hospital every weekend to receive the completed questionnaires it took about three months to finish the data collection from april to june 2018 out of the 480 questionnaires delivered to staff nurses in six hospitals 382 responses were returned however 77 questionnaires were eliminated from the analysis because of missing data in the responses effectively completing a response rate of 6312 of usable responses for this study a copy of the final questionnaire used in this paper is presented in appendix a data analysis technique firstly exploratory factor analysis was implemented to all scales together for a preliminarily assessment of dimensionality convergence and discriminant validity secondly confirmatory factor analysis was carried out to test the full measurement model which included seven constructs and their respective items results demographic characteristics table 1 presents the demographic data of 303 respondents most of them were women and the majority of respondents were aged from 25 to 35 years old in addition their experience in the nursing industry varied mostly from one to 10 years with the rate at 637 reliability and construct validity firstly table 2 illustrates the descriptive statistics of data collection including the mean and standard deviation specifically in terms of the reliability all the cronbachs alphas of the variables were greater than 07 and the corrected itemtotal correlations of all items were larger than 03 which confirms the reliability of the measurement requirements 107 secondly exploratory factor analysis was carried out to explore the possible underlying factor and determine whether a set of variables consistently loaded on the same factor were based on strong correlations particularly this test is used to reduce the number of variables as the measurement indicators for the path analysis of overall model 108 according to reference 109 factor loading can be classified as practical significance if it is greater than 05 moreover the kaisermeyerolkin should be higher than 05 based on these criteria the results of efa led to dropping the following items social impact 1 commitment 1 lme4 and lme5 therefore the total number of items for testing the research hypotheses was 29 and the effective sample size needed to be at least 282 in fact 303 responses were appropriate and identified constructs of this research after eliminating four items the results showed that the constructs fully matched the design and each item was loaded mainly on its designate construct the kmo measure was 0843 which was well within the acceptable limits the bartletts test of sphericity fulfilled the significance threshold total extracted variance of 61908 indicated that seven factors were explained by 61908 of the data variability the remaining factor loadings of valid observed variables were above 05 and no major crossloadings were reported then the study applied kaisers eigenvalue with a greaterthanone criterion to identify the seven factors that were extracted thirdly an important step in cfa is the evaluation of the model fitness most of the model fit indices of cfa presented in table 3 are in accordance with the acceptance requirement except for a goodnessoffit index of 0852 which was only considered as sometimes permissible but was still within the range of threshold notes chisquaredf rootmeansquared error of approximation goodnessoffit index tuckerlewis index comparative fit index convergent validity and discriminant validity to examine the convergent validity of the measurement scale two main indicators need to be considered average variance extracted and composite reliability according to reference 112 the minimum value of ave should be at least 05 however if cr is greater than 06 the minimum value of ave can be accepted as being at least 04 still assuring the construct convergent validity table 4 illustrates that all estimates and aves of all factors were greater than 05 and cr values of all factors were good this means that the convergent validities of all constructs were confirmed and the reliability for all factors and items of the research model fully fulfilled the criteria in addition fornell and larcker 112 suggest that the discriminant validity of the model is certified when the ave of each measurement factor is higher than the square of the biggest correlation estimates of that factor with other ones table 4 also reports the satisfaction of all factors to the mentioned thresholds structural equation modeling and hypothesis testing the structural equation modeling approach used the maximumlikelihood estimate to test the overall fit of the structural model applying the same requirement standards in cfa the results in table 3 state that most of the current indices of sem lay well within the thresholds and a gfi of only 0842 is considered as sometimes permissible but still acceptable before concluding on the fitness of the model the pvalues of correlations between factors were significantly checked if the estimated standardized path coefficients summarized in table 5 are statistically significant the hypothesis will be accepted at the 005 level of confidence most of the path coefficients were positively and negatively significant except for those of hypotheses h4 h5 h8 and h12 as observed from the results lme had a positive and significant impact on highquality workplace relationship com and job performance thus hypotheses h1 h2 and h3 were supported the impacts of hwpr on com and ssi were positively significant while the impact of hwpr on job stressexhaustion was negatively significant indicating that hypotheses h6 h7 and h9 were all supported moreover the results showed that ssi was significantly positively related to js supporting hypothesis h10 in contrast there was no significant impact of coworker relationship and com on jp ssi on com and hwpr on cwr hence hypotheses h4 h5 h8 and h12 were all rejected in this study it was found that the effect of lme on com was more considerable than another predictor hwpr the path coefficient of ssi to js revealed its better contribution when compared to that of hwpr discussion among the two sources of workplace relationships lme was indicated to be positively and significantly related to workplace relationship quality employee commitment and performance appraisal these hypotheses support that high levels of lme which feature mutual trust emotional support respect and reciprocal influence create many positive outcomes including higher standard of patient care 77113 greater job commitment and stronger performance ratings 114 these results are consistent with a majority of previous studies regarding nursing management the findings agreed with brunetto and wharton 115 regarding positive connections between lme levels and the degree of nurses commitment and were in line with han and jekel 116 about the negative influence of high lme levels on nurse turnover rate in the united states additionally in accordance with social exchange theory the results support a recent study of sepdiningtyas et al 117 where lme was positively related to individual performance in the nursing profession the results however pointed out the insignificant contribution of coworker relationships among vietnamese hospital nurses in improving workplace relationship quality and job performance this was explained by the fact that nursing has its own special characteristics when compared to other professions the exchange of information and support is not highly valued among staff nurses since they usually follow their own work shifts or are in charge of different tasks and care areas this line of reasoning is highly consistent with blake 50 who argued that high levels of workplace environment were generated by effective communication and collaboration and decisionmaking promotion among nurses these reasons also support the insignificance of peer relationships and job performance the study opposed wong et al 118 that weighted peer interactions as the stronger driver on work engagement than supervisory relationships were explained by the more frequent peer communications the finding also contradicted previous studies in nursing by abualrub 119 and amarneh et al 120 who reported a positive relationship between coworker social support and job performance among hospital nurses in the united states and jordan respectively the results indicate that highquality workplace relationship was negatively and significantly related to job stress which is highly consistent with previous studies 16 77 78 79 80 this is implied by the fact that within positive workplace relationships nurses are powered by instrumental resources and emotional support from supervisors and peers which results in a lower level of reported stress moreover the findings revealed that highquality workplace relationships were considered as a significant driver of social impact this is because a positive workplace relationship quality creates an understanding for the nurses of what they are doing and their awareness of the difference they are making in society the results agree with caillier 21 in the positive influence of highquality workplace relationships on social impact among nurses additionally there was a significant coefficient describing the positive interaction of social impact and job stress a potential clarification could be that nurses who realize the impact they have on others put more effort and time toward preserving this aim as a result they reported a lower level of job stress or exhaustion in the end the study concluded on the mediating effect of social impact on the correlation between highquality workplace relationship and job stress among staff nurses which was highly consistent with caillier 21 such workplace relationship quality stems from a transformational leadership style which is described through the ideals of influence inspiring motivation individualized consideration and intellectual stimulation 2282121 hence transformational leaders provide staff with meaningful tasks and goals 8384 which in turn enhances the social impact among nurses and contributes to relieving job stress 83 extracted from the results it was observed that highquality workplace relationships were positively and significantly related to nurse commitment these findings support the previous findings they contended that interactions with leaders and peers in a positive workplace relationship enhanced employee psychological attachment to the organization furthermore social impact was found as an insignificant influential factor on nurses attachment to the organization the fact is that the nursing profession is likely to be undervalued by the public since they believe that nurses simply follow doctors instructions however nurses tend to believe in their professional goals to do good for society contribute effortlessly in caring and have a personal feeling of pride for their profession 7273 consistent with this view nurses remain working in the nursing sector and preserve the loyalty to their profession 72 since social impact is not a significant driver of nurse commitment the result otherwise rejects 21 regarding the mediating effect of social impact on the relationship between highquality workplace relationship and nurse commitment finally the study demonstrated that organizational commitment emerged as an insignificant driver of the staff nurses performance in vietnamese hospitals this finding contradicts most of the previous research along this line however the study supported studies of angle and lawson 92 and mathieu and zajacs 93 where the influence of commitment on perceived organizational performance was perceived negative insignificant or even weak the variation can be explained by the way in which commitment and performance were conceptualized in each study gong et al 123 examined different categories of organizational commitment and found out that although affective commitment was explored to enhance job performance continuance commitment was not meanwhile schrock et al 124 reported the negative association between continuance commitment on job performance additionally biçer et als study 94 did not conclude a statistically significant interaction between affective commitment and perceived organizational performance this is likely attributable to the fact that variable design shortcoming and other ambiguities suggest potential associations between kinds of commitment and job performance among vietnamese hospital nurses several suggestions were proposed to enhance the understanding on this relationship including investigating potential moderators 93 and examining different dimensions of performance 92 and commitment conclusions this paper aimed to examine the drivers of job performance among nurses in vietnamese hospitals paying attention to the significance of the quality of workplace interpersonal interactions since a positive workplace relationship is of crucial importance for the proper functioning and goal achievement of an organization this study established an integrated model that aimed to explain the expected association of a highquality workplace relationship its subcategories and working attitudes of vietnamese hospital nurses the findings showed that only the leadermember exchange relationship was a direct and significant predictor of highquality workplace relationships and nurse performance but not coworker relationships additionally it also revealed that a healthy workplace relationship created a significant contribution to enhancing nurse commitment relieving job stressexhaustion and increasing the perception of nurses about the social impact of the nursing profession unfortunately the study did not demonstrate the significant relationship between commitment and job performance and further research would need to be conducted to investigate the connections between the two concepts in the vietnamese context the divergence between the majority of previous studies on the commitmentperformance relationship and that in the vietnamese hospital context was also explained this study contributes to the extant research in two ways firstly the paper firstly clarifies the process via which healthy workplace interactions affect the working behaviors of staff nurses and performance ratings by examining two subcategories of relationships individually secondly the study confirmed the significance of the association between workplace relationships employee work attitudes and job performance by considering different characteristics of the vietnamese healthcare industry the findings of this study will provide valuable evidence and implications for healthcare management with regards to the importance of enhancing interpersonal interactions and performance ratings adequate attention should be paid to prioritizing solid interactions among staff nurses when they are demonstrated to have no contribution to the quality of workplace relationships and job performance among vietnamese hospital nurses since such actions may improve the workplace relationship quality and job performance this will in turn increase commitment reduce stress levels and improve nurses awareness of social impact in spite of the limitations further studies may advance this line of research by widening the measurement variables of job commitment and performance to gain a deeper understanding about the connection between these two concepts among nurses in vietnam in addition considering the generalizability of the findings future research should examine other potential job performance drivers and any positive outcomes of coworker relationships in nurse performance and nurses working attitudes among various hospital sizes and characteristics another obvious limitation is that a largerscale study across several countries should be conducted to eliminate the possible effects of the disparity between countries on the quality of healthcare services

employees working relationships were long determined to be crucial to their overall wellbeing and performance ratings at work however a few studies were found to examine the effects of positive workplace relationships on employees working manners this study aimed to investigate the effects of healthy workplace relationships on employees working behaviors which in turn affect their performance in doing so an integrated model was developed to examine the primary performance drivers of nurses in vietnamese hospitals and focus on the effects of highquality workplace relationships on the working attitudes of the staff this study analyzed a questionnaire survey of 303 hospital nurses using a structural equation modeling approach the findings demonstrated the positive effects of highquality workplace relationships on working manners including higher commitment lower level of reported job stress and increased perception of social impact notably the results also demonstrated that relationships between leaders and their staff nurses make a significant contribution to the quality of workplace relationship and nurses performance in addition the social impact was illustrated to positively moderate the association between healthy workplace interactions and job stress however it had no significant effect on job commitment unfortunately job commitment was surprisingly found to not be related to performance ratings this paper provides some suggestions for the divergence of performance drivers in the hospital context in vietnam

during adolescence a hopeful sense for the future can facilitate positive development and successful transition into adulthood hope is believed to emerge developmentally but few studies have examined individual trajectories of hope or hopelessness during adolescence living in environments characterized by high levels of poverty and violence can have powerful negative impacts on young peoples sense of hope even within these stressful environments positive social connections can buffer and protect young people which may allow hope to flourish and enhance positive health and social outcomes participation in violence is among the most negative of social outcomes for youth and society how environmental and social factors influence the course of hopelessness during adolescence and how the development of hopelessness influences participation in violence among young people living in poverty is not known as background for the current study theory and research about the emergence and evolution of hope and hopelessness during adolescence is reviewed empirical findings about relationships between connections to neighborhood and connections with prosocial nurturing adults and hope are summarized health and social outcomes of hopelessness with an emphasis on involvement in violence are addressed the overall goals of this study were to examine trajectories of hopelessness during middle adolescence among young people from poor urban neighborhoods and to investigate relationships between social connectedness during early adolescence hopelessness trajectories during middle adolescence and involvement in weaponrelated violence during later adolescence among these same young people hope and hopelessness conceptshope has been defined as the anticipation of a future which is good based on mutuality a sense of personal competence coping ability psychological wellbeing purpose and meaning in life and a sense of the possible it reflects a belief that a personal tomorrow exists hope has also been described as the interrelationship between the belief in the ability to initiate and sustain actions towards goals and the capacity to generate routes to reach goals the childrens hope scale assesses goal related hopeful thinking and is a widely used measure for assessing the concept of hope in children and adolescence in contrast hopelessness is defined as having negative expectations for the future an adolescent who is hopeless possesses negative expectancies toward oneself and the future expectations that highly desired outcomes will not occur or that negative ones will occur and that nothing will change things for the better based on becks hopelessness scale the hopelessness scale for children and the brief hopelessness scale have been designed to assess negative expectations about the future in children and adolescents because hope and hopelessness are two distinct concepts an adolescent with a low hope score should not be categorized as hopeless and an adolescent with a low hopelessness score should not be referred to as hopeful developmental courseas human development is a continuous process with the past influencing the future many of the individual factors that influence the development of hope or hopelessness have a basis in the mastery of developmental tasks during infancy and childhood hope has been identified as one of the earliest of the basic ego qualities and a positive outcome of the earliest stage of psychosocial development meeting a childs emotional needs during very early childhood promotes the emergence of hope conversely the roots of hopelessness are formed when emotional needs are not met during early childhood a sense of time that includes the ability to conceptualize and believe in the future is needed before a sense of hope or hopelessness can be discerned thus a certain level of cognitive development must be reached in order for an individual to experience hope or hopelessness the abstract thinking that enables consideration of the multiple dimensions of time is not present in children with the onset of formal operational thinking during early adolescence development of a nuanced sense of past present and future is possible allowing awareness and refinement of a sense of hope or hopelessness and the capacity to assess probabilities and imagine the future throughout adolescence youth become increasingly focused on formation of a coherent identity that integrates past present and future selves as part of identity formation adolescents begin to make decisions about education occupation and social relationships which are all decisions that are influenced by their time perspective the ability for abstract thinking during this time involves the process of envisioning the possibilities and beginning to differentiate between actual and possible selves the projection of self identity to the future is foundational for the development of a sense of hope the empirical literature on changes in hope and hopelessness during adolescence is limited several studies have focused on the concept of hope during adolescence while others have assessed hopelessness hope appears to be dynamic and changes during the adolescent years in a sample of youth ages 1018 the reliability of childrens hope scale scores measured one year apart was moderate suggesting that change occurred in some youth similarly the average level of hope increased among adolescents receiving impatient substance abuse treatment but then decreased after discharge demonstrating that hope is not a fixed attribute likewise the concept of hopelessness appears to change during adolescence among youth aged 919 living in public housing in huntsville al hopelessness was negatively correlated with age among five cohorts of poor urban primarily african american youth who participated in the mobile youth survey for up to six years the average yeartoyear correlation of brief hopelessness scale scores was r 34 supporting the notion of hopelessness as a developmental construct thus while limited research to date suggests that the course of hope and hopelessness is dynamic and changing in response to maturation and adaptation to life events hope and hopelessness social and neighborhood influences as adolescents are complex and dynamic beings influenced by their own development and their interaction with their social and environmental contexts hope can be learned through social interactions and physical environments during childhood and early adolescence neighborhoods play an important role in influencing a young persons values expectations for normative behaviors and expectations for the future neighborhood factors such as violence and poverty may limit an adolescents ability to think about the future and inhibit the development of hope poverty may negatively influence an adolescents options for the future leading to feelings of hopelessness likewise life within a chronically violent community is one in which trust and hope are not easily cultivated adolescents who grow up in violent environments may believe their only option is a life of violence which in turn may lead to perceptions of hopelessness without hope adolescents are less likely to be concerned about poor choices that may adversely affect their future neighborhoods also offer features that promote the healthy development of young people including the development of hopefulness positive neighborhoods offer young people the opportunity to interact with caring adults who reinforce prosocial behaviors these nurturing environments and the involvement of competent and supportive adults who value and reward prosocial behaviors and assist in negotiating barriers may be linked to the development of hope among young people for girls caring exhibited by family and other supportive adults has been associated with lower levels of hopelessness supportive relationships with prosocial adults within and outside of family may nurture the development of hope studies of change in hope or hopelessness over time suggest plausible predictors of developmental course using a linear mixed model with a first order autoregressive covariance structure for responses over time bolland et al found that gender disruptive factors and perceived prosocial connectedness predicted yearroyear change in hopelessness among primarily african american youth living in impoverished neighborhoods this finding suggests the utility of further analyses that describe and predict the developmental course of hopelessness allowing for population heterogeneity in individual course bolland et al examined immediate change in hopelessness subsequent to disruptive or supportive events the impact of these factors through the subsequent course of adolescence is unknown thus we are limited in our understanding of enduring consequences of variation in family and neighborhood factors effects of hopelessness health and social outcomeshopelessness has been associated with negative outcomes including violence depression school problems substance abuse risky sexual behaviors and accidental injury in contrast crosssectional studies have linked high levels of hope during adolescence with scholastic achievement social acceptance feelings of selfworth and overall psychological wellbeing valle et al regarded hope as a psychological strength that moderates the relationship between stressful life events and risk behaviors based on this existing research highlighting associations between hopelessness and negative outcomes that includes violence adolescents who are hopeless appear less likely to avoid circumstances that can lead to involvement in lifethreatening behavior patterns violenceparticipation in violence is a particularly devastating and potentially lifethreatening outcome of hopelessness violence rates peak during the adolescent years and adolescents disproportionately suffer the consequences of violence including imprisonment injury and homicide members of specific demographic groups especially males and african americans are at particular risk for involvement in serious forms of violence and related negative sequelae homicide is the leading cause of death among african american youth males aged 15 to 19 are 62 times more likely to die from homicide than sameage females and murder rates for african american males age 10 to 24 are 3 to 16 times higher than rates for other groups of males males experience greater levels and more serious forms of violence than females gender differences in physical aggression appear to be present early and remain throughout the developmental course however over the past 20 years rates of delinquency and violence have increased among adolescent females by 2004 girls accounted for 30 percent of all juvenile arrests while many risk factors are similar for boys and girls factors specifically for girls include depression a history of sexual or physical abuse and negative peer influences while also relevant for boys violence in girls may be a product of internalized feelings of emotional distress that can no longer be withheld violence becomes a release of negative feelings and anger among low ses african american and hispanic adolescents stueve et al found that changes in attitudes supporting violence were more closely linked with changes in physical aggression among girls based on the existing research gender differences exist in both the developmental course and in the rates of violent behaviors there is a strong link between poverty and violence with violence being more prevalent within poor neighborhoods regardless of race or ethnic makeup of the neighborhood both boys and girls living in disadvantaged neighborhoods are exposed to a greater number of risk factors including exposure to family and community violence than their peers in more advantaged neighborhoods girls are thought to have less exposure to community violence than boys youth living within disadvantaged neighborhoods may also experience fewer opportunities for positive relationships and prosocial role models youth living in poverty are at increased risk for participation in violence risk and protective factors increase or decrease the likelihood that young people will engage in violence neighborhoods with a culture and history of adult violence have elevated rates of youth violence whereas those characterized by cohesion and opportunities for youth to interact with caring adults who reinforce prosocial behaviors appear to confer protection parent and family connectedness protects against violence across social groups of adolescents adolescents more connected to their parents were less likely to commit weapon violence over time in addition high quality parentchild relationships may protect urban male adolescents who have been exposed to violence from engaging in violent behaviors in contrast parent and family attitudes that are favorable to violence are a risk factor for youth violence positive connections to neighborhood and family can offer adolescents protection against participation in violence at the individual level involvement in violence during early adolescence is a potent risk factor for involvement in violence at subsequent ages previous research has identified a temporal path of aggression bullying behaviors and physical fighting preceding more serious violent behaviors such as weapon carrying and weapon use serious fightrelated injuries and homicide among urban adolescents living in poverty those who were more hopeful with a higher sense of purpose in life and less depression werebetter able to withstand the influence of exposure to violencein the home and in the community hopelessness was associated with increased risk for weapon carrying involvement in violence and weapon use in earlier evaluations of mys data various theories have helped explain the origins of violence among urban youth living in poverty including the process of abandonment of hope yet few have empirically tested the role of hopelessness using longitudinal data with a focus on the experiences of individual young people over time purpose and hypotheses the purpose of this study was to develop and test a longitudinal model linking social connectedness and involvement in violence during early adolescence with involvement in weaponrelated violence during later adolescence via trajectories of hopelessness during middle adolescence ecological theory and existing research inform figure 1 the conceptual model for this study of youth living in impoverished neighborhoods as proposed in figure 1 positive social connections and involvement in violence during early adolescence are thought to shape the course of hopelessness during middle adolescence in turn trajectories of hopelessness in middle adolescence explain subsequent participation in violence with a weapon during later adolescence the model suggests a variety of increasing and decreasing change patterns with and without acceleration for individual hopelessness trajectories the possibility of similarities in change between individuals is incorporated by proposing the existence of latent classes initial analyses examine associations between measures of social connections and involvement in violence during early adolescence change in hopelessness during middle adolescence and rates of violence with a weapon during later adolescence then general growth mixture modeling is used to link social connections and violence in early adolescence and violence with a weapon in later adolescence via hopelessness trajectories during middle adolescence because prior research identified gender differences in predictors of youth violence changes in hopelessness during adolescence and differences in rates of serious involvement in violence analyses are completed using both boys and girls as known groups in the ggmm a model selection approach identifies the best fitting model from a set of four proposed theoretically plausible models derived from figure 1 table 1 lists key characteristics of the four competing models that are estimated and compared characteristics of the proposed models reflect different hypotheses about the form of change in hopelessness during middle adolescence and nature of the predictive relationships across the phases of adolescence our first aim was to examine changes in hopelessness during middle adolescence we expected that adolescents hopelessness trajectories would change during middle adolescence as youth cognitively become more self aware and have increasing time perspective two functional forms for change in hopelessness were proposed the linear models reflect a constant rate of growth or decline in hopelessness during middle adolescence whereas the quadratic models hypothesize a changing rate of change in hopelessness as the transition to adulthood approaches an increasingly rapid shift in perception for the future is implied by the quadratic form the growth mixture model was used because similarities in change in hopelessness were anticipated and could be identified using latent classes but the uniqueness of individual change in hopelessness was preserved by hypothesizing withinclass variation this view reflects the perspective that individual development is unique and that growth curves vary continuously in the population our second aim was to examine the extent to which social connections and violence during early adolescence predicted to certain hopelessness trajectory groups we hypothesized latent classspecific prediction of growth parameters because the latent hopelessness trajectory classes were expected to be qualitatively different however the simpler more parsimonious equal prediction model was also explored our final aim was to explore the association between latent hopelessness trajectory class and engagement in serious violence in later adolescent latent classes characterized by increasing hopelessness were expected to be associated with a higher probability of violence with a weapon during later adolescence findings from this study will fill critical gaps in scientific understanding of the development of hopelessness during adolescence and the roots of youth violence by assessing change at the individual level the study explicitly links theory about change in hopelessness longitudinal study design and a general growth mixture model consistent with the theory and design understanding trajectories of hopelessness during adolescence and examining the role of hopelessness trajectories in the relationship between social connectedness and involvement in violence has potential to serve as foundation for innovative developmentally based interventions designed to promote healthy development and prevent violence among impoverished atrisk youth method the mobile youth survey settingthis study used data from the mobile youth survey a communitybased multiple cohort study of 10 19 year old adolescents living in 13 extremely impoverished neighborhoods in the mobile alabama metropolitan statistical area mobile has a population of approximately 200000 residents in 2000 461 of mobiles population was african american and 224 lived in poverty prichard is a city of nearly 30000 residents in 2000 833 of prichards population was african american and 441 of residents lived in poverty in 1990 42 of african americans in the msa lived in highpoverty census tracts placing mobile third in the nation in this measure of concentrated poverty the 13 neighborhoods targeted for study were homogeneous in regards to poverty rates and community composition when selected for participation in 1998 the median household income in the neighborhoods was approximately 5000 and 73 of the residents in these neighborhoods lived below the poverty level the median poverty rate in 2000 was approximately 57 with 305 of residents living in extreme poverty and the median household income was less than 12000 ninetyfive percent of residents in these neighborhoods were african american seven of the neighborhoods were public housing developments and six were nonpublic housing neighborhoods sampling and recruitmentthe first mys cohort was enrolled in 1998 using both active and passive recruitment strategies within the targeted public housing neighborhoods approximately one half of the apartments identified by the housing authority records as having youth residents between the ages of 10 and 18 were randomly selected for participation in the nonpublic housing neighborhoods approximately half of the houses and apartments were selected for active recruitment through door knocking project staff attempted to make contact with adult caregivers in each of these active recruitment residences to obtain parental consent and to recruit adolescents to participate in the study in addition passive recruitment was done through posting flyers about the study and word of mouth in the targeted neighborhoods in 1998 1771 youths were surveyed in 1999 project staff attempted to resurvey each of the 1998 participants in addition a new random sample was also actively recruited between 2000 and 2006 similar active and passive strategies were used to recruit new cohorts of mys participants past participants were actively recruited to be resurveyed since 1999 annual cohort size ranged from 2185 to 2632 youth each year approximately 30 of the sample were new participants from 1998 to 2006 7664 youth participated in mys since 1998 the active recruitment response rate each year has hovered around 90 reflecting an increased awareness of and trust in the survey and the research team data collection proceduresparticipants completed surveys at local community centers personal information parent consent and participant assent was verified at checkin individuals completed surveys in a room with 10 20 other mys participants survey questions were read aloud by trained staff with participants marking responses in their survey booklet those who needed individual attention were assisted oneonone however most participants completed the survey independently the paperpencil forcedchoice survey took 60 to 90 minutes to complete each participating youth received 10 per year for the hour that was required to complete the paperpencil survey cohortsthe nine mys cohorts are similar on most demographic factors except that percentage of public housing residents declined following changes in policy and availability of housing each year the sample was split evenly between males and females and the mean age ranged between 126 years and 136 years the vast majority of the youths identified themselves as africanamerican with an additional 4 to 6 identifying themselves as mixedrace or creole and the remainder identifying as caucasian each year between 448 and 623 of respondents reported living in public housing and between 873 and 930 reported receiving free or reducedcost lunches additional descriptions of the mys purpose setting and design are available elsewhere the current sample the current study is based on a subsample of mys participants this subsample consisted of 723 adolescents aged 10 18 years who participated in the mys five or more years between 1998 and 2006 with at least one survey completed between ages 1012 and at least one survey completed between ages 1618 demographic characteristics are reported in table 3 the proportions of males and females were approximately equal the majority of the sample reported being african american about 75 of participants contributed 6 or more annual data points and about 81 started participation prior to age 12 there is some overlap in participants selected for the current study and the prior report of bolland et al the current sample adds occasions for all participants whose responses were used in the prior analysis deletes cases who did not participate at least five times including once during both early and later adolescence and adds cases from later cohorts variables and measurement ageage in years and birth date were reported by participants at each measurement occasion participant selfreported age was used unless inconsistencies were noted inconsistencies in the self reported age were verified using birth date and correct age recalculated occasions of measurement were then classified into early middle and later adolescent phases age 13 represents transition from early to middle adolescence and age 16 represents transition from middle to later adolescence age ranges for our phases approximate those often used by many social scientists age was used to select variables from the mys database during the early and later adolescent phases many participants had completed multiple surveys during early and later phases but only a single time point for measurement of variables during these phases was desired during early adolescence surveys from age 12 were available for 653 cases for those cases where it was not available we used either age 11 data or age 10 data during later adolescence survey data was available at age 16 for most cases for those cases where it was not available we used either age 17 data or age 18 data age was used as the predictor for modeling growth in hopelessness during middle adolescence age was centered on 13 so that intercepts in the hopelessness trajectories could be interpreted as baseline values at the start of middle adolescence trajectories of hopelessness during the middle adolescent phase were based on all available time points for each participant during this period connection to mother during early adolescenceconnection to mother during early adolescence was measured with the warmth towards mother scale a 6item scale that measured selfreported closeness to their mother or the person who was most like a mother the scale includes items such as she usually helps me if there is something i dont understand responses to individual items were summed to create a scale with scores ranging from 0 6 higher scores reflected greater warmth towards mother internal consistency reliability for the current sample during early adolescence was α 76 positive neighborhood connectedness during early adolescence connectedness to neighborhood during early adolescence was measured using 6 items from the psychological sense of community scale the 6item scale measures positive connections to ones neighborhood and includes items such as there are people in my neighborhood other than my family who really care about me responses to individual items were summed to create a scale score ranging from 0 6 higher scores reflected higher levels of positive neighborhood connectedness internal consistency reliability for the current sample during early adolescence was α 72 physical fighting during early adolescencephysical fighting during early adolescence consisted of a single item in the past 3 months were you in a physical fight the original item response options were no yes just once and yes more than once for this study a dichotomous variable was created with 0 indicating no and 1 indicating any level of physical fighting in the past 90 days violence with a weapon during early adolescenceviolence with a weapon during early adolescence was a composite measure of 4 items assessing the overt violent behaviors of threatening someone with a weapon in the past 90 days pulling a weapon on someone in the past 90 days and shooting or stabbing someone in the past year for this study a dichotomous variable was created with 0 indicating a no response to every item and 1 indicating that a participant reported participating in any of the violence with a weapon items hopelessness during middle adolescencehopelessness was measured using the brief hopelessness scale it includes five items from kazdins hopelessness scale for children and one item developed to assess hopelessness in dangerous neighborhoods all items were negatively worded and had response options of agree 1 disagree 0 responses to individual items were summed to obtain a total score that could range from 0 to 6 higher scores indicated higher levels of hopelessness for purposes of this study bhs measures were derived from all annual mys surveys completed by participants between the ages of 1316 years with middle adolescent data from the current sample internal consistency reliability estimates for the bhs for ages 1316 ranged from α 7280 violence with a weapon during later adolescencemeasurement of violence with a weapon during later adolescence was based on responses to four overt violent behaviors of threatening someone with a weapon in the past 90 days brandishing a weapon on someone in the past 90 days and shooting or stabbing someone in the past year a dichotomous variable was created with 0 indicating a no response to all items and 1 indicating that the participant reported involvement in any of the items genderparticipant gender was assessed using a single self report item girls were coded as 0 and boys were coded as 1 analysis plan characteristics of the participants and data quality indicators were summarized using descriptive statistics associations among social connectedness violence and gender variables during early adolescence were examined with correlations and ttests a set of theoretically plausible ggmms were estimated using mplus and compared using aic bic sample adjusted bic and entropy to select the best approximating model missing data in mplus ggmms are estimated using the maximum likelihood approach with the em algorithm allowing data missing at random on the repeated measures variable and dichotomous outcome during middle adolescence data for 3 of 4 timepoints was available for about 84 of the participants coverage gives the proportion of cases contributing to each element in the variancecovariance matrix the minimum covariance coverage recommended for reliable model convergence is 010 covariance coverage ranged from 069 to 100 results within phases early adolescenceaverage levels of social connectedness fighting and violence with a weapon during early adolescence for boys and girls are summarized in table 4 results presented for early adolescence is primarily based on data collected at age 12 high levels of connectedness to mother were common among all participants but the average was significantly higher for girls than boys there was no difference in connectedness to neighborhood almost half of the sample reported getting into a physical fight in the past 90 days and 25 reported violence with a weapon boys reported significantly more physical fighting and violence with a weapon than girls correlations between social connectedness fighting and violence with a weapon during early adolescence are summarized separately for boys and girls in table 5 violence with a weapon was associated with lower connectedness to mother in both groups for boys violence with a weapon was associated with lower levels of connectedness to neighborhood middle adolescenceaverage levels of hopelessness responses by age and gender are reported in table 6 mean hopelessness decreased with age for girls from an average of 130 at age 13 to 97 at age 16 for boys average levels of hopelessness decreased from age 13 to age 14 then increased again at age 15 and 16 later adolescenceviolence with a weapon during later adolescence was more common among boys than girls between phases general growth mixture modelingggmm with maximum likelihood estimation was used to describe the pattern of hopelessness over time identify latent classes based on hopelessness trajectories and link latent classes with social connectedness and violence across adolescent phases the hypothesized models based on the concepts and relationships summarized in figure 1 incorporated the following temporal design features variables and model specifications hypothesized models included latent growth factors and 4 measurement time points between the ages of 13 16 for the continuous measure of hopelessness the hypothesized models also included 4 covariates x measured during early adolescence and a distal outcome u measured during later adolescence multiple group analysis within ggmmbased on the literature and preliminary analysis gender differences in involvement in violence were expected it was also anticipated that the relationships between social connectedness course of hopelessness over time and violence during adolescence would vary based on gender gender was treated as a known group in the ggmm framework the known groups approach is preferable to treating gender as a covariate in the models which would impose equalities between genders that may not be valid in this multiple group analysis latent class membership is treated as partially known and fully informed by genderspecific growth mixture models partially known means that for example girls could be in only those classes derived from mixture models carried out for girls but the exact latent class membership was reestimated within the multiple group model candidate modelsbased on previous literature and the preliminary assessment of data by gender four theoretically plausible multiple group models were estimated simultaneously for boys and for girls using mplus and compared using aic bic sample adjusted bic and entropy to select the best model in the set the proposed models varied in two aspects first individual change in hopelessness was either linear with a constant rate of change throughout middle adolescence or quadratic with variable change that accelerated or decelerated over time second the relationship between the covariate predictors was either held equal or allowed to vary based on class membership initial solutions produced negative variance estimates for intercepts and slopes and slopes to keep parameter estimates within bounds the residual intercept and slope variances in model 1 were fixed at 0 and the residual slope variance in model 2 was fixed at 0 and the models were reestimated model 4 was eliminated due to high correlations between the linear and quadratic coefficients among the remaining three models the akaike information criteria bayesian information criterion and the sampleadjusted bic were used to select the model with the smallest combination of population misfit and sampling error all are based on the negative log likelihood of the model with a penalty function for the number of parameters comparatively smaller values for all indices indicate the best model model 3 was the best approximating model as indicated by the lowest aic bic and sample adjusted bic entropy a summary measure of how well people are classified into classes is measured on a 0 to 1 scale entropy greater than 90 indicates more distinct groups both model 2 and model 3 had entropy greater than 90 based on statistical fit provided by the information criteria and entropy model 3 was most satisfactory results from model 3 the final model are described below parameter estimates are presented in table 8 final model change in hopelessness and latent classesmodel 3 incorporates genderspecific quadratic change in hopelessness with equal covariate prediction two latent classes emerged for both boys and girls a consistently low hopelessness class characterized by a lower initial status of hopelessness that continues to decrease over time and an increasingly hopeless class characterized by higher initial levels of hopelessness that decrease slightly at age 14 then accelerate with time hopelessness trajectory predictors the relationship between connection to mother during early adolescence and hopelessness during middle adolescence was significant early adolescent connection to mother was negatively associated with initial level of hopelessness during middle adolescence there were no significant relationships between the other early adolescent covariates and initial levels of hopelessness there were no significant relationships between any of the early adolescent covariates and change in hopelessness during middle adolescence violence in later adolescenceprobabilities of engaging in violence with a weapon associated with class membership and gender derived from the logit parameters are shown in table 8 table 9 shows the odds ratios for violence in later adolescence using all gender by class comparisons the probabilities are higher for boys than girls and higher in increasing hopelessness classes compared to the low hopelessness classes predicted values of violence with a weapon during later adolescence were very different for the girls in the increasingly hopeless class compared to those in the low hopeless class among boys hopelessness class membership was less related to predicted violence the predicted value for of increasingly hopeless class was 53 and 51 for low hopeless class table 10 lists the modeled means for the early adolescent covariates and hopelessness at each time point during middle adolescence weighted by the estimated class probabilities for each class in the final model mean hopelessness trajectories associated with each latent class are depicted in figure 3 mean trajectories in the low hopelessness classes are nearly parallel for girls and boys with the boys class trajectory elevated compared to girls mean trajectories for the increasingly hopeless classes for boys and girls are nearly indistinguishable discussion youth living in extreme poverty face many challenges as they move toward adulthood limited educational and occupational opportunity and exposure to harsh living conditions including exposure to serious violence create sobering and welldocumented barriers to successful transition from adolescence to adulthood personal engagement in serious violence during later adolescence is a strong signal that the transition to adulthood is failing even within bleak environments a hopeful sense for the future may emerge during adolescence to mitigate the impact of negative factors earlier positive social connections are possible sources of hope we proposed a theoretical model linking trajectories of hopelessness during middle adolescence with social connections and violence during early adolescence and engagement in serious violence during later adolescence prospective longitudinal data provided by impoverished youth taking part in the mobile youth survey were used to explore the dynamics of hopelessness over time and evaluate modelderived hypotheses using a ggmm approach gender was treated as a known group in the ggmms because a vast literature documents differences in the adolescent experiences of girls and boys we hypothesized that hopelessness would change during middle adolescence we expected both uniqueness and commonality in the course of hopelessness results supported our hypothesis that population heterogeneity in trajectories of hopelessness exist during middle adolescence among youth living in extreme poverty two hopelessness trajectory classes were identified for both boys and girls a low class and an increasing accelerating class whose typical course was modeled with a quadratic functional form for change acceleration in hopelessness implies an increase in the rate of change of hopelessness and perceptions about their future as time elapses and the transition to adulthood nears for boys increasing hopelessness beginning at age 15 was apparent in the trend in means of hopelessness for girls the ggmm analysis uncovered a subset of girls with a similar pattern but whose observed data were swamped by the greater numbers of girls with the low hopelessness pattern increasing and accelerating hopelessness trajectories during middle adolescence proved to be a sign of troubled development as indicated by probabilities of subsequent engagement in serious violence an association between hopelessness and involvement in violence was recognized in early studies of impoverished youth including the mys for this reason we hypothesized that violence with a weapon during later adolescence would vary by hopelessness class results affirmed this hypothesis the low hopelessness class of girls had the lowest estimated probability of violence with a weapon during later adolescence of all groups in comparison increasingly hopeless girls had a higher probability of violence with a weapon during later adolescence the low hopelessness class of boys had a notably high probability of later adolescent violence with a weapon despite having lower and decreasing hopelessness throughout middle adolescence increasingly hopeless boys had the highest estimated probability of violence with a weapon during later adolescence thus female gender and trajectories of decreasing hopelessness during middle adolescence were protective against violence with a weapon during later adolescence our longitudinal findings extend our understanding of relationships between hopelessness and violence highlighted in earlier research males and youth with trajectories of increasing hopelessness during middle adolescence are at increased risk of involvement in violence during later adolescence we hypothesized that lower or higher levels of hopelessness during middle adolescence emerged in response to positive social connections and personal involvement with violence during early adolescence within the context of the model comparison approach we used equal prediction of growth factors for middle adolescent hopelessness by early adolescent covariates was more reasonable than class specific prediction among covariates only connection to mother was a significant predictor of hopelessness across classes youth who reported stronger connections to their mothers during early adolescence reported less hopelessness at age 13 the studys findings suggest that connections to mothers may start an adolescent out on a better or worse course in terms of the hopelessness experience itself as well as its association with later violence there was no relationship between connectedness to neighborhood and parameters of hopelessness trajectories during middle adolescence the finding of no relationship is different from studies reporting that connectedness to neighborhoods is protective or risky more research is needed to reconcile these disparate findings the current analysis extends understanding of the course of hopelessness in impoverished urban youth by emphasizing the individual course and by identifying latent subgroups with similar hopelessness experiences over time significance of growth parameters and variation among individuals supports the view of hopehopelessness as a developmental construct with salience during middle adolescence the final ggmm model applied to mys data employed variables and measurement points highlighting the dynamics of hopelessness during middle adolescence as a link between social connectedness during early adolescence and violence with a weapon during later adolescence the model is useful because it succinctly summarized the data from a statistical perspective parameters were scientifically interpretable and it predicted violence with a weapon a very high risk behavior during later adolescence these outcomes are all valuable characteristics of a high quality approximating model the mys has been conducted annually since 1998 over 9000 youth have participated over the past 12 years many of the youth completing an annual survey for up to 9 years as such it is now constitutes a unique research resource using the information in multiple ways will aid understanding and improvement of their lives earlier analysis of mys data focused on the prediction of hopelessness from prioryear disruptive events using the 19982003 cohorts and the association between hopelessness and risky behaviors using crosssectional data from the 1998 cohort findings from these reports were instrumental to moving forward with our inquiry capitalizing on data provided by earlier and new cohorts since the time of the earlier reports we were able to link the roots of hopelessness in early adolescence the development of hopelessness over time during middle adolescence and its consequences for involvement in violence during later adolescence at the individual level although there was some overlap in the data used the questions addressed were novel and allowed earlier findings to be extended strengths and limitations design issuesthe models we estimated necessarily reflect choices made in the design of this study including choice of a priori cut points for the adolescent periods as well as frequency and duration of observations despite the common use of adolescent stages in developmental research there is a lack of uniformity in decisions about age cutpoints or other criteria indicating transition from one stage to the next the most common cut points used by social sciences are based on typical age for academic transitions our use of cut points based on age made the assumption that all adolescents transition between adolescent phases at the same chronologic points in time this simplifying assumption may not be realistic as the timing of puberty and the accompanying transition into adolescence varies widely however obtaining information about puberty status is beyond the scope of this study more frequent measurement of hopelessness during middle adolescence would permit greater precision in estimating growth during this period and further exploration of the aptness of models with accelerating or decelerating change incorporating measures of hopelessness from early and later adolescence into the growth model would allow exploration of whether phase changes in hopelessness trajectories are coincident with agebased criteria for identifying adolescent developmental stages adolescents included in this analysis completed surveys on 5 or more occasions during early middle and later adolescence this level of participation represents intensive involvement in a research study and may reflect commitment to the endeavor or particular responsiveness to the money incentives that were offered however our sample reflected the overall mys sample in both demographic characteristics and levels of hopelessness generalizibilitythis analysis was based on data collected through an observational longitudinal study of adolescents from impoverished neighborhoods in an urban area in the american south the adolescents in this study were primarily african american living in predominately african american neighborhoods between 1998 and 2006 even with understanding the characteristics of the sample additional data are needed to determine the generalizibility of these results factors of race culture geography ses history and cohort are part of a young persons social context and may influence the way participants perceive and respond to relationships hope for the future and violence events taking place during the data collection period may have influenced responses if measured today recent events such as the election of the first african american president of the united states may influence an adolescents hope or hopelessness and result in different findings replication is needed to determine whether relationships examined in this study vary by ethnicity and culture socioeconomic status and period in historical time predicting hopelessness and violenceto provide a more complete picture of adolescents social contexts additional aspects should be modeled specific factors or turning point events that trigger abrupt change in otherwise smooth trajectories of hopelessness should be explored understanding triggers of hopelessness may help to identify specific developmental points or events for targeted interventions in addition the identification of specific events that modify hopelessness trajectories potentially increasing the chance a young person moves from nonviolence to violence or from physical fighting to more serious violence with a weapon could aid in developing more timespecific developmentally appropriate interventions peers and school were not included in our model but are also important to understanding internal states such as hopelessness as well as overt behaviors during adolescence the importance of social influences through peer networks increases during adolescence and can offer either prosocial or negative influences youth who socialize with peers who are engaged in violent behaviors are more likely to engage in violent behaviors themselves whereas associating with peers who disapprove of delinquent behavior inhibits participation in violence school is an important aspect in the lives of adolescence as much of their time is spent in school school can play an important part in protecting adolescents from participating in serious violence young people who report feeling connected to school were less likely to participate in violence and other risk behaviors schools also offer the opportunity for connections to other caring adults children and adolescent who perform poorly at school have a low degree of commitment to school and have problems with truancy and suspension are at risk for violence school transitions in particular multiple transitions over a short period of time have also been associated with increased violence these research findings can be used to extend the theoretical model for hopelessness trajectories practical applications youth violence is a complex problem and interventions at the individual family school and community levels have been used to try to prevent its occurrence our findings suggest that hopebased interventions have potential hope is fundamental to finding answers for some of the fundamental questions of adolescence and in finding a sense of purpose in life within families schools and other youthoriented groups individual level interventions need to be designed to instill a sense of hope and empowerment in youth at the group level interventions should aim to develop group cohesion prosocial norms and collective efficacy focusing on the ability of youth to act effectively in their community and in identifying and developing a sense of hope meaning and purpose conclusion this study contributes to the understanding of developmental trajectories of hopelessness during middle adolescence early adolescent factors that shape those trajectories and how those trajectories impact involvement in weaponrelated violence during later adolescence among urban youth living in poverty connections to their mother during early adolescence positioned middle adolescents for subsequent hopelessness course during middle adolescence violence was more prevalent in youth who reported trajectories of increasing hopelessness and regardless of hopelessness trajectory boys reported higher levels of violence than girls as with the current study much of the research examining youth living in impoverished neighborhoods has focused on negative outcomes like the development of hopelessness future research should measure and examine the development of hope and a sense of purpose as protective factors against involvement in at risk behavior final multiple group model of mean trajectories for hopelessness classes over time adjusted for the effects of the covariates low hopelessness girls increasingly hopeless girls low hopelessness boys and increasingly hopeless boys

youth living in impoverished urban neighborhoods are at risk for becoming hopeless about their future and engaging in violent behaviors the current study seeks to examine the longitudinal relationship between social connections hopelessness trajectories and subsequent violent behavior across adolescence our sample included 723 49 female african american youth living in impoverished urban neighborhoods who participated in the mobile youth survey from 1998 through 2006 using general growth mixture modeling we found two hopelessness trajectory classes for both boys and girls during middle adolescence a consistently low hopelessness class and an increasingly hopeless class with quadratic change in all classes youth who reported stronger early adolescent connections to their mothers were less hopeless at age 13 the probability of later adolescent violence with a weapon was higher for boys and was associated with the increasingly hopeless class for both boys and girls implications for new avenues of research and design of hopebased prevention interventions will be discussed

background approximately 9095 of the everyday management of diabetes is under the control of the patient 1 nonetheless providers play a primary role in fostering dsm visàvis partnering with patients to develop reasonable dsm approaches and recommending relevant programs and services 23 optimizing diabetes outcomes therefore entails providers and patients working together on dsm from a position of mutual understanding and shared decisionmaking culture inherently influences these processes and subsequently the ability to work in partnership toward optimal diabetesrelated goals moreover the impact of culture may be especially significant among populations such as arab americans who hold unique health beliefs and behaviors that differ significantly from the cultural norms of the general us population 4 5 6 the arab american institute 7 estimates that there are over 35 million arab americans nationwide while underrepresented in diabetes research the nine studies that have examined the prevalence of diabetes among arab americans have yielded diabetes estimates ranging from 48 to 330 8 9 10 11 12 13 14 15 16 in dearborn michigan which has the second largest population of arab americans in the us one study estimated the prevalence of diabetes in the arab american population to be 18 13 in addition another study conducted among the dearborn population suggests that less than one third of arab american patients with diabetes achieve targeted glycemic control and most receive less aggressive pharmacotherapy compared to national standards 5 despite the impact of culture on dsm and the high prevalence of diabetes among this group there is limited literature on these topics information on cultural impacts of dsm including how arab american patients understand dsm compared to providers serving arab american patients is critical for improving outcomes 1718 to this end we present findings from a qualitative study examining arab american provider and patients perspectives of the meaning of dsm and perceived culture related barriers and facilitators to dsm and discuss how insights gained from the study could inform clinical practice and future research methods design we conducted five focus groups two sessions were conducted with arab american healthcare practitioners and three sessions were conducted with arab american patients with type 2 diabetes mellitus the focus group approach was chosen because it is an effective method to understand individual experiences and to identify factors that influence behaviors data was analyzed using an inductive approach to qualitative content analysis without a priori categories 1920 the study protocol was approved by the wayne state university institutional review board setting and study participants a convenience sample of arab american healthcare providers including pharmacists and physicians were recruited from the communityatlarge and from health care facilities located in dearborn michigan in neighborhoods mainly populated by arab americans providers were eligible if they selfreported that they practiced in dearborn mi and that ≥50 of their patients were arab americans the pi contacted providers who practiced in the study area and if they met the screening criteria they were invited to participate in the study fifteen providers were invited to participate in the study we chose to focus our recruitment on pharmacists and physicians because our previous research and clinical experience suggested that arab americans most commonly seek diabetesrelated care from these two professions recruitment began by contacting arab american pharmacists practicing in the study area pharmacists were provided with inclusion and exclusion criteria for participation in the study and were asked to identify and refer eligible patients that visited their pharmacy to study staff for screening and enrollment patient and provider participants were also recruited directly by the pi through personal contacts in the arab american community and through wordofmouthapproaches that have been effective when conducting previous research in this closeknit community 15 the physician participants for our study were all recruited directly by the pi bilingual recruiting personnel used arabic or english depending on the preference of the approached patient patient participants were included if they selfidentified as arab or arab american were 18 years or older spoke primarily arabic and had a selfreported diagnosis of diabetes pregnant individuals were excluded data collection two digital video recorders were used to record the focus groups the camera configuration allowed investigators to visibly identify all individual patient and provider participant responses diminish the possibility of data loss and effectively address limited instances of semantic noise all patient and provider participants were checkedin given the opportunity to ask questions underwent written informed consent and completed the intake form and questionnaire in a reception area prior to entering a conference room that was setup in advance of participant arrival patient participants were requested to complete a sociodemographic and general health questionnaire provider participants were asked to complete a biographical questionnaire the informed consent stated that focus groups would be audioand videorecorded and notes would be taken during the session participants were then seated at a conference table each focus group began with a brief description of the study purpose and focus group etiquette followed by brief introductions and the opportunity to ask questions and receive answers the skilled moderator a syrian trained physician fluent in arabic and with extensive diabetes care experience conducted the focus groups the provider focus groups included both pharmacists and physicians and were conducted in english while the patient sessions were conducted in arabic provider and patient focus groups followed the same protocol during each session the moderator presented the group participants with four questions specific to their perceptions of dsm barriers and facilitators to dsm and perceived influences of arab american culture on dsm a fifth and final openended question offered participants the opportunity to share any pertinent information or beliefs they felt were not addressed in the previous questions data analysis all focus group discussions were transcribed verbatim because most of the patient focus group participants responded in arabic the patient focus groups were translated from arabic to english next transcripts were reviewed and compared to video recordings by the moderator to ensure accuracy of transcription after review the transcripts were analyzed using an inductive qualitative content analysis approach 21 the analysis procedures began with two researchers independently reading transcripts and assigning codes to segments of text initial codes were then grouped into main themes to assess intercoder reliability the researchers then met to review their codes and discuss their findings which revealed a consensus level of 80 disagreements about codes were discussed until agreement could be reached after this step a third researcher who was not involved in the coding then reviewed and confirmed the final themes and subthemes the consolidated criteria for reporting qualitative research were used when planning and executing this study guba and lincolns 22 four criteria for judging qualitative rigor were also followed results arab american providers included physicians and pharmacists with the majority being male and the remaining 38 female most patient participants were female and many originated from lebanon which is the most common arab nationality represented in michigan 7 approximately half reported no educational degree similar educational findings have been previously reported in dearborn 13 the majority of patient participants reported that their health was fair or poor which would be expected based on inclusion criteria four distinct themes emerged from the discussions of providers and patients perceptions of dsm limited resources for dsm education and support stigma as a barrier to ongoing support family support as an opportunity and challenge and arab american patientprovider relationships each theme is presented in further detail below table 1 includes illustrative quotes related to each theme limited resources for dsm education and support providers and patients agreed that a key challenge was the significant continuum of gaps in availability and quality of culturally appropriate dsm resources for arab americans with diabetes which contributed to patients not understanding the seriousness of the disease or how to perform dsm as one provider group 2 provider 4 stated in the arabic community … most of the time they dont understand the seriousness of a disease one key limitation that providers faced was the lack of linguistically and culturally appropriate dsm educational materials obtaining arabic language dsm materials could be difficult and even when patients were given arabic language materials providers expressed that the content was not always sensitive to arab culture this gap extended to the provision of supportive health services as well providers discussed the need for multidisciplinary teams of arabicspeaking healthcare providers to better facilitate dsm with their patients especially in the context of increasingly brief clinical encounters where it was difficult to comprehensively address their patients dsm needs nonetheless most providers lacked access to such resources and had few alternatives to assist their arab american patients providers also discussed that they did counsel their patients about dsm and that they had to adapt their dsm counseling to the educational level of their patients while also having to address cultural beliefs that impeded dsm taken together providers felt these limitations and barriers impacted their ability to deliver quality diabetes care and guide their patients in dsm while patients also emphasized that education was essential for dsm they did not explicitly discuss access to a multidisciplinary team and with the exception of mentioning pharmacists did not differentiate other healthcare practitioners in their discussions instead patients emphasized that their primary barrier to dsm was the lack of formalized dsme programs and they perceived that a comprehensive program did not exist locally without access to educational resources patients felt ill equipped to engage in dsm and actively advocated for themselves expressing the need for more dsme programs tailored to arab americans see table 1 for examples of provider and patient illustrative quotes stigma as a barrier to ongoing support continuing support was also perceived as important for sustaining diabetes dsm across time a cultural element that providers identified as being a barrier to ongoing dsm support was the cultural stigma associated with diabetes or illness of any kind specifically providers discussed that the stigma associated with disease could lead to patients avoiding acknowledging the disease or engaging in selfmanagement activities providers also expressed that the impact of stigma on health could be significant because it could prevent patients from making healthpromoting choices or cause patients to withdraw from meaningful social activities moreover as one provider noted there were few supports available for patient feeling stigmatized because of their disease interestingly patients did not directly discuss feeling stigmatized though patients discussed that they were not likely to disclose their condition in social situations this was because social activities often centered on food and some they felt that it would be disrespectful to turn something down from someone in their house see table 2 for examples of provider and patient illustrative quotes family support as an opportunity and challenge providers and patients both expressed that family was very important in arab culture nonetheless they differed in their perceptions of how family impacted ongoing dsm providers repeatedly identified the family as an important source of dsm support and that without family supports patients were likely to have poor dsm moreover as the following excerpt suggests providers actively engaged family members in hopes of improving the chances of dsm success giving examples of enlisting the assistance of families to watch out for and motivate patients in contrast patients did not discuss their families as actively supporting their dsm efforts instead patients expressed that daily life stress made their ongoing dsm difficult and often attributed daily life stress to their families in addition some patient participants linked stress to increases in their blood glucose levels thus while family may support arab americans dsm efforts they may also impede them as well see table 3 for examples of provider and patient illustrative quotes arab american patientprovider communication and clinical relationships providers and patients also discussed that the nature of the patientprovider relationship impacted patients dsm efforts both groups expressed that patients held both positive and negative attitudes toward providerpatient interactions but differed somewhat in their views about why patients felt the way they did providers perceived that patients held positive attitudes about providerpatient interactions because healthcare providers enjoyed a position of respect within arab culture because of their social status some patients would make extra efforts to be adherent to dsm regimens in order to please providers the majority of patients that held a positive view of their patientprovider relationship emphasized the provider as a respected authority who was ultimately the best source of guidance on dsm related matters other patient participants with positive attitudes perceived the role of provider as less of an ultimate authority and more as part of a team in this view patients emphasized they did not blame providers for poor dsm both patients and providers held responsibility for successful interactions the primary reason that providers gave for their patients holding negative views of the patientprovider relationship was the tendency in arab culture to associate physicians with illness which could lead to reluctance to seek care from medical professionals dissatisfaction with care and poor adherence to provider recommendations patients that held negative attitudes about providerpatient encounters however did not relate these attitudes to associating their provider with illness instead patients negativity stemmed from their perceptions that arab american providers were not as caring examples of not caring included the perception that providers accepted more patients than they could provide care for that they overly focused on prescribing medications while neglecting other areas of dsm and that they didnt maintain expected followup with patients see table 4 for examples of provider and patient illustrative quotes discussion to our knowledge this is the first study exploring the cultural influences on dsm from the perspective of arab american patients with diabetes and arab american providers while we are unable to generalize our findings beyond our small sample the themes presented here suggest several potential avenues for future inquiry into dsm and associated outcomes among arab american with diabetes one challenge provider participants identified was the lack of basic educational materials available to arab american patients with diabetes arabic language resources are becoming increasingly available nonetheless findings suggest that at least some dsme materials could be further improved by being tailored to arab cultural norms and traditions that impact dsm such as specific dsm instructions during the holy month of ramadan another area of concern was the lack of arabic speaking multidisciplinary teams available to assist arabic speaking patients in the absence of sufficient bilingual allied health staff this barrier may be most feasibly overcome through the use of overthe phone interpreter services while these devices are now commonplace in many hospital settings their use in primary care and related outpatient settings is unclear nonetheless evidence suggests that using such devices may be cost effective and ultimately can contribute to improved patient care in low english language proficiency populations 2223 another way to augment the dsm counseling provided by the physician is the use of group format dsm interventions while purely speculative at this time groupbased interventions may also serve to reduce stigma and increase social supports for those facing dsm one example of this approach is the stanford diabetes selfmanagement program which has been shown to improve selfmanagement practices across a range of conditions and ethnic groups while the stanford diabetes specific program is not available in arabic future research could address programs for use among arab american populations an equally important finding was the different perspectives on the patientprovider relationship although both groups acknowledged patients dissatisfaction with clinical encounters reasons for dissatisfaction differed if providers believed that patient satisfactiondissatisfaction stems from cultural beliefs alone then it was unlikely that they modified other care processes that may have contributed to patient dissatisfaction further the diversity of perspectives arising from this small sample suggests further research is warranted to better identify the root causes of patient dissatisfaction a better understanding of these dynamics is necessary for improving patient provider interactions among this population similarly findings also suggest disparate views regarding the familys role in supporting dsm providers actively recruited family members as partners in supporting dsm while providers felt that this was an effective strategy considering the gaps in dsm education at the individual level it is plausible that family members are equally ill informed about dsm moreover while our study did not explicitly query this domain patients comments about stress and recent research in the area of family involvement in dsm suggests that family members may be unprepared for this role and that patients and family members may experience emotional distress as a result 24 familycentered interventions are gaining in popularity 2526 given the familys central role in the arab culture future research is warranted to examine whether or not intervening at the family level enhances the effectiveness of future dsm interventions in the arab american population limitations despite the important contributions of this current work study findings are limited to the small convenience sample of arab american patients and providers recruited from one geographic area this sample also includes a high percentage of recently emigrated arab americans immigrants who had limited formal education these findings should therefore be interpreted with caution and may not reflect the challenges faced by other healthcare providers who care for arab american patients or the opinions of other arab americans with diabetes conclusions study findings suggest several domains that should be considered in future work and that hold relevance for clinical practice specifically the current study suggests that there is a need to develop linguistically and culturally reliant dsm educational materials and relevant supports for use in the arab american population further the findings draw attention to the differing views that providers and patients have on the role of family members in supporting dsm efforts and why some patients feel dissatisfied with clinical encounters informed by these findings we are currently working to develop a familycentered dsm intervention and systematically evaluate the effects of this approach on dsm outcomes in arab americans with diabetes competing interests the authors declare that they have no competing interests all authors listed on the manuscript contributed to the study design data collection data analysis and interpretation of the findings and drafting and reviewing the final manuscript

background arab americans have a high burden of diabetes and poor outcomes compared to the general us population diabetes selfmanagement dsm requires a partnership between patients and providers that fosters mutual understanding and shared decisionmaking cultural factors influence this process however little is known regarding the cultural impact on dsm or if perceptions differ between patients and providers methods qualitative content analysis was used to analyze five focus groupstwo groups with arab american providers n 8 and three groups with adult arab americans with diabetes n 23 focus groups examined patient and provider perspectives on the meaning of dsm and cultural barriers and facilitators among arab american patients results four distinct themes included limited resources for dsm education and support stigma as a barrier to ongoing support family support as an opportunity and challenge and arab american patientprovider relationships conclusions findings indicate several domains should be considered for clinical practice including a need to develop linguistically and culturally reliant educational materials and relevant supports for use in the arab american population findings highlight differing views among providers and patients on the familial role in supporting dsm efforts and why some patients feel dissatisfied with clinical encounters

introduction the covid19 pandemic has persisted in indonesia for more than two years and has yet to be officially concluded despite a decline in the number of cases positive cases continue to be reported as communicated by the world health organization in addition the provinces with the highest number of cases include dki jakarta west java central java east java and banten covid19 is primarily transmitted through the human respiratory tract specifically in the absence of health precautions such as mask usage hand hygiene and physical distancing viruses attached to droplets or splashes produced during coughing or sneezing can enter the respiratory tracts of others potentially altering how individuals and society perceive and interpret the risks associated with the disease risk perception refers to individuals subjective responses to disease death and injury and their assessment of managing the attached risks factors influencing risk perception range from individual aspects such as experience beliefs judgment attitude knowledge conception and misconceptions to wider aspects such as social cultural and organizational structure the world health organization issued preventive measures in the form of health protocols after observing the characteristics of the transmission mode of covid19 such measures include wearing masks to cover the nose and mouth maintaining a 15meter distance between individuals and frequent hand washing using water and soap or alcohol the study conducted in the united states by bruine de bruin and bennett showed that communities have implemented protective behaviors it is essential to consistently promote efforts to raise public awareness about the virus and control its spread by implementing health protocols since it is a present public health risk by suppressing the spread the burden on health facilities in terms of accommodating and treating patients will be reduced in addition learning from the occurrences in various countries transmission can only be successfully suppressed through discipline and strict implementation of control measures health promotion is one measure expected to suppress the spread of covid19 by shaping behaviors both individually and in groups the implementation of health protocol still appears to be underestimated this might be due to the lack of proper risk perception in the community or ignorance of the effects and transmission of covid19 in the community this study aims to analyze community risk perception information regarding covid19 transmission experiences in indonesia this covers several aspects including the number of victims severity transmission speed of transmission seriousness fear outdoor transmission not wearing masks ability to control transmission and transmission readiness method instrument this analyticdescriptive crosssectional study was conducted involving participants aged 18 years and above it was carried out from june to november 2022 and covered all provinces in indonesia ethical approval was obtained from the research and community engagement ethical committee faculty of public health university of indonesia data collection involved the use of online forms designed using google forms and distributed through social media the questions presented to the respondents contained sociodemographic data including covid19 experiences and ten questions on the risk perception of covid19 the questionnaire was standardized based on effective communication in outbreak management for europe 2015 furthermore the health belief model approach was used as a framework to construct the survey before combining it with demographic backgrounds such as gender covid19 transmission experiences religion occupation and education sample size in this study the sampling method used was purposive sampling and the population sampled was obtained from the updated covid19 cases in indonesia reference was made to the indonesian governments covid19 database on august 2022 with a total of 6049541 cases using the slovin formula the minimum sample size required was 400 respondents chisquare was used to analyze the data while the software used was spss version 25 results demographic characteristics data were collected from 775 respondents from several regions in indonesia the majority of respondents were muslim followed by catholic protestant buddha hindu konghucu and those who were not willing to mention the place of origin was mostly west java dki jakarta south sulawesi bali central java banten east kalimantan and other provinces most respondents were female private employees and bachelors degree holders furthermore the covid19 experience data were collected from 760 respondents with 474 reporting no transmission and 438 previously infected table 1 presents the sociodemographic data of respondents regarding the distribution of risk perception data among respondents the majority perceived that covid19 results in many victims causes severe health effects is contagious has a fast transmission rate and is a serious disease additionally 6206 of the respondents reported fear of this disease and 7626 believed that outdoor activity increased the risk of transmission specifically when they were not wearing a mask despite most respondents considering the disease as a serious threat 8206 reported readiness to face the transmission risk and 𝑛 𝑁 1 𝑁𝑒 � � 8168 of respondents are able to control the risk as shown in figure 1 data analysis the data analysis revealed a significant correlation between covid19 experience and various factors including the perceived number of victims severity transmission transmission speed seriousness readiness to face the risk of transmission perceived ability to control transmission risk and perceived risk of transmission while not wearing a mask and engaging in outdoor activities the p values for these correlations are 0001 0010 0000 0000 0005 0018 0004 and 0002 respectively however there was no correlation between covid19 experience and perceived dread or perceived risk of transmission during outdoor activity with p values of 0105 and 0111 respectively discussion experience with covid19 transmission table 3 presents the responses to the question of whether respondents had ever been infected with covid19 which were divided into three categories namely never been infected and unknown based on the responses 474 of the respondents reported that they had never been infected while 438 had been infected figure 1 shows that regardless of their transmission experience category most respondents perceived covid19 as a threat with 8581 believing it causes many fatalities and 8194 reporting severe health effects the same trend was observed for other risk perception questions an example of respondents covid19 transmission experience is their infection or that of their close relatives this result is consistent with the expectations that the covid19 transmission experience would trigger and impact community risk perception numerous factors affect individuals risk perception which can be classified into internal and external factors internal factors include demographic data such as gender education level and occupation these data are closely related to individual perceptions when observing certain objects or events regarding respondents occupation data distribution the majority work in the private sector followed by students and government officials these areas have the most information regarding covid19 and also have a high potential for transmission due to their intense and frequent interaction another data distribution also revealed that most respondents are from dki jakarta and west java both of which have a high number of active cases the educational background of most respondents is a bachelors degree which provides greater access to covid19 profile information several studies showed that the community dreads the rapid transmission of covid19 according to domínguez et al direct contact with a person who suffered from covid19 has a significant impact on the communitys risk perception this is evident when individuals have relatives who work in healthcare facilities or live with relatives who suffered from covid19 as the likelihood of transmission increases another study conducted by ruizfrutos et al revealed that the pandemic has resulted in a decrease in individual psychological conditions this is attributed to the fact that many individuals work outside the home and meet and interact with other people resulting in exhaustion decreased sleep and increased work stress subsequently this affects the psychological aspect and body endurance and causes reduced personal hygiene dyregrov et al found that young people in norway experience three essential qualitative aspects related to covid19 dread the first is the fear that the virus will infect their family members or close relatives despite implementing tight health protocols the second aspect is the fear of contracting it themselves as it could limit interaction with parents and friends and influence their performance at work and school the last aspect is related to social situations such as the pandemic persisting for a long time deteriorating or collapsing the social life order and economic conditions or leading to massive deaths the covid19 pandemic has created various ways for individuals or communities to respond to the transmission and prevent it individual risk perception plays an important role in the effectiveness of implementing voluntary health protocols abdelrahman stated that individuals who tend to comply with social norms and have anxiety or fear prefer to implement physical distancing this is because in direct social interaction there is a risk of rapid transmission furthermore the willingness to implement health protocols is influenced by how the community perceives covid19 whether as a threat or not individuals who have had any experience with the virus regardless of whether or not they have been infected will have many considerations when implementing health protocol different perceptions might arise among individuals who have varying experiences with covid19 for example those who have no experience may not prioritize the implementation of health protocols meanwhile individuals who have had close relatives friends or themselves infected would consider health protocol implementation essential and mandatory risk perception and self efficacy the distribution of risk perception data from the number of covid19 victims severity transmission rate seriousness dread and the perceived risk of transmission during outdoor activities without wearing a mask showed that over 70 of respondents perceive covid19 as a threat with negative outcomes interestingly more than 80 of respondents despite perceiving it as a threat were ready to face the transmission and believe they can control the transmission this suggested that most respondents were well informed had prepared and understand how to control the transmission according to the health belief model theory the first aspect to be considered in implementing the protective behaviors in this case health protocol is to the management of the perceived threat this involves perceived susceptibility and severity as well as perceived barriers and benefits of implementing health protocols and selfefficacy to trigger cues that promote actions to prevent transmission all of these aspects of perception are correlated in addition the perceived threat will affect individual perceptions when the susceptibility and severity of covid19 infection is significant the health belief model risk perception theory also underscores the importance of the perceived benefit of implementing protective behaviors in other words the health protocols will not be established unless these measures provide benefits and eliminate the threat of transmission susceptibility and severity the perceptual entry into the cognitive aspect is also influenced by perceptions of barriers and selfefficacy in determining the necessary protective behaviors and precautions therefore the lack of complete information knowledge socioeconomic condition and beliefs can impede individuals from implementing health protocols the study conducted by jose et al also showed that inadequate knowledge may prevent individuals from implementing behavioral changes due to its impact on risk perception factors such as learning from experience new information and observation can positively and negatively impact individual selfefficacy social media also plays a vital role in communicating the risks of covid19 such as the disease profile transmission modes treatments government policies and protection programs particularly for individuals with a lower level of education it aids in conveying new information forming perceptions sharing insights and facilitating interaction with other readers as well as building community resilience in the face of the pandemic the method used to disseminate information affects the public risk perception knowledge and actions taken therefore the media should communicate clear and accountable information misunderstandings can arise when respondents lack awareness of the covid19 characteristics or obtain information from inaccurate sources this study revealed that 613 of respondents were women while 387 were men several studies have shown that women have higher risk perception than men including perception of fear and caution this could be because women have more data on the severity of covid19 than men this result is also consistent with the study conducted by yoo shim and kim that stated that at the onset of the pandemic many housewives with schoolage children had more anxiety and sought accurate information on the covid19 profile and how to control it selfefficacy is critical in enabling individuals to discover incomplete information remove barriers and determine the necessary actions to implement health protocols the threat of covid19 transmission can also be seen as fatal as it creates conditions that are considered severe and uncertain this transmission risk can also serve as an early warning indicator where individuals apply control measures or health protocols to prevent losses however the limitation of this study is that it only seeks information and measures the correlation between risk perception and covid19 transmission experience among individuals in indonesia conclusion based on the results several factors influence the risk perception of covid19 in the community the accuracy and sources of the received information significantly determine how the public perceives the dangers of covid19 transmission experiences in individuals or communities shape their perspective of the disease profile individuals who have been infected with covid19 might have a different perception from those who have not been infected furthermore events such as covid19 transmission involving their relatives and friends will also shape their risk perception specifically in implementing protective behaviors such as health protocols control measures based on gender are also considered important to reach effectiveness of the covid19 risk management

the covid19 pandemic in indonesia has not officially ended and due to the apparent underestimation of protective behavior it is imperative to continuously promote public awareness and implement health protocols to control its spread therefore this study aims to analyze the communitys risk perception and experiences of covid19 transmission in indonesia method this study was conducted in 2022 using an online survey the questionnaire was developed based on a standard questionnaire ecom 2015 on the risk perception of an infectious disease outbreak it was then distributed through various social media platforms including whatsapp facebook and instagram result according to all ten risk perception distribution data the majority of respondents considered covid19 a threat this showed that most respondents had intense covid19 transmission directly or indirectly this study also revealed that there were more female respondents than men conclusion individuals who had contracted covid19 might have different perceptions compared to those who had not been infected furthermore experiences such as the covid19 transmission involving relatives and friends might also shape an individuals risk perception particularly in implementing protective behavior in this case health protocol control measures based on gender should also be considered to ensure the effectiveness of the covid19 risk management

introduction as the academic field of entrepreneurship has evolved and matured it has benefited from the injection of ideas derived from a broad array of theoretical traditions and methodologies the borrowing of approaches from other fields has helped to cultivate the garden of entrepreneurial theories…from many different disciplines and perspectives this has allowed entrepreneurship researchers to develop and refine understanding of the social processes involved in entrepreneurial action and has led to novel and incremental advances in theory development focusing on the domain of social entrepreneurship we seek to contribute to this task of theory extraction generation and extension by using the conceptual lens of bricolage social entrepreneurship has become an increasingly significant domain of enquiry its emergence is closely aligned to changing perceptions about the role and function of markets whereby particularly in the late twentieth century it came to be seen as an important mechanism for supporting economic activity in areas deemed unprofitable by the private sector and neglected by the state there is now an established body of work which has firstly they pursue revenue generation strategies through trading organizations in the nonprofit sector have traditionally relied on donations and philanthropy for their income however towards the end of the 20 th century in western society a new logic began to emerge which promoted independent revenue generation from trading this was in part due to the gradual withdrawal of traditional sources of contributed income such as grants and donations as well as increased expectations by governments charitable foundations and others that organizations in the sector become more enterprising and financially sustainable the advantages of revenue generation from trading are that it increases the autonomy and flexibility of the organization to adapt to and meet the needs of the constituencies they serve once released from the restrictive covenants of grants and donations social enterprises have been encouraged to be innovative in the business models they implement the generation of revenue from trading confers greater independence on the social enterprise in terms of its legal structure strategies and markets served secondly they aim to achieve social and environmental goals thus the purpose of the social enterprise extends beyond simply revenue generation or profit maximization to include producing goods and services in response to the needs of a community their ethos of financing social purpose through commercial activity ensures that their social outcomes are integral to their economic performance di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x thirdly as well as supplying products and delivering services to individuals and communities they seek to generate additional benefits such as increased social capital and enhanced community cohesion this is achieved through close and active stakeholder participation in the creation and management of the enterprise as well as its governance structures and procedures when done effectively this ensures that social enterprises are both embedded in and remain accountable to the communities that they serve therefore at their core social enterprises are businesses that are marketdriven with commercial interests and activities used to effect social and community benefits finally although social enterprises can be found in a range of contexts they are most closely associated with communities characterized by limited access to resources and typically emerge as a response to the lack of facilities and services in those communities both urban and rural resource constraints push the social enterprise into finding innovative ways of using existing resources and acquiring new resources in order to achieve both financial sustainability and generate social outcomes it is the distinctive nature of the resource constraints that social enterprises face which is of particular relevance for our study while most entrepreneurs operate under conditions of resource scarcity social entrepreneurs face a specific set of challenges because they purposely locate their activities in areas where markets function poorly thus while commercial entrepreneurs seek markets with sufficient carrying capacity to support growth social entrepreneurs actually seek markets characterized by a paucity of resources this raises some intriguing issues about resource acquisition in the context of social enterprise and underpins the motivation for our research more specifically our study sought to address the following question how do social enterprises acquire resources in resource scarce environments using evidence derived from case studies of eight ukbased social enterprises our paper di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x augments current understanding of the processes involved in social enterprise creation to explore the specific issue of resource acquisition we draw on theories of bricolage and seek to extend them by proposing a new model of social bricolage the structure of the paper is as follows to begin we outline our theoretical framework which is rooted in existing conceptualizations of bricolage this is followed by a discussion of the methods used to collect and analyze the empirical data the analysis then distills from the data evidence of the core principles of bricolage as well as a set of processes that are distinctive to social entrepreneurship the conclusion summarizes the theoretical tenets of what we propose as a new concept of social bricolage and suggests areas for future research conceptual framework entrepreneurship and resource cooptation the creation of an enterprise clearly requires resources and entrepreneurs have been found to use a range of tools and strategies to garner resources to establish their ventures resources resource limitations and resourcefulness are therefore central concepts in the study of entrepreneurship the literature highlights a number of ways in which entrepreneurs assemble resources in resource poor environments these include the use of networks and social resourcing financial bootstrapping strategies of effectuation and bricolage we consider these in turn there is an extensive body of work on entrepreneurial networks and their fundamental role in providing access to knowledge information and resources while many of the resources that entrepreneurs acquire through networks are tangible such as capital and physical assets others are relational for example the literature on social resourcing and social contracting di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x emphasises that social as well as economic exchange is a significant element of resource acquisition particularly under conditions of resource scarcity these studies highlight how entrepreneurs use personal networks such as kinship ties and family mentors in order to access support skills and experience thereby facilitating market penetration financial bootstrapping acknowledges the important role that resources not owned or controlled by the entrepreneur often play in new venture creation sometimes used colloquially it is essentially concerned with the sources from which entrepreneurs with limited funds access finance for their ventures bootstrapping techniques aim to avoid using finance raised from external investors such as venture capital public equity and debt financing winborg and landstrom identify six specific bootstrapping methods namely owner financing minimizing monies owed to the firm sharing equipment andor staff with other firms delaying payment of monies owed by the firm minimizing inventory and subsidy finance bootstrapping emphasises finance acquisition during startup and could be considered indicative of bricoleurial activity another concept that sheds light on the process of entrepreneurial resource acquisition under conditions of resource scarcity is effectuation rooted theoretically in march and olsens work on organizational learning the strategy of effectuation is an approach to decision making whereby an entrepreneur envisions a range of possible pathways for his or her firm rather than a definitive goal or objective and seeks to exploit environmental uncertainty by responding intuitively to situations as they arise rather than eliminate uncertainty through meticulous forward planning di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x venkataraman and sarasvathy use the metaphor of a patchwork quilt to illustrate this phenomenon while each patch used in the quilt is a rather arbitrary piece of fabric some belonging to the quilter and others brought to them at one time or another by friends a good quilter manages to construct an aesthetically appealing and even meaningful pattern while a strategy of effectuation carries with it a higher risk of entrepreneurial failure it is also liable to be more efficient because entrepreneurs following it are able to change tack more easily in response to changing circumstances and to take advantage of new resources as they become available these approaches go some way towards an appreciation of the social dimension of entrepreneurship and the more personal intangible and opportunistic mechanisms used by entrepreneurs to acquire resources and build competitive advantage however they are arguably limited by the fact that they have been designed specifically to explain the challenges associated with the creation of a commercial venture while we acknowledge that these literatures do have the potential to shed light on social enterprise dynamics we feel that the concept of bricolage is most appropriate in this respect while as noted below bricloage has been used to consider commercial entrepreneurship its application to other social and economic domains suggest that it is a flexible approach that may be especially suited to the study of an organizational form designed to create both social and commercial value under conditions of resource scarcity bricolage and resources lévi strauss introduced the original concept of intellectual bricolage to refer to the process of making do with what is at hand he used the bricolage metaphor to contrast two parallel world views the mythical and the scientific as distinct but equal modes di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x of thought unlike the scientist the individual bricoleur acquires compiles and stores materials for future use the awareness of their eventual application remains unformed in the early stages of resource acquisition creating flexibility for their later deployment for whatever purpose at hand the tools not only shape their end purpose but the purpose is also shaped by the resources available the nature of resources and resultant project are thus unrestricted a priori and are only made apparent through the bricolage process as a theoretical concept bricolage has been applied to a range of disciplines and contexts theorizations have elucidated the conceptual components of making do as using resources at hand for new purposes these have been interpreted in various ways in cultural anthropology they involve the development of new ideologies and ways of thinking by adopting elements of existing myths and social world views in jurisprudence they involve the construction of new laws from fragments of existing ones in education they involve drawing upon existing skills and competencies in dealing with challenging learners and in genetics there is a particularly prominent field of evolutionary bricolage in their sociological study of erosion of categorical boundaries rao et al explore bricolage as hybridization using the blending of elements between classical and nouvelle cuisine styles within french gastronomy to illustrate the process the closely aligned terms of political bricolage and institutional bricolage are both used sometimes interchangeably to refer to the process of making do by applying the elements of prior and existing institutions for the creation of new institutions in this way the categories and frames of reference in use are subject to a continuous process of social reproduction through applying bricabrac remains of previous debates and assertions for the next issue at hand individuals act as di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x bricoleurs by improvising borrowing and experimenting with new or tinkering with existing elements this notion of institutional bricolage has subsequently been applied to development case studies to denote a process whereby institutions are constructed through borrowing practices and styles of thought that are already part of existing institutions the characteristic of making do is frequently found in accounts of social entrepreneurship for example the business model of the furniture resource centre is based on the collection refurbishment and resale of domestic furniture which is no longer needed by its owners as is the business model of greenworks which specializes in recycling office furniture the furniture is donated to these organizations which then make do with them to create a strategy of selling the products to individuals communities or organizations bricolage has been used to denote resourcefulness and adaptability within an existing context the bricoleur is said to be ready to deploy whatever strategies are required under various circumstances such as new organizational combinations in response to unpredicted activity and disasters the process of bricolage thus denotes a dynamic assembly of ongoing transformations and reconfigurations in the entrepreneurship literature bricolage has been used to analyze entrepreneurship in resource poor environments baker and nelson investigated the process of making do by applying combinations of the resources at hand to new problems and opportunities they proposed that entrepreneurial bricolage occurs when entrepreneurs in resource poor environments recombine elements at hand for new purposes and in doing so exploit contributions unutilized by other firms their di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x analysis extended the concept beyond making do to include refusal to enact limitations whereby actors consciously and consistently tested conventional limitations rather than enactment per se baker and nelson specifically emphasized an entrepreneurial refusal to be constrained by resource limitations imposed by institutional andor political settings thus rather than refusing to enact actors resist environmental constraints imposed upon them other studies have contrasted bricolage approaches with breakthrough strategies in technology entrepreneurship breakthrough strategies attempt to generate dramatic outcomes that exceed rivals efforts but lack bricolages adaptiveness and actors resourcefulness in deploying more modest resources to progressively pursue their ends thus the principle of refusal to enact limitations is a recurring theme in the entrepreneurship literature in terms of social entrepreneurship the failure of the private sector and government agencies to supply products and deliver services to communities is the institutional void into which social enterprises have stepped the financial limitations of inadequate market returns or the governance gap resulting in an inability to define and deliver appropriate services is overcome by innovative strategies adopted by social enterprises to satisfy unmet demand for example sunderland homecare associates has built on its close relationships with and deep knowledge of clients needs to create a social enterprise which provides domestic care services to clients across the north of england the limitations of the market are overcome by a business model which is based on contracts with local government agencies to deliver services and their close relationships with carers and their clients is used to accurately define and deliver the services required by individual clients the constructs of making do and refusal to be constrained by limitations imply a close relationship in practice to improvisation miner et al for instance investigate organizational improvisation and comment that such extemporaneous activity offers a promising lens for investigating processes whereby actors are engaged in making do with materials at hand weicks study of the mann gulch fire disaster in montana in 1949 links bricolage irrevocably with improvisation he draws on lévi strauss and also harper to show that improvisation as part of bricolage can result in organizational resilience thus actors reconfigure themselves as bricoleurs people able to create order out of whatever materials were at hand in order to swiftly replace a traditional order with an improvised order bricoleurs remain creative under pressure…and they proceed with whatever materials are at hand knowing these materials intimately they are then able usually in the company of other similarly skilled people to form the materials or insights into novel combinations baker et al similarly highlight the concept of improvisation when they state that bricolage is a construct frequently used to describe the resource set invoked by improvisation miettinen and virkkunen refer to bricoleurs as tinkerers…improvising imagining playing and searching for new unexpected cultural resources however the treatment of bricolage and improvisation and their relationship to one another varies due in part to the fact that improvisation has received a greater amount of scholarly attention than bricolage in organization studies to date some use the terms interchangeably or tend to characterize bricolage as a feature of organizational improvisation di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x whereas others argue that improvisers often engage in bricolage but claim that this may occur separately as a precursor to improvisation the characteristic of improvisation broadly construed across resources and strategies is also a common theme in the social entrepreneurship literature in many communities the availability of an unused and no longer needed capital asset is the starting point for community mobilization to create a social enterprise for example in england the origins of the goodwin development trust and ibstock community enterprises can both be traced back to the acquisition by community groups of a vacant terraced house in the city of hull and the village of ibstock respectively and the luton innovation centre to a former hat factory in the city these social enterprises have each improvised the assets to create office space for rental as part of their business model the notion of the social is central to bricolage within a social entrepreneurship frame of reference the relationships between individuals their interactions and networks are key facets of the social dimension of entrepreneurship and are indeed an endemic feature of the bricoleurial toolkit interesting links in this vein are implied by johannisson and olaison who use the term social bricolage to infer social networking activity and spontaneous collective action as part of an emergency rapid response we extend their thinking to examine the creation and development of social enterprises in summary the concept of bricolage is characterized by the constructs of making do refusal to enact limitations and improvisation few studies to date have adopted this theoretical lens to study social entrepreneurship social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x zahra et al 2009 our research therefore extends a small but important body of work which examines the microprocesses of social enterprise creation our empirical analysis will point to the fact that although the main constructs of bricolage are indeed applicable to and characteristic of social entrepreneurship three further constructs are also integral to this process through our case study analysis we will suggest that these three further constructs when combined with those constructs identified in the existing literature on bricolage combine to produce a new model of social bricolage methodology approach and data collection the empirical research adopted a qualitative methodology and employed a multiple embedded case study design table 1 provides a brief description of the eight social enterprises from which we gathered data from informants the participating organizations were selected to represent different geographical locations within the uk and a range of social enterprise contexts derived from pearce a diverse and heterogeneous group of organizations was selected to enable theoretical diversity and allow for extrapolation and saturation both within and across cases the cases include social enterprises in urban and more rural locations and engaging in the following activities trading service delivery contracts and crosssector partnerships cultural arts community development education and employment skills training childcare provision community safety lowcost transport recycling and infrastructure and subsidized housing the purposive di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x sample was used to identify common behavior patterns among units of analysis which face diverse resource conditions and constraints thus allowing for greater claims to theoretical extraction than with a more homogenous sample the tendency for social enterprises to be situated within environments that are de facto resource poor justifies an investigation of social entrepreneurial actions orchestrated to counter these constraints and create social value a series of semistructured interviews was conducted with informants from each social enterprise the first interview at each enterprise was with either the chief executive or a senior manager and this was followed by further interviews with other informants identified as important by the first interviewee this approach gave access to multiple informants from each participating enterprise all interviews were taperecorded and later transcribed verbatim and we have used extracts from the texts from 16 informants to develop our framework of social bricolage to respect the anonymity of our informants the names and businesses have been allocated a code hence when we refer to primary data we use a crossreference index of the social enterprise as identified in table 1 in addition to the interviews site visits observations and documentary evidence have been used to add depth to the case studies insert table 1 here analysis data analysis included individual case study analysis and crosscase comparison and was carried out using atlasti a qualitative analysis software package for data management coding and retrieval the operating principle of atlasti is based on the technique of thematic analysis in line with established procedures for inductive theorybuilding social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x 1998 miles huberman 1994 we worked recursively between the data from each case study and the existing literature and then between the data and analysis from the eight case studies to begin a list of conceptual categories was identified in the literature relating to bricolage and this was used to create an initial thematic template the template was then used to sort the data gathered in the first round of primary data collection from the field for each case study the initial template was used and then extended to include any new themes found in the specific case the purpose of this was to conceptually categorize the text for each case study this was followed by crosscase comparison during which the themes from each case study were compared and elaborated following repeated interrogation of the literature and primary data text extracts from across the range of informants were isolated and recurrent patterns in the data grouped into conceptual categories thus the interview data were subject to data reduction and interpretation by means of thematic coding and both within case and crosscase comparison we then extracted the new conceptual dimensions which emerged from this process to develop the framework of social bricolage insert table 2 here the inductive coding strategy using atlasti uncovered the categories of social bricolage our analysis also supports and provides more detail about the existing constructs of bricolage table 3 demonstrates the analysis and coding strategy used the different categories yielded by the data and the relations between concept dimensions these are divided into overarching meta codes construct dimensions and subcodes themes elicited from interrogation of the data concept dimensions both those derived from the literature and those emerging from the di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x empirical data are conceptually linked unpacking and then linking the subelements in this way shows how social bricolage is constituted in practice moreover the conceptual links identified show the value of the method in drawing together the full palette of activities and strategies for dealing with resource scarcity employed by the social enterprises the next two sections of the paper delve further into construct relations through explication of our empirical findings insert table 3 here bricolage and social entrepreneurship as might be expected from a qualitative study the empirical data consists of extracts of text from interviews with informants given the constraints of space we are parsimonious with our use of data in the discussion however we present additional data in table 2 to illustrate the processes of data extraction crosscase comparison and synthesis this combined with table 3 shows how the emergent and inductive analysis was informed by the multidisciplinary literatures on bricolage and extended by the empirical data making do the first construct of bricolage was identified as making do this refers to a process whereby bricoleurs acquire resources and recombine them in novel ways to solve problems and respond to opportunities this carryover or recombination of resources is akin to penroses notion of the services or new uses that the resources can render as determined by the new functions to which they are put the characteristic of di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x making do was observed in all eight cases for the purpose of social value creation this process involves three main approaches to resource acquisition and construction creating something from nothing such as creating a new market or providing a new service where none existed beforehand using discarded disused or unwanted resources for new purposes and using hidden or untapped local resources that other organizations fail to recognize value or use adequately an example of bricolage as making do by providing a new service where none existed beforehand was given by the chief executive of case 4 he described how the enterprise had grown from a local resource base as a response to the lack of amenities and facilities in a deprived housing estate with severe social problems including high unemployment poor housing and high levels of crime the social enterprise was initially established as part of a smallscale community centre with the aim of offering skills training and improving employment opportunities for local people and making available social amenities such as a public house and a network of community wardens to promote safety on the estate the success of these initiatives resulted in a rapid process of enterprise growth and generated further demand for services which were subsequently delivered across a larger geographical area this process of creating something from nothing was emphasized you know were a service provider for the community providing a citywide service that we interviewee emphasis invented it wasnt there before and thats hugely a second aspect of making do is the reuse of unwanted materials discarded by others when their practical use is perceived to have expired this activity involved the recombination or manipulation of resources sought donated or happened upon for example the entire business model for case 6 a social enterprise founded in 1995 was based on the recycling of discarded and disused computers from corporations and refurbishing them for community use the chief executive described the way this evolved from a local community initiative established to enhance employment skills through computer literacy thus social value creation was not determined a priori but was largely shaped by the resources that were available initially we wanted to train wouldbe women returnees in computer skills we had a very stark choice which was that if we wanted 12 computers which we did we needed to arrange the finance for 12 computers and in those days that was a fair amount of money… i didnt see the point quite honestly of trying to raise all that money when somebody surely would give me 12 computers for free… so i persevered and eventually came back to me and said that they had some computers and how many did i want so that was my first moment of entrepreneurial genius… i think we probably ended up with far more than 1000 …it was quite easy… so we started looking at ways of actually making it into a company it really was one of those sitting in the pub type conversations and somehow out of that came the idea well actually the natural environment is an asset isnt it particularly wind…so that started the idea for the wind farm project in sum we believe that the evidence we have presented clearly supports the enactment of strategies consistent with making do in the social enterprises that we studied we suggest that for social enterprises seeking to create social value in the context of resource scarcity these strategies are quite typical refusal to enact or be constrained by limitations the second construct of bricolage identified by baker and nelson is a refusal to enact limitations this refers to efforts to test andor counteract existing or conventional limitations imposed by institutional or political settings and the available resource environment based on our analysis we have recharacterized this as a refusal to be constrained by limitations our data revealed this to be an important aspect of the behavior of the social enterprises that we studied we found specific examples of respondents consciously and consistently counteracting conventional limitations imposed by their environments and developing solutions to subvert these limitations in order to create social value di domenico m haugh h and tracey p funding or cuts in government funding this feature of the environment affected all the social enterprises in our study and had led informants to identify local resources at hand which could be converted into assets all the informants discussed at least one strategy to counteract this limitation responses tended to concentrate on assetbased development whereby property and other capital assets are acquired or constructed in order to secure a stable and regular income stream from rent paid to the social enterprise as well as illustrating their ability to make do with resources at hand for new purposes this strategy demonstrates their adaptability to changes occurring in the macro regulatory environment and a refusal to be irrevocably constrained by these limitations i think being a social enterprise has got a different set of problems trying to achieve social compliance with goals at the same time which everyone holds up as the holy grail or peaches and cream is not that easy to pull off unless youre very big and have a lot of assets i dont think it matters what were called its what were trying to do thats important the following anecdote from the chief executive of case 1 provides further evidence of this response to reduced availability of funding faced with the prospect of a major reduction in eu grant funding their main income source the executive team decided to use a former religious building as an asset base to compensate for the lost income the chapel was owned by the local authority who wanted to demolish it to make way for a new di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x road however before doing so they were constitutionally required to ascertain whether any public use remained for the building by the local community a strong case for retention was made by the social enterprise and ownership of the chapel was then acquired the building now provides space for arts and drama workshops for the local community and generates significant income for the enterprise we were really into this idea of assetbased development owning assets that would generate an income…wed bought a derelict chapel and converted it into a community facility and we did have tenants in there who provided a level of income we had other aspirations to develop more buildings but i think we would just think transcendentally really about other assets another way in which social enterprises challenge the limitations imposed by resource constrained environments which inhibit their ability to create social value is by subverting existing structures the main example of subversion that we encountered involved social enterprises setting up a legally distinct forprofit trading venture to generate additional revenue streams and diverting funds from this venture into sociallyoriented activities such forprofit ventures are often located in relatively affluent areas which are more able to sustain marketbased activity and where resource constraints are less pressing for example one of the social enterprises we studied owns and controls commercial retail outlets which are managed as social franchises in association with a large corporate retailer profit is generated through retail trading outlets which in turn use positive discrimination to recruit and employ lowskilled and longterm unemployed local people in this way the profitmaking di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x ventures either directly provided employment for or crosssubsidized social activities to counter the limitations of resource poor environments people talk about the socalled debate between the social and the economic were living it and its a continual debate and a continual challenge its about managing it and making decisions in our data we identified a broadly shared strategic response to traditional structures and limitations two expressions of this were particularly evident namely trying out solutions to counteract limitations imposed by institutional and political settings and subverting the limitations imposed by available resource environments on their ability to create social value thus whilst their aim was to counter the limitations imposed upon them the social enterprises in our study were nevertheless acutely aware of their social obligations and the consequent constraints they face whilst active resource seeking and in many ways entrepreneurial they are at the same time pragmatic in the way they conduct business improvisation the third construct of bricolage improvisation is associated with adapting standard ways of working and creative thinking in order to counteract environmental limitations the need to improvise by initiating a range of projects and constantly responding to potential opportunities was frequently mentioned by informants it can be considered as part of the social entrepreneurs toolkit through which a best fit approach is shaped within the constraints of limited resources we provide evidence for this activity and show how it is used as a mechanism to generate social value in impoverished environments repeated testimonies and observations point towards the use of improvisation in the social entrepreneurs response to resource scarcity specific tactics are used to make the social enterprise more resilient and foster useful networks various terms used by participants to refer to their enterprises allude to this process for example the chief executive of case 3 described the way he acted as a bit of a chameleon by appealing to the relevant audience at the relevant time in order to engender support and access finance adopting strategies that involved trying things out to generate social value or responding in a way that benefitted community needs was emphasized as important by all informants even when such methods were not necessarily the most financially efficient informants also reported that they were willing to try out different solutions to social issues even where they involved greater risks of failure than alternative but less communitydriven strategies this indicates the prioritization of social value creation over revenue generation and the adoption and shaping of bricoleurial strategies in ways that are best suited to the particular circumstances of the social enterprise and its context for example an important priority for all informants entailed involving members of the local community in decisionmaking and governance of the social enterprise this created social value by fostering community engagement through active participation and dialogue however finding an appropriate composition of board members was often challenging this process was managed through trial and error and adaptation rather than by devising prescriptive a priori characteristics for determining the selection of board members di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x well you could say what is he doing hes retired what does he know he used to work in a shop i mean its terrible really theyre given no credence at all and thats irritating because i have the utmost respect for people who have put in a fantastic amount of effort … were very willing to just take any sort of not even risks really try anything …there are nicer places to live than this if were going to make this a nice place to live lets try something out why dont we just give it a go its not going to cost much lets just try it it might work we wont pay them anything well just get them to come along if they make mad decisions and try and run off with the money well well get rid of them again but just give it a try the process involved sustained perseverance in order to achieve the enterprises social mission the same informant went on to explain that you get half a dozen people who turn up for a board they havent got a pa they havent got anybody organizing their notes we turn up with a pile of papers like that please read that i mean its very difficult people need support it takes time for them to get into that what you need to do is gear your organization up to support them this section has presented field data to illustrate how the concept of bricolage relates to the creation and management of social enterprises specifically the empirical evidence provides support for the three constructs of making do a refusal to be constrained by limitations and improvisation in addition to these constructs through our coding we found empirical di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x evidence of three further processes namely social value creation stakeholder participation and persuasion we consider these processes in the next section social bricolage social value creation the aim of creating social value is a defining characteristic of social enterprises and is espoused in their articles of association policies and procedures and enacted in their business model and operating strategies this characteristic has not been considered in previous expositions of bricolage which have focused on individual entrepreneurs and private enterprises social value creation has already been referred to in the previous section on bricolage and in table 1 and therefore we present just one further example here specifically informants from case 3 were acutely aware of the need to remain effective and to counteract the difficulties of working for and within resource poor communities characterized by many social and welfare problems and the consequent high demand for their services this was expressed by one informant who emphasized that in order to create social value there was an endemic need for dynamic resource creation as a necessary tactical response to the pressure of resource scarcity this was achieved by altering existing arrangements where the need arose and improvising and adapting rather than remaining rigidly resolute to predetermined plans or formulae di domenico m haugh h and tracey p stakeholder participation following on from accounts of improvisation and social value creation all informants referred to the active involvement of stakeholders in the creation management and governance of their social enterprise in practice each social enterprise used stakeholder participation in effect operating a social networking strategy as a means of extending their governance structures to generate new contacts and links with key players or to those with valuable resources or expertise which might benefit the enterprise this strategy was described by case 5s chief executive who was considering undertaking a number of largescale building development projects but lacked the necessary legal expertise to do so this was remedied by adapting the boards composition for example the deputy chair of the board is now a local solicitor he has a very large practice … so potentially there is a very important link there with somebody who can actually go and talk to developers about things which could benefit us because were about to mushroom in terms of development community stakeholder participation was also used to generate support for planned strategies and projects informants reported how they used this to take advantage of valuable di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x opportunities in the following example case 1 used community stakeholder participation to secure the consent of a local land owner in order to pursue the possibility of developing wind turbines on his land the building up of close relationships with stakeholders is often helped by the embeddedness and legitimacy of the social enterprise within the local community as illustrated in the following example … our first meetings with him were across the farm gate we didnt even get through the gate on a wet rainy night the next meeting we met in a cowshed and it took a few attempts and we got in the kitchen and it took a few years until we got a cup of tea…yes it was quite difficult to secure his agreement…us as a company being fairly wellknown locally and having a fairly positive orientation locally helped…his wife knew of us…i think to be honest she helped pave the way with her husband…so yes that thing of being based locally and being based there for quite a long time the case evidence highlights the processes of obtaining stakeholder participation to alter existing social enterprise arrangements through adapting structures and persuading stakeholders in response to environmental and social needs the interplay between making do and stakeholder participation was also found by johannisson and olaison in their analysis of emergency entrepreneurship starr and macmillan noted the role of the social assets of friendship liking trust obligation and gratitude in coopting resources into an entrepreneurial venture our di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x analysis supports the importance of social relations in entrepreneurial activities and identified the use of a set of persuasive tactics by informants to acquire resources and implement the strategies of the social enterprise persuasion was used to convince stakeholders of the potential usefulness of resources and assets and of the business case for social value creation persuasion they did this in a number of specific ways first they sought to influence other key actors by clearly articulating the case for their inherent social legitimacy in particular they sought support from those who owned the resources needed by the social enterprise by demonstrating its ability to create social value second they engaged in political activity to control local agendas by espousing community values thereby augmenting and reinforcing their legitimacy persuasion is thus used to solve problems deemed to be of social benefit whilst not sacrificing the commercial imperative of the resource setting in which they operate finally they sought to appropriate new resources by exerting influence through leveraging stakeholder participation persuasion is related to the concept of negotiated order introduced by strauss we extend this to include the negotiation and renegotiation of the acquisition of resources by the social enterprise this was repeatedly demonstrated in our data originating from the sociological analysis of strauss et al the negotiated order perspective is influential in understanding processes whereby formal structures and rules are resolved into fragile sets of negotiations and persuasive acts these continual permutations of action mean that influence is not static and may be subject to change disruption and further negotiation features characteristic of bricolage in action thus informants reported that they were instrumental in asserting the aims of the social enterprise and using persuasion as a means to articulate this to a wider audience di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x we are a professional businesscharity and we deliver in a very different sort of way we just see it as a challenge if you open the paper on a weekly basis the local papers we will have two or three articles in it all positive positive pr our stakeholders like that thats what we bring to the table thats what we persuade them with the use of persuasion can be considered as an essential tactic to counteract the limitations imposed by a resource poor environment in order to create social value in each of the case studies the informants reported that they simultaneously engaged with their local communities employees and volunteers as well as with local and national policy makers whom they considered their key stakeholders they actively sought to play a part in controlling agendas through espousing the values of their local community using particular types of language to legitimate their position i discovered that the town council was putting in a competitive bid to fund cctv cameras so i went to see them and i said look we are developing a community safety centre wouldnt it be a good idea for us to sit round the table and talk about whether this could be incorporated within this bid rather than putting in a competitive bid which actually is in danger of undermining both it took quite a lot of persuasion but eventually they have come on board … we managed to convince them that it was a good idea … that it made sense the stakeholderbased governance structure of social enterprises is of course at the heart of the efficacy of their persuasion this was most prominent in lobbying and advocacy di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x interestingly their effectiveness in these respects was enhanced by the increased autonomy that resulted from their reduced reliance on grants and donations moreover many of the social enterprises had originally been set up by individuals who were members of the community within which the enterprises were embedded and which they served for example the grass roots nature of the enterprises origins was described by the case 7 chief executive who emphasized the power of persuasion through lobbying and striving to achieve a consensus which would be to the communitys advantage these acts underpinned the original need to set up the social enterprise it was a locallybased group that went into direct action … we were one of those groups who were active in the lobbying for regeneration that meant something … so it had a historical route to it and we campaigned for this building … we had a long campaign for use of this building by the community and to do that we needed to have a community development trust … we had already been through two years of community consultation some of it high tension stuff like people picketing the building and public meetings attended by 400 or 500 people in the end the whole community ends up with a consensus that we sign up to and this building was at the heart of our tenyear delivery strategy in summary this section has presented evidence from the empirical case studies which we have used to extend the generic concept of bricolage to social entrepreneurship and to conceptualize a new process of social bricolage social bricolage is a process which involves making do the refusal to be constrained by limitations improvisation social value creation stakeholder participation and persuasion it is therefore distinct from previous conceptions of di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x bricolage such as intellectual and political bricolage and bricolage in the private sector we propose an integrated conceptual framework of social bricolage in the context of social entrepreneurship the constructs combine to form a contextualized amalgam of social action capabilities that can be leveraged by social entrepreneurs in their efforts to create social value insert table 4 here the three constructs of making do the refusal to be constrained by limitations and improvisation that underpin the bricolage literature have not until now been subject to systematic analysis in the context of social entrepreneurship moreover the three new constructs of social value creation stakeholder participation and persuasion extend the bricolage concept and allow us to introduce and conceptualize the notion of social bricolage although constructs such as persuasion and stakeholder participation can be found in the entrepreneurship literature to address alternative phenomena they have not been thus far linked explicitly to bricolage our research has uncovered these links empirically and offers a model of social bricolage in common with financial bootstrapping by recognizing the potential value unused in resources social bricolage has the potential to lower costs reduce the risks associated with financial expenditure and potentially increase the returns on assets by engaging with stakeholders social bricolage also creates extends and strengthens social relations among communities and augments the legitimacy of social enterprise di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x conclusion we set out to explore the microprocesses of social entrepreneurship in which resources were identified acquired and used by the social enterprise to achieve social goals within the structure of a financially sustainable business venture our analysis of the existing literature revealed that social enterprises are typically created in response to unmet needs within a community leverage resources that are either unused or considered worthless by existing organizations and that when necessary they improvise their use of resources to achieve their goals these characteristics led us to adopt the concept of bricolage as an approach to analyzing social enterprise creation and development through a critical analysis of the bricolage literature across multiple disciplines we highlighted the processes of making do refusal to be constrained by limitations and improvisation our multiple case qualitative study not only supported these processes but also uncovered three other processes associated with social entrepreneurship and from this we have proposed a new conceptual framework of social bricolage we propose that the identification of the constructs of social value creation stakeholder participation and persuasion means that social bricolage is conceptually distinct from other forms of bricolage in social entrepreneurship the concept of agency is crucial in resource acquisition and construction instead of adopting the same mindset as others the social enterprise bricoleur responds to the unmet needs of communities by making do and creating something from nothing this can be traced to the need to continually adapt and remain responsive to the macro structural environment and local resource constraints as cleaver comments the concept of bricolage implies an active assembly of parts the adaptation of norms values and arrangements to suit a new purpose using resources at hand and di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x recombining them for new purposes is fundamental to creating social value in resource poor environments and achieving financial sustainability this dynamic use and exchange of resources by social enterprise bricoleurs within their environment reflects a recognition of institutional pressures in which the social enterprise moves beyond the constraints of institutional rules and structures to fashion its own bundle of resources and repertoire of strategies and activities we have shown that social bricolage has a tangible impact on organizational outcomes with the potential to create a sustainable enterprise which also generates social and community benefits we contend that the process of social bricolage is associated with resource poor environments in which the lack of resources pushes the social enterprise to use all available means to acquire unused or underused resources which are capable of being leveraged in a different way to create social value uncovering the microprocesses of social entrepreneurship naturally lends itself to qualitative research in which informants give their personal accounts of their involvement in social enterprise creation and development consequently our study is exploratory and inductive and draws on empirical data from a group of case studies while we make an important contribution to the entrepreneurship social entrepreneurship and bricolage literatures we recognize that more work is needed to refine and extend our model of social bricolage in the remainder of this section we offer three possible directions for future research which we believe have the potential to move the field forward in this important area first it would be useful to learn more about and extend the repertoire of persuasive practices used by social enterprises as they acquire and construct their resources portfolios moreover other practices such as benevolence and altruism might serve a similar function to persuasion and research which sought to uncover such practices has the potential to make a significant contribution 4 a social enterprise in the north east of england responsible for administering projects that meet the specific needs of the community such as childcare a community wardens scheme community transport services and assistance with job placements 5 a social enterprise and registered limited company with charitable objectives located in south east england provides projects and services in order to secure and oversee the use of resources in the regeneration of the local area and district 6 a social enterprise located in a large town to the north of london acquires disused computers from companies carries out the appropriate refurbishment and modifies them to be sold on at reduced cost to charities and people on low incomes also exports computers to developing countries employs many lowincome and longterm unemployed case evidence of social value creation in resource poor environments acquisition of derelict chapel and conversion into community centre acquisition of disused fire station building and conversion into community centre acquisition of building through community advocacy as impetus for establishing enterprise acquisition of former public baths in bad state of repair facing closure and conversion into youth centre and community facility inventing or creating resources providing products or services that would otherwise be unavailable because of poverty or lack of provision eg community services such as a network of community wardens to a deprived housing estate job training and access services for migrant communities in local area tapping of neglected skills resources by local longterm unemployed recycling of discarded computers from corporations and refurbishing them for community use making do with limited resources available and creating something from nothing to produce social value running multiple projects and services addressing various needs of the community whilst securing funds from trading and targeting resources in several directions in order to generate new sustainable revenue streams due to greater restrictions on contributed incometypically via assetbased development involving stakeholders in project work allowing and encouraging the use of amateur skills that would otherwise go unapplied use of the low skilled longterm unemployed to provide youth training on the front line of the business community support harnessed during process of securing planning permission for wind farm site refusal to be constrained by limitations imposed by pervading environmental constraints in pursuit of social value creation and involving stakeholders in social enterprise creation and governance adapting and responding to the particular needs of the community due to purposeful location of business and services in deprived and under resourced communities such as housing estates and areas with high scores of relative deprivation involving members of the local community in decision making and organizational governance altering existing organizational norms by adapting structures and improvising as the environment and social needs of the form dictateeg adapting governance structures to generate new contacts and links with key players or those with valuable resource expertise data synthesis data synthesis di domenico m haugh h and tracey p social bricolage theorizing social value creation in social enterprises entrepreneurship theory and practice 34 pp 681703 doi 101111j15406520201000370x improvisation to enable active pursuit of social value assertion of organizational rationale and persuasion of others of the business case for sociallyoriented activity in order to leverage social legitimacy for organizational advantageprocess facilitated by embedded agency and community engagement eg persuasion of town council to submit joint funding bid engendering media links in order to disseminate organizational purpose to a wide audience and generate high profile positive pr obtaining consent of an initially unreceptive local land owner to use his land for the site of a wind farm development lobbying and advocacy as tools to achieve community consensus and for persuasion of local authority of community needs leading to creation of social enterprise

current theorizations of bricolage in entrepreneurship studies require refinement and development to be used as a theoretical framework for social entrepreneurship our analysis traces bricolages conceptual underpinnings from various disciplines identifying its key constructs as making do a refusal to be constrained by limitations and improvisation although these characteristics appear to epitomize the process of creating social enterprises our research identifies three further constructs associated with social entrepreneurship social value creation stakeholder participation and persuasion using data from a qualitative study of eight uk social enterprises we apply the bricolage concept to social entrepreneurial action and propose an extended theoretical framework of social bricolage

introduction a dverse childhood experiences such as pa rental mental illness or substance abuse witnessing domestic violence and physical sexual and emotional child abuse are constellations of exposures related to poor adulthood health 1 recent evidence suggests that women with military service history report greater burdens of aces than women who have never served in the military 2 however little research has examined if aces may contribute to poorer health among women veterans compared with nonveterans the scant research about childhood abuse and women veterans has relied on clinical samples namely women veterans using veterans health administration care 3 4 5 though a significant proportion of veterans do not use vha services consequently health outcomes and factors related to health among nonvha samples of women veterans are needed in order to more comprehensively understand the broader population of women veterans in the united states aces have been linked to a greater likelihood of adulthood substance use and abuse depression suicide ideation and attempts obesity chronic physical health conditions and premature mortality among the general population 6 7 8 9 10 11 12 13 researchers have suggested several potential mechanisms underlying the association of aces and adult health suggesting the accumulation of adversityand the bodys stress responsecan be detrimental to later health or that there are latent effects of exposure to adversity during critical periods of development 14 15 16 aces are also associated with risk behaviors which may be maladaptive behavioral responses to early childhood trauma resulting in later poor adult health 1718 because multiple traumatic experiences can have particularly deleterious impacts on health 19 20 21 earlylife traumas like aces are important to consider among populations with high risks of adulthood trauma previous research documents high rates of unique forms of adulthood trauma among women veterans including combat exposure military sexual trauma and intimate partner violence 22 23 24 women who have served in the military also report particularly high prevalence of aces though data comparing women veterans with nonveterans are scarce one study of 2010 behavioral risk factor surveillance system data from 10 states and the district of columbia found that women with a history of military service which included those on active duty and those in the reserves or national guard regardless of activation reported higher rates of household physical abuse emotional abuse and exposure to domestic violence compared with women who had not served in the military 2 this study though did not assess whether a higher burden of aces was associated with health outcomes a study of 2010 brfss data from washington state found that military service increased the association between aces and mental health outcomes 25 however that study did not stratify analysis by sex thus not presenting specific effects for women who tend to experience more aces than do men 26 other limitations of current literature on aces among veteran women include the primary focus on sexual abuse the use of convenience samples and a lack of a nonveteran comparison group limitations which the current study adresses 2728 unlike other studies examining the association between aces and military service 225 the focus of this study was specifically on women veterans those who had served in and separated from military service the purposes of the present study were to document the prevalence of aces among women veterans compared with women nonveterans assess a range of physical and mental health outcomes among women veterans and nonveterans and determine the role of aces in health differences among veteran and nonveteran women specifically we hypothesized that women veterans would experience greater prevalence of aces than women nonveterans women veterans would report poorer health indicators than women nonveterans and aces would account for differences in health outcomes between women veterans and nonveterans materials and methods data data are from the 2010 behavioral risk factor surveillance system a probabilitybased nationally representative telephone survey of noninstitutionalized adults over age 18 years in the united states 29 surveys were conducted by trained interviewers using computerassisted telephone interview software respondents completed the core brfss items and optional modules which varied by state we restricted analyses to the 11 states that included the adverse childhood experiences module in their brfss response rates by state ranged from 4995 to 6878 with a mean of 5505 for the 11 states included in the current analyses 30 our sample included 36485 women who selfidentified as veteran or nonveteran with the latter category including reserves and national guard who did not serve on active duty due to the focus on veteran status we excluded women who indicated current active duty measures demographic characteristics included age education income and partnership status due to the small number of women veterans across racial categories raceethnicity was dichotomized into nonhispanic white versus racialethnic minority our primary predictor was veteran status measured with the survey item have you ever served on active duty in the united states armed forces either in the regular military or in a national guard or military reserve unit active duty does not include training for the reserves or national guard but does include activation for example for the persian gulf war participants who indicated they had served on active duty in the past were classified as veterans women who had never served in the military or who trained for the reserves or national guard but were never activated were classified as nonveteran due to the focus on veteran status we excluded women who indicated current active duty the ace module includes six items related to household dysfunction and five items related to childhood abuse 12 at the beginning of the ace module all respondents received the following prompt all questions refer to the time period before you were 18 years of age now looking back before you were 18 years of age followed by each ace item differences in aces between women veterans and nonveterans were examined in three ways as individual items as a fourcategory variable representing no aces household dysfunction only abuse only and both household dysfunction and abuse and count of the number of aces participants experienced internal consistency reliability for the 11 items in the present subanalysis was 077 which is comparable to the overall sample of participants who completed the ace module 31 health outcomes were coded dichotomously and included the following three domains mental health risk indicators included frequent mental distress inadequate sleep low satisfaction with life and poor social or emotional support frequent mental distress was assessed with the item now thinking about your mental health which includes stress depression and problems with emotions for how many days during the past 30 days was your mental health not good participants indicated the number of days and those with ‡6 days of poor mental health 32 were classified as having frequent mental distress inadequate sleep was assessed with the item during the past 30 days for about how many days have you felt you did not get enough rest or sleep with ‡14 days as the threshold for not getting enough rest or sleep 3334 life satisfaction was measured with the item in general how satisfied are you with your life with responses on a 4point likert scale from very dissatisfied to very satisfied responses were dichotomized as very dissatisfied or dissatisfied versus satisfied or very satisfied finally poor social or emotional support was measured with the item how often do you get the social and emotional support you need responses were on a 5point likerttype scale and were recoded to always usually and sometimes versus rarely or never health risk indicators included current smoking 35 heavy alcohol use was operationalized as either having more than one alcoholic drink per day in the last 30 days or binge drinking in the past 30 days using centers for disease control and prevention derived varaibles 36 respondents selfreport their height and weight which cdc uses to create a calculated variable for bmi overweight or obese was classified as having a bmi ‡25 finally physical health indicators included lifetime diagnosis by a health care professional of asthma diabetes or symptoms of cardiovascular disease disability was classified as having any health problem that requires you to use special equipment such as a cane a wheelchair a special bed or a special telephone analysis weighted chisquared tests and wald tests of means were used to examine crude differences between veterans and nonveterans in demographic characteristics aces and health outcomes we used two sets of multivariable logistic regression analyses to assess the association of veteran status with each health outcome the first set of regression models examined whether veteran status was associated with each health outcome after controlling for age raceethnicity education income and partnership status in the second set of models we included the same sociodemographic variables and added aces to the model to determine if veteran status remained significantly associated with health outcomes after also adjusting for aces we report weighted adjusted odds ratios with 95 confidence intervals for veteran status all analyses were conducted using statase 12 and weighted to create representative estimates for the subsample by accounting for nonresponse noncoverage and the complex sampling design of the brfss this study was approved by the institutional review board at the va pittsburgh healthcare system results almost two percent of women in the analytic sample identified as veterans childhood adversities among veteran women women veterans and nonveterans were similar in age race ethnicity household income and partnership status however a larger proportion of women veterans reported having at least some college education or higher compared with women nonveterans consistent with hypothesis 1 we found that women veterans reported a higher prevalence of several types of aces than women nonveterans including household alcohol abuse exposure to domestic violence physical abuse emotional abuse and sexual abuse additionally a significantly greater proportion of women veterans reported both family dysfunction and abuse and had a higher mean ace score than women nonveterans mental health risk indicators health risk behaviors and physical health outcomes were generally similar among women veterans and nonveterans although a greater proportion of women veterans were current smokers and reported a disability the associations of veteran status with current smoking and with disability persisted after controlling for age raceethnicity education income and partner status in multivariable models providing partial support for hypothesis 2 controlling for demographics and veteran status the number of aces was associated with elevated odds of all health outcomes adjusted odds ranged from 106 to 127 the association between veteran status and current smoking status was attenuated when accounting for aces similarly in the multivariable model examining disability the association between veteran status and disability was attenuated after adjusting for aces both of the findings for smoking and for disability supported hypothesis 3 discussion our findings suggest that women veterans are significantly more likely than women nonveterans to have experienced both childhood household dysfunction and abuse women veterans had higher odds of two health outcomes compared with nonveteran women however these associations attenuated to nonsignificance when we controlled for women veterans differential exposure to childhood adversity literature has long supported an association between aces and smoking 37 and our results suggest that aces may help to explain the higher smoking rate among women veterans than nonveterans in our sample that veteran status was significantly associated with disability even after adjusting for sociodemographic characteristics may be due to women veterans military service however it is notable that after adjusting for aces veteran status was no longer significant aces have been robustly associated with disability 3839 and present results suggest that burden of aces may help to explain differences in disability among women above and beyond that of military service smoking and disability notwithstanding women veterans generally did not report increased mental health risk indicators or poorer physical health compared to nonveteran women despite having higher prevalence of 7 out of 11 unique aces and higher prevalence of multiple aces we offer two potential explanations for these findings first it is possible that despite or perhaps because of childhood adversity there is a resiliency among women veterans that buffers them from experiencing poor health as adults despite their excess prevalence of early childhood adversity studies suggest that some women join the military as a way to escape stressful or abusive home lives 3 and the intentional act of enlisting may indicate general selfefficacy that bodes for improved health over the lifecourse resiliency also may be built through increased resources developed while in the military 40 resiliency and coping strategies among women veterans warrant further studyparticularly through qualitative methodsto better understand the unique situations that may inform a phenomenon such as resiliency in the context of traumatic histories an additional explanation for the lack of differences in health outcomes between women veterans and nonveterans in the face of women veterans high prevalence ace involves a selection effect known as the healthy soldier effect 41 it is possible that women veterans are healthier than the general population due to mental and physical health requirements for military service consequently this selection effectsetting military experienced populations apart from the general population as healthiermay have compensated for the poor health one would expect to see in a group with high ace exposure based on literature from the general population 1 health characteristics of women veterans however may be more similar to women nonveteran civilians than to women actively serving in the military since the healthy soldier effect may wane with age 42 unfortunately brfss data do not indicate time since serving in active duty and the number of active duty women in the sample was too small to analyze additional research that can incorporate more nuanced information about veteran status such as date of severance from service could help in understanding how and if aces impact women veterans health based on their time since service although these findings are in a large populationbased sample several limitations must be considered first we were only able to use data from states that included the ace module limiting the generalizability of our findings to veteran and nonveteran women in hawaii nevada vermont wisconsin the district of colombia maine nebraska ohio pennsylvania utah and washington second recall bias of ace may be a potential concern but research has shown that the bias is typically in the direction of underestimates 43 third some of the items in the brfss are crude such as mental distress and although the mental distress item has been shown to be valid 32 a more nuanced scale of mental health may have facilitated better detection of differences between veteran and nonveteran populations an additional limitation of the brfss dataset includes nonresponse bias which would result in the underestimation of hardertoreach populations 44 the cdc does not provide information on the differences between responders and nonresponders to assess the extent to which this potential bias impacts the current analyses though the states included here achieved response rates greater than the threshold that has been assessed previously in the literature 44 nevertheless this potential bias should be kept in mind when interpreting the present findings fourth the veteran status was selfreported and could not be verified against records of service which may result in potential misclassification bias fifth further information about length of service number of deployments time since service and servicerelated disability would provide better context within which to interpret these findings moreover other measures of trauma experienced while on active duty were not measured in this nationally representative dataset precluding us from commenting on the role of military sexual assault and other violence victimization in predicting subsequent health outcomes among veteran women finally the majority of sample was in middle adulthood and it is possible that the chronic health effects of ace which could have delayed presentation had not yet surfaced at detectable levels 16 these limitations notwithstanding the higher prevalence of ace among women veterans is concerning further research is needed to discern the etiology of this disparity and to explore with more nuanced measures and larger samples how ace and other forms of trauma may impact health outcomes among women veterans our finding that veteran women and nonveteran women have similar health outcomes despite the higher prevalence of ace indicates that there may be unmeasured protective factors unique to the experience of veteran women important next steps include assessing for these protective factors to inform potential interventions and build resilience among other populations vulnerable to poor health after trauma exposure the opinions expressed in this work are those of the authors and do not represent the funders institutions the department of veterans affairs or the united states government author disclosure statement no competing financial interests exist

background women veterans represent a vulnerable population with unique health needs and disparities in access to care one constellation of exposures related to subsequent poor health includes adverse childhood experiences aces eg physical and sexual child abuse though research on impacts of aces among women veterans is limited methods data were drawn from the 2010 behavioral risk factor surveillance system for the 11 states that included the ace module n 36485 weighted chisquared tests and multivariable logistic regression were used to assess the prevalence of aces among women veterans compared with women nonveterans and differences in the following outcomes controlling for aces social support inadequate sleep life satisfaction mental distress smoking heavy alcohol use obesity diabetes cardiovascular disease symptoms asthma and disability results women veterans 16 of the total sample reported a higher prevalence of 7 out of 11 childhood adversities and higher mean ace score than women nonveterans women veterans were more likely to be current smokers and report a disability associations which were attenuated when controlling for ace conclusions despite women veterans higher prevalence of ace their health outcomes did not differ substantially from nonveterans further research is needed to understand the intersections of traumatic experiences and sources of resilience over the lifecourse among women veterans

hhas via uber rides will 1 improve metrics among hhas 2 increase racial ethnic socioeconomic and geographic diversity of older adults with cognitive impairments receiving homecare community partner cchers helps residents of publicpubliclyassisted housing in highneed areas of greater boston gain training and entrylevel employment in healthcare as hhas through its collaborations with other groups cchers identified that lack of affordable accessible reliable transportation was among the mostcited barriers affecting hhas and equitable homecare delivery corporate partner uber health through work in preliminary socialimpact case studies identified the platforms central ridecoordination approach as preferred by black and hispanic women in the 1845y age group mgh researchers study goals and metrics were informed by input of partners with its communityengaged approach innovative partnerships and focus on achieving equity objectives to benefit patients and homecare workers alike this project has potential for strong local impacts and future implications for state andor national policies to provide highquality equitable homecare by directly addressing employment transportationrelated barriers session 4465 abstract citation id igad1041803 bridging research to practice prohome empowers care partners to promote exercise in home care chair naoko muramatsu regular physical activity benefits people of all ages mounting scientific evidence shows pas health benefits in older persons with chronic conditions however there remains a large researchtopractice gap in pa especially in longterm services and supports older adults who need help with basic daily activities such as walking or standing continue to face barriers at multiple levels of ltss to become and remain physically active this symposium will address the muchdebated researchtopractice gaps focusing on frail communitydwelling older adults in the context of a niafunded clinical trial promoting seniors health with home care aides tests the effectiveness of a gentle lowintensity pa program delivered by home care aides for communitydwelling older adults with nursinghome eligible care needs in realworld home care settings prohome is innovative because it empowers direct care workers with an easytolearn toolkit to deliver the program and keep their older clients motivated the symposium starts with an overview of prohome barriers and facilitators of prohome at multiple levels of the ltss system followed by prohomes critical elements of research and practice clienthca dyad relationships and partnerships with stakeholders inhome assessment of motor function in frail older adults and

despite facing greater risks for poorer health lowincome white and bipoc older adults underutilize mental health services even when they have indicated need increasing the repertoire for depression care that is communitybased and uses paraprofessionals has potential to increase access and engagement we are testing the effectiveness of a peer support intervention called peer enhanced depression care peers which is an 8week communitybased intervention that uses trained peer mentors to deliver emotional appraisal and informational support in addition to encouraging selfcare skills to depressed lowincome white and bipoc older adults enrolled participants are randomized to either the peer support intervention peers or to the social interaction control and followed for 12 months the primary outcome is depression and secondary outcomes include engagement mental health service use and social emotional and physical functioning challenges related to the onset of the covid19 pandemic and social isolation required a shift from recruitment initially focused on the health care system to communitybased organizations serving older adults required contactless recruitment strategies eg flyers and newspaper ads led to selfreferral of communitydwelling older adults to the study challenges to participant enrollment included barriers related to communication stigma related to helpseeking distrust and unfamiliarity with research recruitment of peer mentors was facilitated by a robust infrastructure supporting the employment of the peer support workforce continued pm supervision after initial training review of skills and evaluation of performance were important in maintaining quality and fidelity to the intervention

introduction the novel infectious coronavirus disease was first reported in december 2019 and was characterised by the world health organization as a pandemic on 11 march 2020 since then it has affected over 250 million people worldwide with more than 5 million confirmed deaths as of 10 november 2021 covid19 has caused major disruptions in daily life by home quarantine social distancing travel restrictions the closure of schools and nonessential businesses it has also illustrated the fragility of our justintime food system and how people provide food for themselves recent evidence reports that the covid19 pandemic has exacerbated the situations for households experiencing food insecurity and food poverty rapidly increased during this crisis food poverty a condition defined as the inability to afford or to have access to foods that make up a healthy diet is associated with poor health outcomes in both the shortand longterm people living in food poverty and food insecurity have been reported to have poorquality diets and are more likely to have nutritionrelated chronic diseases such as obesity and diabetes this risk increases as severity of food insecurity increases according to the united nations world food programmes report 135 million people around the world were facing severe food insecurity before the coronavirus pandemic due to covid19 impacts the un estimated that global food insecurity doubled to 265 million by the end of 2020 with impacts expected to continue through 20212022 and possibly beyond because of the resulting economic crises and reduced food access at the beginning of the covid19 pandemic there was stockpiling and hoarding of food by consumers these behaviours resulted in empty supermarket shelves in some countries as well as threatening the food security of more vulnerable groups in the uk although there has not been routinely collected national data on household food insecurity the un estimated 84 million people experienced food insecurity and this point was emphasised by the un special rapporteur philip alston in 2018 as a result the use of foodbanks has been continuously increasing the trussell trust the uks largest nongovernmental food aid franchise that runs foodbanks distributed 16 million 3day food parcels between april 2018 and march 2019 a 26fold increase on 2010 during the first 6 months of the pandemic foodbanks in the trussell trusts network reported a nearly 50 increase in need with more than 1 million emergency food parcels distributed to people in crisis between april and september 2020 alone however evidence suggests that not everyone suffering from food insecurity goes to a foodbank as they might feel too embarrassed or stigmatised by themselves or by others during the unfolding coronavirus pandemic the internet became an important platform to obtain information about covid19 social media platforms have become an important information source for a subset of the population the integration of these social network services into health communication activities has provided the opportunity for health communicators to help spread key messages and influence health decision making by encouraging participation conversation and community one of these social media platforms that has grown rapidly is twitter twitter is one of the most popular and wellknown free microblogging service systems that is used by millions of people organisations and businesses to discover and share their thoughts feelings opinions new information and observations by short messages there are other snss such as facebook instagram and tiktok however twitter has been the focus of most studies on social media published in medical journals twitter has also been the focus of the most studies conducted by social media researchers since its data are more accessible to researchers compared to other networks such as facebook there have been calls from recent research to better understand public reactions related to covid19 on social media platforms one of the software tools that can be used to collect analyse and visualise social media network data from twitter is nodexl pro the nodexl pro software is an addin for excel 201020132016 and is produced by a notforprofit organisation called the social media research foundation this organisation is committed to create open tools open data and open scholarship related to social media there have been limited studies to date reporting the application of this tool to the best of our knowledge there are currently no publications studying the use of nodexl pro as a social networking metrics analysis tool to study food poverty conversations during the covid19 pandemic using twitter data exploring twitter conversations about food poverty gives a timely insight into the discussions that are happening about important public health and social issues during an unprecedented time the overall aim of this study was to develop a better understanding on how and what twitter users communicated about food poverty from the beginning of 2020 covid19 pandemic until 23 may 2020 we aimed to identify the main topics considered under the food and poverty terms these terms were searched rather than food and insecurity because this research was conducted in the uk and there has been no established governmentendorsed indicator or definition of food poverty in the uk prior to the recent 2019 decision by government that food poverty will be systematically measured although food poverty and the wider term of food security are influenced by the principles of food availability access utilisation and stability food security is used at a national and global level to address whether countries have an adequate and safe food supply for their populations however food poverty is recognised as being mainly concerned with the access element at the household level in highincome countries such as the us and uk the household level inability to access adequate food is more problematic than issues related to food availability and utilisation this is commonly termed food poverty in the uk and household food insecurity in countries such as the us and canada this study aimed to answer the following questions what discussions were taking place on twitter at the beginning of the covid19 pandemic related to food poverty within the specified time what hashtags and words appeared to be the most mentioned related to food poverty what distinct wordpair groups emerged by social network analysis methods data collection the random sample of twitter data used in this study were collected using nodexl pro software every 2 weeks from twitter sunday 5 april 2020 monday 2021 april 2020 tuesday 5 may 2020 and saturday 23 may 2020 the reason for collecting our data from these selected days within a 2month period was because nodexl pro is limited by twitters public free application programming interface this means that data collected using nodexl pro are only available from the past 89 days and queries can return around 18 000 tweets on each search these temporal ranges were therefore chosen to control these limitations all tweets gathered for this study either contained foodpoverty hashtag or food and poverty keywords or were mentioned or posted in response to tweets that included these hashtag and keywords hashtags are about specificity that allow people to easily follow their interested topics by categorising and giving context to the tweets the collected information is related to different variables for each individual twitter user such as full name description location information web address in the profile number of followers date of account creation date of last tweet total number of tweets and custom profile picture in this research we did not identify individual twitter users the most influential individuals or key players as the purpose of this study was to identify the conversations taking place on twitter recent ethical guidelines state that if seeking informed consent from the twitter users is not possible then researchers need to conduct their analysis only on depersonalised and anonymised data based on such ethical guidelines researchers should only publish a tweet without seeking consent from a user if that tweet is from a public figure account such as politicians and celebrities therefore in the current study we did not obtain consent from individuals whose profile complies with the above definition of public figures and we only included anonymised tweets ethical approval was granted by the chair of the ethics committee for the school of health and life sciences at teesside university uk data cleaning as there were repeated sets of nodes on the edges in our data obtained from nodexl pro the data were cleaned by removing and merging the duplicate edges data analysis social network analysis was used to identify sentimentrelated words top 10 hashtags top words and top word pairs sna is the process of investigating social networks using graph theory to map and measure the relationships between people groups organisations and other sources of information that are connected nodexl pro was used to automatically identify sentimentrelated words nodexl pro uses the opinion lexicon developed by the university of illinois at chicago to identify a word or phrase that is positive or negative nodexl pro also found the top 10 hashtags repliesto and mentions for our imported twitter data visualisation of word pairs the study of top word pairs makes it easier to establish the most important combinations of the words for sentiment analysis the word pairs that appear most of the time in the tweets are placed in the same clusters and the word pairs that have fewer combinations are placed in other clusters thus in this study word pairs were visualised to gain a better understanding of sna for imported twitter data since there were more than 40 000 wordpair edges in each of our networks different studies have used different cutoff values to create graphs for the visualisation of word pairs for our study a cutoff value of more than 10 times covered all the words related to the topic and enabled us to develop a graph with a minimum overlapping of words afterwards relevant programmes in nodexl pro such as degree and betweenness centrality score of each word were used to show which word pairs were repeated more frequently than others by doing this we were able to see the most important words in our network this also enabled us to carry out an evaluation analysis to create coding of the word pairs data the summary of our methods can be seen in the following flow chart results social network analysis the data sets used in this analysis consisted of 63 919 twitter users and 81 249 tweets that contained the terms food and poverty using sna we identified the top 10 hashtags in tweets that were used by most of the twitter users from sunday 5 april 2020 to saturday 23 may 2020 the results of sna for obtaining the top words in tweets is shown in tables 2 and3 for food poverty the frequency of words flagged as positive and negative sentiments are not equal for this sample of tweets there were 62 502 positive words but 152 640 words reflected negative comments about the topic of food poverty the remaining words were noncategorised which were either neutral or because they were written in a language other than english our search was done for englishlanguage tweets however nodexl pro software also captures those tweets that use combination of both english and a different language although we have excluded nonenglish words during data cleaning process very few nonenglish words remained by error as the data sets used for the study were large evaluation analysis the overall patterns of word pairs communicated in our network based on each word pairs frequency were visualised for each time period the details of visualised word pairs were different for each data set of the four time periods however similar overall patterns were observed f i g u r e 1 methodology flow chart for each of these data sets as a consequence one image was selected to avoid repetition the overall patterns of word pairs communicated in our networks indicated that the words food and poverty appeared as bigger nodes which means they were repeated more frequently than others that appeared in the graph as shown in figure 2 groups 1 and 2 were the biggest groups for all our data a more focused view of figure 2 indicates patterns of word pairs used more than 10 times in group 1 for the data obtained from 5 to 6 april 2020 for all the data obtained from sunday 5 april 2020 to saturday 23 may 2020 the most relevant nodes in group 1 in terms of frequency were related to food access social care afford poverty lockdown covid19 health crisis pandemic insecurity support and government figure 4 displays the results of the themes we obtained from coding of these word pairs alongside examples of anonymised tweets in group 2 for our data the most relevant nodes in terms of frequency were related to poverty more help support need poor families lockdown covid19 provide aid enough emergency community parcels lack nutritious world and hunger the results of the coding for these word pairs alongside examples of anonymised tweets can be found in figure 5 other clusters in the peripheral groups also covered important words discussed in the network for instance panic buying food and shortages were repeated more frequently in g9 according to the themes obtained from the coding of these word pairs lockdown measures during covid19 were criticised as the cause of panic buying and food shortages tweet extracts from coding of these word pairs include in my country there were 44 deaths 2700 hospitalisations from the flu this winter nearly 6 times the number for covid19 now the world is locked down with millions unemployed panic buying risk of food shortages poverty malnutrition and unrest that can kill millions also poverty cheap unhealthy food and obesity were frequently mentioned in g20 obesity as the result of poverty and eating of cheap unhealthy food was referred to as an important factor to explain why coronavirus death rate was higher in some specific places in comparison to other places tweet extracts from coding of these word pairs include poverty fat unhealthy food is cheap most people who live in and around new orleans are service workers and live at or below the poverty level why is new orleans coronavirus death rate seven times new yorks obesity is a factor although no geographical restrictions were placed on tweets gathered in this study we did not identify regions of tweets posted as the purpose was to indicate the conversations taking place on twitter however the content of tweets revealed that many of them were posted by those in the uk and us d iscussion in light of the ongoing covid19 pandemic this is the first research that investigated twitter conversations around food poverty our analysis illustrated the content of topics that were tweeted replied mentioned or retweeted by twitter users about food poverty over a specified time period the first uk national lockdown at the beginning of the covid19 pandemic we used sna in our study as it includes a set of techniques that helps to study the structure of large and complex networks by means of community detection and network visualisation in our data individuals tweets overwhelmingly contained views about the rise of hunger food poverty and food insecurity due to the response to the covid19 pandemic in march 2020 twitter users perceived that when the pandemic began many foodsecure families were pushed into food insecurity due to rapid rise in unemployment and rising poverty due to quarantine and stayathome instructions they also addressed the sharp rise in food poverty that was driven by panic buying food shortages food affordability disruptions in food supply and food systems recent studies have also reported similar results to the above theme that we obtained according to uk research conducted by the food foundation in april 2020 there was a sharp rise in food poverty with more than 3 million people in britain going hungry because of the covid19 pandemic the survey of 4343 adults indicated that this rise was being driven by selfisolation and stark drops in income that ta b l e 2 positive negative top words in tweets and total words tweeted related to food poverty from week 3 to week 9 lockdown top words in tweets count top words in tweets count top words in tweets count top words in tweets count positive other efforts to offset loss of school meals included increase in supplemental nutrition assistance program emergency benefits the grocery voucher programmes and access to grabandgo meals scheme for newly unemployed families despite these responses it is reported that access to enough food among children in poverty remains limited in england in response to fears that children on free school meals might go hungry during the covid19 lockdown the childrens food voucher scheme was set up for 13 million children who were entitled to fsms in our analysis users tweeted about their concern around families experiencing food poverty who were not eligible for this governments new national voucher scheme for fsms this reflected theme must be considered as an important concern since evidence indicates that even shortterm periods of food insecurity can cause longterm physical and psychological harms in schoolaged children the uk national food strategy reported that around 50 of families with children who live with food insecurity would not qualify for fsms under the current threshold for defining poverty children from lowincome households were further disadvantaged by nutrition shortages driven by the pandemic this was reflected in a campaign launched by uk footballer and campaigner marcus rashford who has been leading a child food poverty task force to call for government to support vulnerable children in a petition he also called on members of the public to pledge support to endchildfoodpoverty this was echoed by a coalition of health experts charities and food campaigners who called on the uks secretary of state for education to extend free school meals during the autumn halfterm and christmas holiday periods by proposing a topup grant more recently the national food strategy also recommended the expansion of eligibility for fsms to all those families with children who are at risk of food insecurity throughout our analysis we found general tweets many of them asking for donations to provide food and support to those who face food poverty because of the pandemic a substantial number of these tweets highlighted the rise in foodbank demand while a decrease in donations by people as the result of panic buying stockpiling and a rapid change in the populations shopping habits as they stayed at home the independent food aid network which works with more than 250 foodbanks all over the uk reported an increase demand of 300 for foodbanks in some areas while they experienced a dramatic drop in food donations as people were stockpiling for themselves rationing of tinned foods which foodbanks usually rely on by supermarkets were also reported as the cause of drop in food donations and concern for foodbanks to being able to access adequate food in the us foodbanks were similarly reported to struggle to meet overwhelming demands as the pandemic grew and unemployment surged a further difficulty for foodbanks other than adequacy of supplies has been reported to be related to an immediate drop in the number of volunteers due to shielding of vulnerable volunteers all these reflected themes and difficulties with the foodbank system might highlight the fragility of this voluntary food aid sector which cannot possibly deal with a crisis like covid19 pandemic this fact has been also reflected in a recent letter from academics who called on the uks prime minister to protect vulnerable and lowincome people by initiating a healthbased food rationing scheme as well as amending the agriculture bill to ensure everyone has access to food our analysis suggested that twitter users discussed the failure of food systems caused by coronavirus that allowed large quantities of food to be wasted while foodbank demand soared for instance they addressed the food waste especially in the dairy industry where it was reported that thousands of gallons of fresh milk 2 for word pairs used more than 10 times in group 1 for data obtained from 5 to 6 april 2020 in this figure a closeup image taken from figure 2 has been used as an example to clearly indicate the patterns of word pairs used more than 10 times were dumped as farmers could no longer sell them to their major consumers like closed public schools and coffee shops it was reported that these stricken farmers donated part of their surplus to foodbanks but limited numbers of refrigerators and volunteers available for food charities made it impossible for so much perishable food to be donated other factors that made it impossible include the costs of harvesting processing transporting and packaging in the current industrial system twitter users in our study also conversed in their tweets about the impacts of the covid19 pandemic on the supply chain disruptions of food that resulted in increased food costs they addressed the importance of critical measures that are needed to protect people against high food price inflation and poverty triggered by the pandemicrelated restrictions similar to this reflected theme the special envoy for the 2021 food systems summit also warned about the risk of increasing food prices and a repeat of the 20072008 food price spike due to global trade and travel restrictions by governments during the pandemic in another theme emerging from tweets it was said that comorbidities like obesity are driven by food poverty these comorbidities have significant health consequences in their tweets users mentioned obesity as a result of poverty and eating of cheap unhealthy foods they referred to obesity as an important factor to explain why the death toll from covid19 was higher in some areas compared to others based on the evidence food poverty and food insecurity contribute to both malnutrition and obesity as poorer families can only afford food that is poor quality energy dense and low in nutrients recent studies reported that people living with obesity and diabetes have been found to be more likely to die from covid19 while hunger is increasing in many countries it is estimated that 2 billion people are either overweight or obese and 30 of all deaths are linked to nutritionrelated diseases the recent uk national food strategy has also called for urgent action to tackle both the significant rise in obesity prevalence especially in the most deprived communities in england as well as high levels of food insecurity an important and predominant theme that emerged from analysis of tweets in our data was related to calls on governments to introduce emergency food plans that could end coronavirus food poverty affecting millions of people users in their tweets referred to the right to food as one of the most basic human rights f i g u r e 3 closeup image taken from figure all the abovementioned themes were similar for tweets posted by those in the uk and us tweets posted by those in the uk also focused on a different theme related to universal credit a payment to help with living costs in the uk in our analysis users addressed uc in their tweets as an element that has caused an increase in poverty and food poverty the content of their tweets revealed that the implementation of this welfare reform had led to increases in problems such as leaving more people homeless and in poverty having to use foodbanks and household debt this theme was mostly related to the data we obtained towards the end of may 2020 and also addressed delays in uc payments as one of the underlying causes of the rise in food poverty during the pandemic as new uc claimants had to wait for 5 weeks before getting their first payment in their tweets users asked the uk government to end this 5week wait for the initial uc payments as claimants needed this vital support during the pandemic crisis studies however indicated this social safety net had a number of features that could increase the risk of economic hardship and in turn rises in food bank usage even before covid19 had begun before the covid19 crisis research led by cheetham et al found that uc claimants were being forced into debt rent arrears fuel and food poverty with serious negative impact on their health and wellbeing additionally earlier work by eskandari et al found that twitter users addressed welfare reforms and uc as the cause of the growing numbers of foodbanks in the uk in their conversations a recent uk study used official statistics on the introduction of uc with data on foodbank usage from trussell trust to explore the association between the rollout of uc and rising foodbank usage the study found that the rollout of uc was associated with the rise in foodbank usage as a critical indicator of financial hardship and food poverty it also found that moving to the digital version of uc that happened from april 2016 has increased the proportion of people receiving food parcels from trussell trust foodbanks as the service may exclude those who lack it skills and makes the claims submission process harder for some in terms of delays in receiving uc payment a qualitative study explored the key factors that influence food choice and eating behaviour of individuals who experienced food poverty in the north west of england the study found that participants reported frequent delays in receiving the payment as the main reason for their reduced ability to afford food and for attending foodbanks our study rapidly collected discussions occurring on twitter during the beginning of the covid19 pandemic and the subsequent national lockdown there are some limitations to consider we could not identify whether individuals involved in this community network were those with lived experience of food poverty as twitter does not provide demographic information about the users users of social media platforms such as twitter may not be representative of the community members diversity and not all individuals experiencing food poverty have access to or engage in smart technologies or social network platforms based on 2017 ofcom figures only 47 of those on lowincome individuals use broadband internet at home a further limitation of our study is that without acquiring informed consent we did not identify individual twitter users unless they were public figures corporations or charities this means we did not identify the most influential twitter users in the formation of such conversations and topics regarding food poverty during this pandemic communication theories were not used as the aim of this study was not to explain the reasons and motives that led twitter users to communicate via this platform as a particular source of information related to food poverty we acknowledge that a more detailed discussion about the extent to which the covid19 infodemic and related misinformation being spread on twitter impacted the discussion of the topic of food poverty would be desirable but it was beyond the scope of the aims and objectives of the current research therefore our results and interpretations especially with respect to the extent to which they are evidence of an actual increase in food insecurity should be considered in the context of the spread of misinformation and false narratives related to the covid19 pandemic via social media platforms like twitter which has been significantly increased by the global spread of coronavirus in addition although the use of the foodpoverty hashtag offered some reassurance that our collected twitter data was restricted to the topic of food poverty it should be considered that using hashtags might bias twitter data sets this is because those who use hashtags in their tweets are usually familiar with twitter and might have a particular interest in the related topics this means that the conversations investigated in this study might reflect views and opinions of a specific group of twitter users interested in the topic of food poverty rather than twitter users as a whole these limitations highlight the need and potential for future studies to investigate the characteristics of twitter users tweeting and creating such conversations and discussions around the issue of food poverty to this end healthrelated communication theories such as uses and gratification and media system dependency theories could be used to explain both the goals motivating twitter users to use such social media platform and the influence of this use on health behaviour on different levels we fully acknowledge and respect that other countries are represented on twitter in regard to the topic of this study and it is not our intension to underrepresent them however the majority of tweets appeared to be ukand usbased this we propose will be as a result of the sampling twitter provides and that not all tweets are accessible in the free api search parameters we feel that it is important to keep looking more broadly for increased diversity with regards to this issue conclusion the social and economic upheaval caused by the coronavirus pandemic has been a serious public health issue globally the present study has contributed to a better understanding of conversations that occurred about food poverty on the social media platform twitter during the covid19 crisis these findings highlight the conversations and offer suggestions of how to best inform and address future policy changes to improve the food security status especially for the most atrisk individuals at the time of writing when new variants of this virus threaten the current vaccination programme and it is probable that future restrictions may occur this study identifies lessons to learn by exposing vulnerabilities in the system and capturing the struggles of populations moreover the methodology provides a framework to gather real time data on a range of crisis management topics it is concluded that twitter users in our network perceived that to mitigate food poverty or to prevent a hunger pandemic robust and longer term policy responses and economic supports are needed to strengthen the resilience of food systems to future pandemic emergencies as the covid19 pandemic evolves the early results from twitter conversations about food poverty documented in this study are likely to continue future research could continue to conduct a followup analysis of twitter data on this topic although the identified limitations of this type of analysis should also be considered ack nowled gem ent s this research is being carried out as part of a phd feesfunded studentship awarded to fatemeh eskandari by teesside university co n fli c t of i n terest no potential conflict of interest to disclose data avai l abi li t y statem ent data available on request from the authors orc i d fatemeh eskandari org0000000152555997 amelia a lake r e f e r e n c e s

this novel and mixedmethod study investigated food poverty conversations at the beginning of the covid19 pandemic and the subsequent national lockdown on the social media platform twitter nodexl pro software was used to collect tweets using the terms food and poverty in any order somewhere in a tweet sent on selected days between april 5 and may 23 2020 the data obtained from nodexl pro were cleaned social network analysis tools were used to analyse and visualise our data using this method sentimentrelated words positive or negative words the top the most mentioned 10 hashtags top words and top word pairs were identified the patterns of word pairs communicated in our network were visualised based on each word pairs frequency this also enabled us to carry out a content analysis to create coding of the word pairs data a total of 81 249 tweets were identified that contained the terms food and poverty our findings revealed that individuals tweets overwhelmingly contained views about the increase in hunger food poverty and food insecurity due to the covid19 pandemic twitter users perceived that when the pandemic measures began many foodsecure families were pushed into food insecurity due to a rapid rise in unemployment and rising poverty due to the quarantine and stayathome instructions in place at the time they also addressed the sharp rise in food poverty being driven by panic buying food shortages food affordability and disruptions in food supply and food systems our analysis of this data suggests that to mitigate food poverty or to prevent a hunger pandemic for future pandemic emergencies comprehensive and longer term policy responses and economic supports are needed to strengthen the resilience of food systems however the highlighted limitations of this study must be considered

background it has been well established both conceptually and empirically that more social capital later in life is linked to a wide range of better health outcomes important to older adults key measures of social capital include 1 social network structure and 2 levels of social engagement 1 seminal research published by berkman and syme in 1979 2 showed that the extent of ones social network predicted 9year mortality in a prospective study of adults in alameda county california with the most isolated group being over twotimes as likely to die during the followup period than the most socially connected group follow up work by house et al in 1982 3 using data from the tecumseh community health study added that in addition to ones social network increased participation in various social and community activities also predicted lower mortality in men over a 912 year followup period since then a myriad of olderadult focused studies examining social capital have linked social networks and social engagement to a variety of key physical and mental health benefits in older adults including protection against dementia 45 and disability 6 higher levels of life satisfaction and perceived quality of life 78 better selfrated health 9 and overall lower mortality 10 while the mechanisms behind these beneficial associations are not yet fully understood 11 a leading theory is that social networks alter social and interpersonal behaviors like physical activity which in turn influence health 12 physical activity has well established beneficial effects both immediate and longterm on the health of older adults 13 immediate benefits include improved sleep insulin sensitivity and reduced blood pressure 13 in the long term activity lowers risk for coronary heart disease diabetes colon and breast cancers fractures and falls dementia and depression and anxiety 14 physical activity promotes feelings of wellbeing and delays disability and frailty for older adults both of which are crucial for maintaining independent living 15 previous studies have suggested some aspects of social capital may be related to physical activity though few studies focus specifically on older adults and almost all use selfreported physical activity measures in particular social network composition network size and social engagement may be related selfreported pa older adults reporting diverse or largely friendbased networks report higher pa levels than those who report primarily familybased or restricted networks 16 17 18 in fact loprinzi joyner et al in 2016 found a doserelated relationship such that the greater the number of close friends reported in an older adults network the greater their selfreported physical activity participation 19 social engagement with friends and family whether in formal or informal groups has repeatedly been seen to predict selfreported physical activity levels in middleaged and older adults 20 21 22 23 24 conversely those with greater social isolation defined by a lack of social network ties and social integration are the least physically active 2526 one significant drawback of the above studies is that they rely on selfreported pa measures which are subject to recall bias 27 and tend to overestimate true pa levels when compared to physical activity measured by accelerometry 2728 to the best of our knowledge no studies have directly related objective pa levels to social network and social engagement measures in older adults loprinzi crush et al in 2018 related social support network measures to accelerometrymeasured sedentary behavior rather than physical activity and found spousal social support for men and larger household sizes to be associated with lower levels of sedentary behavior 29 carlson et al reported an association between accelerometrymeasured pa and social support related specifically to pa but did not study other aspects of social capital such as social network size or composition or social engagement 30 to extend the existing research the aim of this study was to relate an objective measurement of physical activity wrist accelerometry 2831 to social capital measures in a nationally representative dataset of older adults in the united states we analyzed social capital measures pertaining to social network structure and levels of engagement in social and community activities all of which are unique and independently important aspects of social health that are modifiable by physicians caretakers and policy makers through targeted public health initiatives we hypothesized that older adults with larger network sizes a friendfocused network composition and higher levels of social engagement would exhibit higher accelerometermeasured physical activity levels methods study design and sample we conducted a crosssectional analysis of communitydwelling us older adults using data from the national social life health and aging project a populationbased longitudinal study that collects extensive survey and biomeasure data on the physical cognitive and social health of older adults 32 the nshap data collection methods have been previously described in detail 33 in brief wave 1 consisted of a nationallyrepresentative probability sample of communitydwelling adults born between 1920 and 47 including oversamples of africanamericans hispanics and men 33 five years later respondents remaining alive were reinterviewed in wave 2 along with their cohabiting spouse or partner for a total wave 2 sample size of 3377 respondents were interviewed in their homes by professional interviewers from norc at the university of chicago by random selection one third of the wave 2 respondents were invited to participate in a sleepactivity module the sleepactivity module included wearing an accelerometer as well as completing additional questionnaires 3435 the nshap study was approved by norcs institutional review board and secondary analysis of deidentified data was deemed exempt from further review by the university of chicago institutional review board our sample of interest consisted of a subset of 738 respondents in wave 2 randomly chosen to participate in the wrist accelerometer substudy wrist accelerometer data collection and physical activity measures the primary outcome of interest for this study was average daily physical activity as assessed by wrist accelerometry participants in the accelerometer substudy wore the actiwatch spectrum 36 on their nondominant wrist for 72 consecutive hours the actiwatch spectrum is a validated uniaxial omnidirectional and waterproof piezoelectric device 37 detailed descriptions of the device and usage in nshap have been published elsewhere 34 briefly the device continuously collects acceleration and deceleration data which is then averaged over oneminute intervals and recorded as an activity count when no activity occurred over a given minute such as during sleep or rest the activity count was recorded as 0 nonwear time was automatically detected by a builtin galvanic heat sensor and excluded from analysis sleep and wake intervals were determined using manufacturersuggested guidelines and were manually curated to account for respondent recordings in a takehome sleep log accelerometer data on ambient light and participant event markers noting time to bed and time awake 35 following best practices in accelerometry data analysis only days with 10 h or more of wake time accelerometry recordings were considered valid days of activity measurement and included in analyses this necessary requirement reduced the skewing of average activity calculations due to abbreviated wear times for this analysis mean daily counts were calculated for each participant as an estimate of average daily activity volume by taking the total wake activity counts divided by the total wake hours worn the number of hours worn number of weekend days worn and month of wear were also recorded and adjusted for in all analyses to adjust for variations in activity resulting from seasonality of the wear period and consistently observed differences between weekday and weekend physical activity levels among adults 3438 social relationship characteristics the social capital data collected in nshap covered two overarching dimensions 1 social networks and 2 social engagement within social networks we considered network size and network proportion friends network size refers to the number of individuals with whom the respondent feels comfortable discussing important matters 32 network size in nshap was determined using nshaps network roster module which asked respondents to name up to five people with whom the respondent had discussed important matters within the last 12 months 32 the number of names that the respondent listed was summed to generate a network size 0 indicating a network size of 0 persons network proportion friends was analyzed as the number of people named in the network as a friend divided by the total number of people named in the network the level of social engagement refers to the existence quantity and frequency of contact with particular informal and formal ties 11 there were five social engagement questions included in nshap four of which asked about the frequencies within the last year that the participant 1 socialized with friends or relatives 2 attended religious services 3 attended organized group meetings and 4 volunteered for religious charitable political healthrelated or other organizations the fifth social engagement question asked about the frequency with which neighbors in the area visit in each others homes or on the street response options for all of the social engagement questions except visiting with neighbors used a 7point scale the frequency of visiting with neighbors was a 4point scale responses from all five questions were recoded during analysis to a condensed 3point scale and treated as interval variables leveraging prior categorizations by kotwal et al 39 we also grouped the social engagement variables into two composite scales socializing and community involvement covariates we included demographics comorbidities functional status mental and cognitive status and selfrated physical health status as covariates that were considered to be potential confounders in our analysis demographics demographic covariates included participants selfreported age gender education marital status employment status and net worth which was calculated as household net worth of property and financial assets after accounting for outstanding loans comorbidities weight status was assessed via calculation of body mass index 40 using collected height and weight data which was further categorized into underweightnormal overweight and obese level of comorbidities was assessed using a surveymodified charlson comorbidity index 41 functional status we controlled for degree of disability and frailty which may contribute independently to physical inactivity disability was identified when respondents reported having any difficulty with one or more instrumental activities of daily living or having difficulty with one or more activities of daily living we used slow gait and weakness to adjust for frailty slow gait was measured directly by asking respondents to walk 3 m at their usual pace those requiring ≥57 s to complete the faster of two timed walksas well as those who were wheelchair bound or could not complete the exercise safelywere determined to have slow gait 34 to identify weakness respondents were asked to stand up and sitdown from a chair five times as quickly as possible and were considered weak if they required ≥167 s to complete the exercise were wheelchair bound or could not complete the task safely 34 participants with missing data for these measures were categorized separately and included in analyses cognitive and mental status depressive symptoms were measured using an adaptation of the center for epidemiological studiesdepression scale 42 cognitive status was measured using an 18item surveyadapted montreal cognitive assessment from which moca scores were estimated using a linear prediction model 39 selfrated health status selfrated physical health status was reported as poor fair good very good or excellent statistical analysis descriptive statistics were generated for the study sample using means and frequencies correlations among all variable pairs were estimated using spearman correlation coefficients multivariate linear regression models were used to explore how physical activity varied with each social capital variable a first set of regression models were run for each social capital variable while controlling for wrist accelerometry wear time number of weekend days worn and wear month a second set of regression models additionally controlled for demographics comorbidities functional health cognitive and mental health and selfrated physical health all models incorporated survey weights distributed with the dataset to results descriptive demographic health and activity characteristics of the study sample are listed in table 1 of the 738 participants in the accelerometry substudy 673 had the complete set of accelerometry demographic and health data required to be included in the study sample the mean age was 719 years 540 were female and 839 were whitecaucasian a majority was married and 248 was still working one in five participants rated their physical health as poor or fair some degree of disability was common in this sample 310 and 389 of the sample reported having difficulty performing at least one adl and at least one iadl respectively the group wore the wrist accelerometers for an average of 363 waking hours over the 72h wear period 184 wore the accelerometer on one weekend day and 221 wore the accelerometer over both weekend days the mean accelerometermeasured activity level was 2229 countsperminute social relationship characteristics are described in table 2 the mean network size was 39 persons and 476 of the sample reported having 5 people in their network the mean network proportion consisting of friends was 027 the reported frequencies of visiting with neighbors attending a community group meeting attending a religious service and volunteering were relatively equally distributed across response options however 533 of respondents reported socializing with friends or relatives often and 570 of respondents did not volunteer in the past year multivariate linear regression models each consisting of mean daily counts as the outcome variable and a single social capital variable plus covariates as the independent variables revealed that a number of social capital measures were significantly associated with accelerometryassessed activity when adjusting for accelerometerwear covariates only all hypothesized social capital measures were significantly associated with physical activity larger network size higher network proportion friends more frequent socializing and higher levels of community involvement all predicted higher pa levels after additionally controlling for demographic health and accelerometry covariates network size network proportion friends and frequency of socializing persisted as significant predictors of activity additional regression analyses were conducted on the individual social activities comprising the composite social engagement measures to assess whether the effects of certain activities predominated in their associations with physical activity for socializing the frequency of visiting with neighbors was found to largely account for the predictive value of socializing as a composite measure to illustrate after adjusting for all other covariates older adults who reported often visiting with neighbors had a predicted mean activity level that was 135 higher than those who reported never or rarely visiting with their neighbors 2456 cpm vs 2163 cpm in contrast the frequency of socializing with friendsrelatives did not significantly predict physical activity even prior to full adjustment with covariates for community involvement attendance at organized group meetings showed a positive association with pa that persisted after adjustment for demographic and health covariates frequency of volunteering was significantly associated with pa when adjusting for accelerometry covariates only and lost significance as a predictor of physical activity after controlling for demographic variables notably gender and assets no significant relationship was found between physical activity and frequency of attending religious services discussion we are among the first to use an objective measure of physical activity to explore how social capital is related to physical activity in a nationally representative sample of us older adults we found significant associations between social capital and accelerometrymeasured physical activity even after adjusting for potential confounders most notably largersized networks networks with higher proportion of friends and more frequent socialization with neighbors predicted higher pa levels the positive association between total network size and physical activity agreed with findings from previous research studies using selfreported physical activity data 2161819 one potential explanation is that larger social networks protect against the detrimental psychological and physiological effects of social isolation 225 the network size captured by nshap which includes people that the respondent feels close enough with to discuss important matters indicates the extent to which the respondent has strong frequently accessed relationships through which support and resources can flow 32 conversely respondents in nshap with small to nonexistent network are likely to feel socially isolated a major risk factor for andor consequence of various negative health behaviors and outcomes including decreased physical activity levels and increased sedentary time 3435 we also found that study participants reporting networks with higher proportions of friends also had higher levels of accelerometrymeasured pa prior research characterizing friendships in older adults has found that interactions with friends are more likely to be dictated by pleasure and enjoyment whereas family interactions often involve daily needs and routine tasks moreover older adults frequently name friends as the network members with whom they enjoy spending their time and engaging in leisure activities 43 which substantiate our findings that older adults with relatively more friendfocused networks also had higher pa levels our findings add to the growing evidence that maintaining friendships later in life may benefit health andor reflect better health in ways that having relationships with family members cannot 19 43 44 45 46 we found the predictive value of frequency of socializing seen in our study to be driven by a strong association between visiting with neighbors and physical activity our analyses showed that all else being equal an older adult who often visited with their neighbors was predicted to have a daily physical activity level that was 135 higher than an older adult who never or rarely visited with their neighbors recent studies have concluded that even small increases in activity level are associated with meaningful health benefits 4748 likewise the 135 increase associated with visiting neighbors seen in this study suggests a clinically meaningful increase in activity especially for older adults who spend the majority of their time completely inactive moreover due to the wording of this question responses may have reflected characteristics of the respondents neighborhood and built environment as much as the respondents own social behaviors and preferences for instance van holle et al 20 found that higher frequencies of talking with frequency with which respondent participates in the specified social engagement activity in the past 12 months e frequency with which respondent or hisher neighbors visit with one another in homes or on the streets f community involvement refers to the composite scale comprised of frequencies of attending organized group meetings attending religious services and volunteering neighbors were related to higher levels of selfreported walking for recreation or transport in a sample of communitydwelling belgian older adults our finding along with other studies observing the impact of neighborhood walkability aesthetics accessibility to parks and neighborhood safety on selfreported physical activity levels 20 49 50 51 points to the potential physical and social health importance of the neighborhood and environment in which an older adult lives in addition to visiting with neighbors two of the community involvement activities attendance at organized group meetings and volunteering significantly predicted pa levels the relationship between organized group meeting attendance and pa was not surprising as one of the examples of organized group meetings listed in the survey questionnaire was a sports or exercise group still the observed relationship is useful in testing the validity of our analysis insofar as we did observe the existence of a significant relationship as expected it also points to the effectiveness of participation in organized group exercise among other group activities as a way to engage older adults in physical activity the association between volunteering frequency and pa another relationship we expected was attenuated by demographic variables in particular being female andor having more assets predicted higher levels of both volunteering frequency and pa and helped to explain the association between volunteering and pa possibly indicating volunteering is a surrogate for these demographic measures longitudinal data are necessary to test whether changes in volunteering frequency predict changes in pa even after adjustment for demographic variables in contrast frequencies of socializing with friendsrelatives and religious service attendance were not related to physical activity levels this may in part be explained by the nature of the activities themselves and whether they inherently require some minimum level of physical activity to participate for example compared to get togethers with friends and family that often occur seated inside an older adults home or a religious service during which participants are seated for the majority of the service duration visiting with neighbors in each others homes or on the streets participating in an exercise group or volunteering generally require more physical activity this suggests that not all social activities are equal in their relevance to pa future research should seek to replicate our findings and examine other specific types of social activities that may be relevant for pa and could be targets for interventions our study has several limitations worth noting this was a crosssectional analysis and therefore we were only able to test for associations it should be noted though that study participants were surveyed about their social capital prior to participating in the accelerometry substudy as longitudinal data become available in nshap it will be possible to test causal models linking changes in social activity with subsequent changes in physical activity missing social data reduced our sample size but the application of survey weights ensured the sample analyzed remained nationally representative which is one of the notable strengths of this study 33 52 53 54 finally the accelerometer used in this study has several limitations the hip has traditionally been the preferred location for activity monitoring and activity intensity assessment 55 the nshap used a wrist worn activity device to maximize adherence and to simultaneously evaluate sleep 35 prior studies have shown that output from the actiwatch spectrum is strongly associated with important health indicators in older adults such as disability 5657 supporting its utility as a measure of activity the actiwatch spectrum does not have established cutpoints distinguishing different intensities of activity as other accelerometers have 58 however accelerometer count cutpoints have variable accuracy in predicting energy expenditure among older adults 59 the variable accuracy may be due in part to common agerelated conditions that slow speed yet increase energy costs of mobility such as gait impairment 60 we alternatively used mean daily activity counts to give an estimate of average activity volume the short wear time protocol is not ideal however prior work has found average daily activity assessed over 2 days versus 7 days is highly correlated among us older adults 38 furthermore the shortened wear time protocol facilitates adherence allowing inclusion of a more representative sample of older adults 38 despite these limitations our use of wrist accelerometry extends prior work utilizing selfreported pa data wrist accelerometry is being deployed in each successive wave of nshap data to facilitate longitudinal analyses involving pa in older american adults conclusions this study extends prior research finding an association between aspects of social capital and selfreported physical activity by demonstrating associations between specific aspects of social capital and an objective accelerometrybased measure of physical activity although the causal direction of these associations remains to be determined this study highlights a need to emphasize the social dimension of older adult health in the medical and public health systems to consider how social capital can be promoted to improve older adult health only 620 of older adults over 60 years of age reach the recommended activity targets 5861 and most spend the large majority of their waking hours completely sedentary 6263 social health interventions on an individual or community level could be used to motivate older adults to become more physically active intervention efforts will benefit from future work that explores the mechanisms by which social capital may promote physical activity among older adults additional file additional file 1 contains the complete results of the minimally adjusted and fully adjusted multivariate regression models for each of the four major models highlighted in table 3 authors contributions eh major contributor in writing and revising the manuscript conducted the analysis interpreted the results read and approved the final manuscript lh assisted with analyses assisted with the writing of the manuscript assisted with interpretation of the results read revised and approved the final manuscript wd assisted with interpretation of the results read and approved the final manuscript lw assisted with interpretation of the results read and approved the final manuscript mhs assisted with the writing of the manuscript assisted with the analysis assisted with interpretation of the results read revised and approved the final manuscript competing interests the authors declare that they have no competing interests

background older adults receive important health benefits from more robust social capital yet the mechanisms behind these associations are not fully understood some evidence suggests that higher levels of social capital ultimately affect health through alterations in physical activity pa but most of this research has relied on selfreported levels of pa the aim of this study was to determine whether components of social capital including social network size and composition as well as the frequency of participation in various social and community activities were associated with accelerometrymeasured pa levels in a nationally representative sample of communitydwelling older adults ≥ 62 years methods we conducted a crosssectional analysis using data from the wrist accelerometry substudy n 738 within wave 2 of the national social health and aging project nshap a populationbased longitudinal study that collects extensive survey data on the physical cognitive and social health of older adults participants physical activity was measured with a wrist accelerometer worn for 72 consecutive hours we related seven selfreported social relationship variables network size network proportion friends and frequencies of socializing with friends and family visiting with neighbors attending organized group meetings attending religious services and volunteering to accelerometermeasured pa mean countsperminute using multivariate linear regression analysis while adjusting for potential confounders results larger social networks p 0042 higher network proportion friends p 0013 more frequent visiting with neighbors p 0009 and more frequent attendance at organized group meetings p 0035 were associated with higher pa levels after controlling for demographic and health covariates volunteering was significant prior to adjusting for covariates no significant associations were found between frequencies of socializing with friends and relatives or attendance at religious services and pa

background the case for investing in adolescent health globally and in india investing in adolescents aged 1019 years is crucial for their longterm health and wellbeing and could reduce the intergenerational transmission of undernutrition violence and poverty 1 girls living in lowand middleincome countries are particularly vulnerable due to systematic socioeconomic and health disadvantages 2 twenty percent of the worlds adolescents live in india 3 where gender inequalities persist across many health and development indicators onefourth of girls compared with 8 of boys aged 1524 have never been to school 4 in addition more than half of girls are anaemic and 45 are underweight 5 an estimated 7 of girls aged 1317 have a mental disorder 6 improving the psychosocial wellbeing of adolescent girls in india is thought to be a key strategy to improve their mental and physical health 7 there is increased recognition of the need for holistic community approaches to adolescent health that cut across multiple sectors including education health nutrition and protection from violence in addition there is growing appreciation that engaging with both girls and boys to loosen the hegemonic gender norms that constrain many adolescents is key to achieving longterm gender and health equity 8 evidence gaps the indian governments 2014 adolescent health strategy the rashtriya kishor swasthya karyakram takes a holistic approach to adolescent health promotion 8 it comprises facilityand communitybased activities with a focus on adolescent participation and leadership the community component involves adolescent groups facilitated by peer educators and covering a broad curriculum of healthrelated topics including nutrition mental health sexual and reproductive health and violence peer education interventions are broadly defined as interventions in which adolescent or young adult facilitators seek to increase adolescents knowledge or influence their attitudes 9 interventions facilitated by peers may have several advantages over those delivered by adult providers first working with young laypersons could reduce costs and thereby facilitate scaleup 10 11 12 second peer opinion strongly influences behaviours in adolescence and working with peers to shape norms is now seen as essential to the success of adolescent health campaigns 13 third through their social networks peers may be able to reach marginalised adolescents who are not otherwise engaged in formal health or education programmes peer education interventions have been incorporated into numerous national adolescent health strategies as well as nongovernmental programmes 14 15 16 17 some have been tested in india 18 the rksk peer educator curriculum has never been evaluated although some rksk activities have started such as adolescentfriendly clinics and the recruitment of peer educators many evidence gaps remained when the curriculum was launched what would adolescents and their families want from such an intervention who should the peer educators be what kinds of activities should they perform to keep adolescents engaged in meetings what complementary communitybased activities are required to succeed in improving adolescent health and development to answer these questions we conducted 18 months of formative research aimed at optimising the indian governments proposed community intervention with peer facilitators formative research to develop a community adolescent health intervention we used the medical research council framework for the development and evaluation of complex interventions to develop an intervention for adolescent health and development in rural jharkhand eastern india 19 we built on the indian governments proposal for peer facilitators and adolescent groups assuming that they would eventually be implemented in our study area our formative research included six main components our global systematic review found that peerfacilitated interventions could be beneficial across a range of areas of health with the strongest evidence for mental health 20 our review of indian national and local adolescent health programmes found that many existed but had been designed and implemented by multiple governmental and nongovernmental agencies resulting in a lack of coordination and overlap in eastern india in particular there was discrepancy between planned and actual coverage our baseline survey of 3324 girls aged 1019 years in 50 villages in jharkhand provided additional formative data 21 we found substantial school dropout after the age of 15 less than half of girls aged 1519 were still in school girls left school because they were required for work at home or on the family farm or business around half of all girls were too short for their age around 10 were too thin for their age and less than onefourth had received minimum dietary diversity in the last 24 h violence especially emotional violence was common particularly among younger girls around one in ten girls reported problems related to depression or anxiety girls most common selfreported health problems were high fever and menstrual problems only 30 of girls aged 1519 years had heard of contraception 1 a systematic participants in qualitative discussions described numerous social behavioural and environmental challenges to adolescent health some including lack of access to health facilities violence at home and in school trafficking and lack of livelihood opportunities affected both boys and girls others were more sexspecific alcohol use was more common among boys whereas girls were exposed to sexual harassment early marriage early childbearing and lack of parental and financial support for secondary education among all participants there was a consensus that any community intervention for adolescents should go beyond improving health and help adolescents gain education and vocational skills adolescents parents and teachers indicated that information alone would not engage adolescents and that groups should also be fun and social local facilitators close in age to adolescent group members with engaging personalities and an informal approach could help make the groups more ageappropriate enjoyable and empowering informed by findings from the reviews survey and qualitative study we developed a community intervention to be tested in a trial building on the governmentsupported peer facilitators the interventions components and working theory of change are described below study aim we aim to assess whether an intervention involving a community youth team facilitating participatory peerled adolescent groups youth leadership activities and livelihood promotion can improve school attendance nutrition and mental health among adolescent girls in rural india methods setting the study is located in west singhbhum a largely rural district in the eastern state of jharkhand west singhbhum has a population of 1502338 22 sixtyseven percent of its population belong to scheduled tribes who tend to be socioeconomically disadvantaged compared with other demographic groups 22 onethird of the population are below the age of 15 23 eighteen percent of adolescent girls aged 1019 cannot read and a further 30 read with difficulty 21 more than onefifth of girls aged 1519 are married 21 the study is led by ekjut a civil society organisation in collaboration with university college london and the london school of hygiene and tropical medicine ekjut have been working in west singhbhum since 2004 to improve the health of women and children in rural tribal communities trial design we are undertaking a parallelgroup twoarm superiority clusterrandomised controlled trial with 11 allocation ratio and two crosssectional surveys one at baseline and one at endline the main trial analysis will be a crosssectional comparison of data from the endline survey adjusted for baseline differences we chose this approach in favour of a longitudinal design as we anticipated that a large proportion of older adolescents exposed to the intervention would move out of the district or state for employment opportunities or marriage and thus would be lost to followup with a longitudinal study design we also thought that matching participants between baseline and endline would be challenging maximising our chances of including older adolescents exposed to the intervention was important and the crosssectional design allowed us to interview older girls who had potentially been exposed to the intervention the trial includes 38 clusters each cluster is a purposively selected geographic area with a population of around 1000 people comprising a village and its associated hamlets clusters are separated by natural boundaries in order to minimise contamination between intervention and control arms randomisation we conducted the randomisation on the 22nd of february 2017 allocating 19 clusters to the intervention arm and 19 to the control arm clusters were stratified on the basis of five strata clusters with a secondary school and an adolescent club clusters with a secondary school and no adolescent clubs clusters without a secondary school but with an adolescent club clusters without a secondary school and without an adolescent club and clusters having a population of more than 1500 figure 1 describes the study profile to ensure transparency of the randomisation process we invited participants from the local community to participate in the randomisation we explained the intervention and the purpose of randomisation to the participants clusters were numbered and displayed on a wall identical balls were numbered 1 to 38 representing each of the 38 clusters for each of the five strata participants placed the numbered balls corresponding to the clusters in that strata into a local tombola device they operated the machine and sequentially allocated each ball to the intervention and control arms allocation was not concealed to participants present during the randomisation trial participants and target population all adolescent girls aged 1019 years living in the 38 study clusters during the baseline andor endline surveys are eligible to participate in study interviews girls who decline to be interviewed or who are living outside the study clusters are excluded data from our baseline survey suggest that around 15 of adolescent girls may be living outside the study clusters for reasons including studying away from home and being employed outside the village all adolescent boys and girls aged 1019 years within the study area are eligible to participate in the intervention although for financial and logistical reasons our trial outcomes relate only to girls we decided to include both boys and girls in the intervention because the intervention activities were relevant and potentially beneficial to boys and because some healthrelated problems such as genderbased violence early marriage and sexual and reproductive health may be more effectively addressed by engaging with both boys and girls participation in intervention activities is voluntary and adolescents are free to join or leave at any time intervention strategy the intervention is a community youth team that delivers participatory adolescent groups youth leadership activities and livelihood promotion additional file 1 describes the interventions full theory of change additional file 2 is a short video clip with ekjut team members describing the intervention each cluster has a community youth team delivering parallel intervention activities the team comprises a peer facilitator aged 2025 years a youth leadership facilitator and a livelihood promoter the second member of the community youth team is a youth leadership facilitator who delivers fun confidencebuilding activities for adolescents every 2 months activities are open to all girls and boys in the community and include sports events such as football tournaments archery and runathons as well as problemsolving sessions and nature walks both intervention and control clusters have livelihood promoters who are adults recruited for their skills in farming and environmental management livelihood promotion activities aim to provide adolescents with practical skills which they can use in later life and that improve food security for families the intervention engages and supports frontline health care providers by inviting them to participate in adolescent group meetings and facilitating referrals of adolescents from the community youth teams to community health services an advisory committee involving representatives from local governmental and nongovernmental adolescent services also advises and supports the community youth teams on child protection issues and referral services we describe the community youth teams activities further below yuva saathis and participatory adolescent groups the main role of the yuva saathis is to facilitate monthly participatory groups for adolescent girls and boys over a period of 36 months ekjut recruited 30 yuva saathis in total the recruitment process involved a general knowledge test and facetoface interviews with an assessed roleplay yuva saathis were recruited on the basis of their ability to speak both hindi and ho their performance on a general knowledge test and their ability to demonstrate confidence and good communication skills during a facetoface interview we chose to recruit yuva saathis aged 2025 years because our formative research findings suggested that adolescents preferred facilitators who were slightly older than them and parents teachers and health workers felt that facilitators in this age group would have more confidence to facilitate meetings yuva saathis are paid inr 5000 per month as an incentive and are trained by members of the ekjut team they are supervised by coordinators and supervisors who observe approximately 20 of group meetings and meet with yuva saathis fortnightly to debrief troubleshoot and plan future meetings if yuva saathis have any concerns about adolescents in their group coordinators and supervisors help them organise referrals to health facilities or other services in each cluster yuva saathis facilitate meetings which are mainly held in community meeting spaces the first five meetings aim to introduce adolescents to the intervention groups discuss social and economic influences on adolescents health how to identify and involve vulnerable adolescents in the intervention gender norms and their consequences and the adolescents own needs and expectations these initial meetings are open to all community members including adolescent girls and boys their parents teachers and frontline health workers and yuva saathis actively mobilise community members to attend all meetings involve participatory games and open discussion after the first five meetings the groups work through four consecutive participatory learning and action cycles we chose to use a pla approach for these meetings because there was a consensus that building adolescents confidence and decisionmaking skills would be desirable and ekjut has substantial experience with this method in earlier trials pla interventions enabled communities to improve the survival of newborn infants increase the dietary diversity of pregnant women and young children and reduce underweight in young children 24 25 26 27 pla is now an approach used by the india national health mission to conduct healthrelated meetings in the community and may be extended to peer facilitators of adolescent groups 28 each pla cycle comprises five to seven meetings and has four distinct phases identifying problems affecting adolescents in the community identifying and deciding on strategies to address these problems implementing the strategies and evaluating the process the same yuva saathi facilitates each meeting there is a pla cycle for each of the following four themes education nutrition health and violence the themes were selected on the basis of our formative research and reflect the broad dimensions of adolescent health and development as well as the rksk curriculum at the start of each cycle adolescents are given a choice of meeting in singlesex or mixed groups a discussion is also held with local governance bodies frontline health workers and teachers to seek their ongoing consent for the meetings because topics are considered sensitive in the first phase of each pla cycle in order to stimulate discussion yuva saathis use picture cards showing problems that adolescents might face problems represented on the picture cards under each theme are shown in table 1 and are standardised across groups groups then vote on three problems that they would like to address and they select one or two for further discussion problems mentioned by adolescents that are not represented on the picture cards are written down on blank cards and included in the voting exercise in the second phase of each cycle yuva saathis use stories based on prioritised problems to help groups examine the causes of problems they identified in the first phase the stories prompt groups to consider causes at the family community and societal levels groups decide which of these causes they would like to address develop appropriate strategies and identify ways to evaluate these strategies in the third phase groups implement their chosen strategies during this phase groups also participate in meetings to explore some of the problems that were not prioritised but are considered relevant in light of the formative research at the start of each meeting in this phase the group devotes around 15 min to discuss and review their strategies challenges faced and strategies for overcoming these challenges in the final phase groups review their strategies any challenges they faced and how these challenges were overcome they also organise a community meeting at the end of each pla cycle during which groups share their experience and learning and seek support from the wider community strategies implemented in earlier cycles continue to be implemented throughout the intervention implementation period a community meeting is held at the end of each of the four thematic pla cycles and an overall evaluation meeting to discuss all strategies implemented and the way forward is also held at the end of the intervention through the pla cycles we expect groups across the intervention arm to have devised and implemented a wide range of strategies to address key health and development problems affecting adolescents in their communities the pla cycles are expected to improve adolescents knowledge about health education and nutrition and gender equity through the meetings adolescents are expected to gain confidence to share their needs and problems problems mentioned by adolescents that are not on this list will be written down on blank cards and included in the prioritisation exercise within the group with their parents and peers as well as to improve their problemsolving skills and ability to address issues related to their own health and development marginalised adolescents especially those who are out of school were identified during the five introductory meetings and specifically encouraged to join the groups pla cycles are also expected to have effects on adult members of the community including increasing their knowledge about the health and development needs of adolescents motivating them to support the adolescent groups and their strategies and helping adults to recognise and appreciate adolescents as citizens of the community with their own rights and entitlements youth leadership facilitators research from other settings in india suggests potential benefits of combining peerfacilitated interventions with complementary activities 18 and that developing adolescents selfefficacy and psychosocial resilience is a missing piece in improving girls health 7 our formative research also indicated that adolescents would like opportunities to participate in cultural and sports activities in their communities on this basis the community youth team involves a youth leadership facilitator to deliver fun activities that build adolescents confidence and help to keep them engaged in the pla cycle these activities are also an opportunity to provide information related to adolescent health and development and to reach out to the rest of the community activities are open to all girls and boys in the community and occur every 2 months they run in parallel with the pla cycle and include football tournaments and other sports activities problem management sessions cycling sessions and nature walks youth leadership facilitators are local adults recruited by ekjut on the basis of their leadership skills experience of working with young people and understanding of the principles of pla facilitators participate in monthly meetings with yuva saathis coordinators and supervisors in order to coordinate and plan intervention activities livelihood promoters through our formative research adolescents and their parents informed us that they wanted opportunities to participate in livelihood training to develop practical skills related to farming and environmental management we therefore engaged livelihood promoters who are adults recruited for their skills and knowledge in farming practices and environmental management to deliver a programme of livelihood promotion activities activities reflect the seasons are selected in consultation with communities and include paddy cultivation multicropping compostmaking and other organic farming techniques tree planting rainwater harvesting and revival of farmers and save the forest groups activities will run approximately every 3 months in both intervention and control arms and are familyfocused involving both adolescents and their parents the programme has three main aims to provide adolescents with practical skills that they can use in later life to improve food security for families which will help to improve dietary diversity and to provide a common benefit to both intervention and control arms to help build support for the research across the trial arms trial timeline and status the baseline survey was conducted between june 2016 and january 2017 in april and may 2017 we recruited and trained the community youth teams the intervention will be implemented over 36 months from june 2017 to may 2020 the endline survey will partially overlap with intervention implementation and will be conducted between december 2019 and april 2020 a time frame for the research activities is shown in fig 2 research questions we seek to test the effects of the intervention on three main outcomes school attendance dietary diversity and mental health we chose these to represent the broad range of health and development issues affecting adolescent girls in india and because formative research indicated that these are important problems for girls in the study area primary research questions what is the effect of an intervention comprising participatory adolescent groups youth leadership activities and livelihood promotion delivered by a community youth team on adolescent girls school attendance dietary diversity and mental health secondary research questions secondary research questions explore intermediate effects of the intervention on the pathway to impact on school attendance dietary diversity and mental health we ask does the intervention increase the uptake of schoolrelated entitlements reduce the number of girls who were absent from school in the past 2 weeks increase adolescent girls decisionmaking ability selfefficacy and resilience reduce the percentage of girls who drank alcohol in the past month increase the percentage of girls with attitudes supportive of equitable gender norms related to education and domestic work reduce exposure to emotional and physical violence and increase the number of girls who intervene to reduce emotional and physical violence against their peers study outcomes the trial has three primary outcomes school attendance dietary diversity and mental health problems we will assess the percentage of girls attending school or college at the time of the endline survey information on school attendance will be selfreported and we will crosscheck answers in school registers for 10 of girls randomly selected from the sample we will use the food and nutrition technical assistance tool to measure mean dietary diversity score 19 for mental health problems we will compare the mean score on the brief problem monitoryouth across trial arms 20 the bpmy includes items on internalising externalising and attention problems secondary outcomes on the pathway to change for the primary outcomes are outlined in table 2 and presented in the theory of change tertiary outcomes are also shown in the theory of change and relate to further hypothesised outcomes of the intervention that are not directly related to the primary outcomes additional file 3 also outlines how each outcome is measured and if baseline data are available sample size and power the size of the study area and hence the number of clusters was chosen for logistical reasons with a districtlevel crude birth rate of around 23 per 1000 population and accounting for child deaths we expected to find an estimated 8800 adolescents aged 1019 in our proposed intervention area we anticipated that in each cluster there would be 115 adolescent girls aged 1019 years a total of 3324 adolescent girls aged 1019 years participated in the baseline survey 82 of an estimated 4068 girls in the 38 clusters the mean number of girls in each cluster was 87 we aim to interview the same number of girls in the endline survey with a mean cluster size of 87 a coefficient of variation of cluster sizes of 03 29 and using intracluster correlation coefficients from our baseline data the trial will have 80 power to detect a ninepercentagepoint increase in the proportion of girls attending school or college from a baseline prevalence of 69 to 78 a 09point increase in mean dietary diversity score from a mean baseline score of 34 to 43 and a 27point decrease in bpmy score from a mean baseline score of 60 to 34 the significance level is set at 005 we performed these calculations in stata software we anticipate that including baseline data in our analysis will lead to gains in power but do not attempt to quantify these here data collection cleaning and storage in this section we describe data collection processes for the endline survey these are identical to processes followed at baseline which are described elsewhere 21 twelve monitors who are independent from the community youth teams will undertake data collection in each of the study clusters they will visit all households in order to identify eligible adolescent girls in households with an eligible girl monitors will explain the study to the girl and seek her consent for girls under the age of 18 monitors will also seek consent from the girls caregiver the monitor will then find a convenient time to conduct an interview with the girl in her home if girls are not available when the monitor visits the household the reason for unavailability will be recorded through these interviews we will collect data relating to the primary and secondary outcomes as well as data on the socioeconomic status of the household and for the process evaluation data will be collected using mobile phones programmed using the commcare data collection platform which uses automated skip patterns and inbuilt checking and consistency logic to support data validation data will be downloaded from the server every 2 weeks we will check the number of interviews completed and look for any problems every month we will check the data for outliers errors and missing data using automated dofiles in stata the final dataset will be stored on a passwordprotected hard drive after removing individual identifying information blinding data collection during the endline survey will overlap with intervention activities by approximately 3 months monitors will not be given information about the allocation of clusters however through their monitoring activities in the villages they may encounter some of the intervention activities or meet members of the community youth teams because of the participatory nature of the intervention adolescents and the community youth teams cannot be blind to allocation the researcher conducting the final trial analyses will be blind to allocation analyses for the primary outcomes will be repeated by an independent statistician also blind to allocation analysis plans primary analysis will employ an intentiontotreat approach including all adolescent girls aged 1019 living in the study area regardless of their level of participation in the intervention activities we have three primary outcomes we think that success in improving at least one of these outcomes could help inform decisions about future scaleup we will declare the trial a success if we find a significant benefit for at least one outcome in conjunction with a collectively positive signal for the other two outcomes a positive signal is defined as at least one of the two outcomes in the direction of benefit neither outcome showing significant harm and if for one outcome the direction of effect is towards benefit and for the other it is towards harm then we require the p value for the former outcome to be smaller than that for the latter the type i error rate corresponding to this definition of success varies according to the correlations between the three outcomes which we expect to be positive under perfect positive correlations the type i error rate is 5 under independence and the null hypothesis the probability of observing success in conjunction with one two or three significant benefits observed for individual outcomes is 338 018 and 000 respectively consequently the overall probability is 356 and the type i error rate assuming a symmetric definition of overall trial failure is 712 for primary and secondary outcomes we will conduct crosssectional analyses to compare differences between the control and intervention arms of the trial using regression models with generalised estimating equations to adjust for clustering and model baseline and endline information together we will use the exchangeable working correlation structure to assess the effect of the intervention our regression models will include an indicator of time and an indicator of intervention coded 1 for participants measured at endline in the intervention arm and 0 otherwise this analysis approach has been termed a constrained baseline analysis 30 our baseline data show that dietary diversity is slightly positively skewed and bpmy scores are very positively skewed we will model mean dietary diversity scores using linear regression we will model bpmy scores using linear regression after transformation by the function log noting that our analytic approach provides robustness by avoiding distributional assumptions we will use a logistic regression model to test for a difference in the percentage of girls attending school between arms as a binary outcome we will adjust for the same set of prespecified prognostic factors and for strata for each outcome we will additionally adjust for further socioeconomic factors should the data monitoring committee note important imbalances between arms among baseline participants however because there could be collinearity between such factors or between such factors and the prespecified prognostic factors it may be that not all can be included or that some may need to combined the final model will be selected without reference to intervention effect we do not plan to conduct any sensitivity analysis for the effects of missing data because the refusal rate for the endline survey is expected to be low in line with the baseline survey we think that shortterm crossover between intervention and control areas is likely to be rare because the main reason for moving is to attend boarding school and there are few boarding schools in our study clusters we will be able to identify participants who have crossed over through their exposure to the intervention and will provide an estimate of contamination though we expect this to be less than 1 of participants we plan to carry out two subgroup analyses for the primary outcomes the first will assess the effects of the intervention on the primary outcomes by age categorising girls as younger or older the second will examine intervention effects on the primary outcomes by household wealth quintile for subgroups of age and wealth quintile the intervention effects will be presented within each subgroup following the same approach as in the main analyses formal testing for a difference in intervention effect across subgroups will be based on testing interaction terms tertiary outcomes that are present in the theory of change will be reported in the process evaluation as exploratory analyses we will convene a data monitoring committee in 2019 and 2020 to examine the comparability of trial arms and potentially identify socioeconomic variables that differ between arms to adjust for in the final analysis approve our data analysis plan and ensure we conduct the final analyses in accordance with this and provide recommendations on the interpretation of results and additional analyses the anonymised trial dataset with data on primary and secondary outcomes and code used in the main analyses will be made available as supplementary files with the main trial publication process evaluation through a process evaluation we will assess intervention implementation mechanisms of impact and context 31 process evaluation data will be collected using semistructured interviews and focus group discussions with adolescents and members of the community youth team in purposively selected clusters observation of intervention activities and interactions with adolescents and other community members forms to document attendance at intervention activities and to capture problems and strategies identified by the participatory adolescent groups and data collection through the endline survey to measure participation of adolescents in intervention activities some of the information will be collected quarterlymonthly whereas other information will be collected towards the end of the intervention information that will be collected on an ongoing basis includes sociodemographic profiles of participants attending intervention activities prioritised problems and strategies progress on implementing strategies spontaneously reported adverse events training feedback based on the meeting contents and feedback from participants during meetings group discussions and semistructured interviews with adolescents parents and frontline workers will be conducted at the end of the intervention we do not have financial resources to conduct a full economic evaluation but will report intervention costs from a provider perspective to guide future decisions on implementation ethical considerations in may 2016 we obtained ethical approval for the study from an independent ethics committee in jharkhand convened by ekjut and from the university college london ethics committee the study presents several ethical considerations need for clusterlevel consent from village leaders and individuallevel consent from girls and their parentscaregivers ekjut have previously worked in the study area and are familiar with the village leaders and communities we sought consent for each villages participation from the local village governance institutions and opinion leaders after explaining the studys purpose and processes adolescent girls aged 18 or above were asked to provide informed consent for themselves in the baseline survey and this will be repeated at endline for girls aged 1017 we will first seek informed consent from their parentscaregivers we will not collect data from any girls if they have not themselves provided assent regardless of whether their caregivers have ensuring confidentiality as during the baseline monitors will conduct interviews for the endline survey in or around girls homes in a place of the girls choosing ideally out of earshot but within sight of family and neighbours this will protect confidentiality and ensure that the girl feels comfortable and safe during the interview data will be collected on mobile phones stored on passwordprotected computers and backed up every 2 weeks names of participants will be removed from the final datasets identification of severely anaemic severely acutely malnourished or mentally distressed girls and girls exposed to severe violence as in the baseline survey all girls showing symptoms of severe anaemia and those who are severely acutely malnourished in both intervention and control arms in the endline will be referred to the nearest health facility girls with severe mental health problems or who report experiencing sexual or severe physical violence will be visited by a trained counsellor from ekjut who will review their case and refer as appropriate to a local health facility or other relevant service all girls participating in the study will be provided with the contact details of a person in ekjut benefits to control areas if the intervention is successful we will apply for funding to scale it up in the control arm during the trial livelihood promoters will work in both intervention and control clusters to offer a range of activities related to farming practices and environmental management this was chosen to offer a minimum common benefit to all trial areas to help build support for the research across trial arms increased demand on local health services through the intervention adolescents will be encouraged to seek help from community health services for various health care needs including family planning symptoms of anaemia and mental health problems we will link the community youth team to the health workers by inviting them to attend participatory adolescent group meetings and supporting referrals of adolescents to community health facilities intervention generalisability sustainability and scalability we expect our results will be generalisable to other areas of rural india with a high proportion of scheduled tribes such as odisha chhattisgarh madhya pradesh and rajasthan the government of india has committed to providing peer education through community groups across india through the rksk programme our intervention model is potentially scalable through this programme through the study we will explore how training and supervision of peer facilitators could be sustained by frontline health workers such as sahiyas sevikas and auxiliary nurse midwives we will also explore the feasibility of involving existing education and health personnel such as teachers and health workers in the delivery of the youth leadership and livelihood promotion activities dissemination at the beginning of this study we convened an expert group of representatives from the state government and from local and international nongovernmental organisations working on adolescent health and development to participate in the design of the intervention this helped to ensure the intervention is compatible with existing health and education systems builds on the experience of local stakeholders and is potentially scalable we will reengage this expert group at the end of the trial in order to disseminate results among those involved in adolescent health policy and programming to disseminate our findings in the study area we will hold communitylevel meetings drawing on previously tested dissemination techniques we will also share results with the adolescents who participated in our intervention during the trial discussion we have developed a holistic participatory intervention to mobilise rural communities to take action for adolescent health and development and we are evaluating it through a clusterrandomised controlled trial to the best of our knowledge this is the first trial in india of an integrated community intervention to improve adolescent health and development in tribal communities through the process evaluation we aim to understand to what extent girls from these communities and other marginalised groups are able to participate in the intervention and how it achieves any effects detected we will also try to understand factors that could facilitate or inhibit scaleup of the intervention in other tribal areas of india several trials in india have evaluated community interventions for adolescents mainly in school settings a schoolbased intervention for girls aged 1114 in uttar pradesh involving peer and parental support and sessions on compassion wellbeing and selfefficacy improved nutrition hygiene and reproductive health behaviours 32 a psychosocial resilience curriculum for girls in bihar improved genderequitable attitudes health knowledge and behaviours and resilience selfefficacy socialemotional assets and wellbeing 733 in goa a pilot trial evaluated a multicomponent intervention for boys and girls aged 1624 in rural and urban communities 18 the intervention reduced selfreported violence perpetration and probable depression and it improved knowledge and attitudes about reproductive and sexual health in both rural and urban settings a trial of a multilevel structural and normsbased intervention in karnataka found no evidence of a reduction in school dropout and child marriage among girls aged 1213 34 the wholeschool seher intervention delivered by lay counsellors in bihar improved school climate and healthrelated outcomes among secondary school students 35 our study has several strengths the intervention targets adolescents across the whole span of adolescence and includes inand outofschool and married and unmarried adolescents involving boys and girls in the intervention activities will enable us to tackle issues related to gender norms and hopefully to provide benefits for both genders the intervention builds on the governments existing national adolescent health community strategy it has also been informed by an extensive mixedmethods formative study the study also has limitations our primary outcomes are selfreported girls in intervention areas may be more likely to overreport mental health problems minimum dietary diversity and school attendance due to awarenessraising intervention activities on these issues we seek to address this in several ways first the data collection team is separate from the intervention team reducing the extent to which participants relate the two thus reducing potential social desirability bias second interviewers are experienced and rigorously trained in rapportbuilding this will help participants feel comfortable and able to answer questions truthfully third for the school attendance outcome we will crosscheck a random sample of answers against school registers fourth there may be migration of adolescents into and out of the study clusters we will ask about length of residence in the cluster at endline to check for any systematic bias in inmigration between the intervention and control arms though this is unlikely finally because intervention activities are open to any adolescent we cannot rule out the possibility that adolescents in control areas will participate however clusters were purposively selected so that natural boundaries between clusters reduce the likelihood of this our findings will help to inform the implementation of rksk and will contribute to the evidence base for community interventions to improve adolescent health and development in other settings trial status the trial is ongoing the endline survey will take place between february and april 2020 organisation representatives we also thank the young people parents and teachers who took part in the formative research and intervention sponsor university college london is the trials sponsor the contact person at ucl is the sponsor has no role in the study design collection management analysis and interpretation of data writing of the report or the decision to submit the report for publication hp and ap will have access to the final dataset protocol version and date 14 1st november 2019 supplementary information supplementary information accompanies this paper at 1186s1306301939841 hp and shr led the data collection team hp is the data manager all authors read commented on and approved the manuscript competing interests the authors declare that they have no competing interests

background improving the health and development of adolescents aged 1019 years is a global health priority one in five adolescents globally live in india the rashtriya kishor swasthya karyakram rksk indias national adolescent health strategy recommends supporting communitybased peer educators to conduct group meetings with boys and girls groups aim to give adolescents a space to discuss the social and health issues affecting them and build their capacity to become active community members and leaders there have been no evaluations of the community component of rksk to date in this protocol we describe the evaluation of the jharkhand initiative for adolescent health jiah a community intervention aligned with rksk and designed to improve school attendance dietary diversity and mental health among adolescent girls aged 1019 years in rural jharkhand eastern india

introduction it has been estimated that in the us there were over two million cases of chlamydia 800000 cases of gonorrhea 55000 cases of syphilis and over 41000 new cases of hiv by sexual transmission in 2014 consistent condom use is the most effective preventive and costefficient method against sexually transmitted diseases a partial alternative to condom use prep has become available in recent years prep is a relatively effective alternative to condoms for protection against hiv it is a medication intended to be taken every day that prevents hiv from establishing infection within the body and is related to the medication used to help keep the virus under control for those with hiv currently about 30000 people in the us may be taking prep medication to prevent hiv this is relatively small when looking in comparison to how many new cases of hiv occur each year its primary drawback at this time is that it costs about 1200 per month when used in this way although many insurance companies will help cover some of the cost it is less effective than properly used condoms and provides no protection from other stds because of this many doctors suggest to still use condoms in conjunction with the medicine furthermore the expense of prep makes it infeasible for the general population even for low income persons in serodiscordant relationships thus condoms remain an important resource to reduce the transmission of hiv and other stds while risk behaviors have been reduced since the beginning of the aids epidemic nevertheless the continuing high incidence of sexually transmitted infections is evidence of inconsistent condom use the tendency for people to use condoms inconsistently or not at all is a significant problem for public health in this study we systematically examine 46 possible reasons organized under five general motivations which people may have for using or not using condoms with sex partners we ask reasons associated with specific sex partners in order to capture reasons which may differ across partners in addition we investigate the extent to which reasons differ by own and partner disease status in order to simplify this discussion we refer to hiv persons as role 1s hiv persons with hiv partners as role 2s and hivpersons with hivpartners as role 3s reasons for using condoms the continuing spread of hiv has led to continuing research examining reasons for condom use and nonuse in most cases research has focused on global reasons that is on general reasons for condom use or nonuse irrespective of partner while some reasons may be properly global other reasons certainly depend on the partner and on the partners known or suspected disease status only a few studies of condom use decisions explicitly identify the hiv status of study participants while most do not test or collect hiv status data on participants also most studies do not discuss their participants partners and their statuses some studies of hiv persons focus on assumed hivpartners we found no studies that explicitly studied hivpersons with known hiv partners in order to productively study behavior between partners with different disease characteristics it is important to consider the multiple motivations that may be influencing condom use there are a number of potential motivations that may be behind the reasons that persons may give for using or not using condoms self protection a majority of studies addressing reasons for using a condom can be understood to invoke the motivation of self protection against hiv and other stds the self protection motivation is highlighted in theories such as the health belief model the theory of reasoned action theory of planned behavior social cognitive theory diffusion of innovations theory stages of change or the transtheoretical model the aidsrisk reduction model harm reduction theory and protection motivation theory sometimes investigators explicitly ask participants whether their reason for condom use is to protect oneself more often however self protection is taken as an implicit assumption when researchers ask about knowledge or perception of condom efficacy partner protection partner protection is another potential motivation for condom use this motivation is particularly pertinent for role 1 hiv persons with hivpartners but it may be relevant to any person who has opportunities to become infected and thus may potentially serve as an intermediary to transmit disease from one partner to another most of the prominent theories of risk discussed above make no explicit acknowledgement of an independent partner protection motivation instead some theories address this issue as an external social norm an altruistic or caregiving motivation may lead a person to protect a partner they feel emotionally close to an altruistic concern to protect the partner has been studied by several researchers who focus primarily on the hiv population relationship we have already seen that protection of self from the partner and protection of the partner from self are reasons for condom use sexual activities that can transmit hiv are joint activities so there are two persons who can be at risk the dyadic nature of sexual relationships means that participation and consent by the partner are important elements in condom usenonuse decisions condom use and the discussion of condom use can convey messages about the relationship in research studies of role 3 samples whose hiv status is known to be negative or unknown and presumed to be negative condom use has been observed to be lower for main or primary partners than for secondary or casual partners lower for longterm partners than shortterm partners and lower for close partners than nonclose partners faith in the partners honesty has been suggested to lead to a lowered sense of susceptibility that underestimates what risk an objective observer might estimate on the other side it is more common for hiv persons to use condoms and disclose their hiv status with their primary partner rather than casual partners most study samples are probably comprised largely of role 3s and results often suggest that participants tend to have a low level of concern for hiv and a higher concern for relationship issues many relationship reasons for condom nonuse examined in these studies have been associated with fear apprehension or concern fear of the partners reaction fear that asking to use a condom could lead to partner distrust fear of partner violence and fear that suggesting a condom may lead to the loss of the relationship other related reasons for nonuse have been seen as influenced by the power that one sexual partner may have over another low power has thus been seen as a major barrier to reducing hiv risk the difference in relationship power may prevent some persons from successfully negotiating condom use because the partner either does not want to use or demands not to use a condom norms social norms are cited as a motivation for condom use in several prominent theories of risk the aids risk reduction model theory of planned behavior and theory of reasoned action a number of researchers have underlined the importance of social norms in the prevention of sexual transmission of hiv among heterosexual and especially msm populations where a strong community effort has been reported to promote condoms out of an ethical concern to protect from transmitting hiv to others in some cases such norms have been formulated into laws that hold those who are aware of their hiv status responsible to disclose and protect those who are hivfrom transmission in contrast there are some countervailing norms that actively discourage condom use for example some persons report that their friends think condoms are inconvenient that their religion prohibits condom use or among males that it is the partners responsibility to make the decision about condom use condom use norms while often promoted at the community level may be burdensome at the individual level persons report not conforming to the condom use norm because condoms are a hassle and because they do not carry condoms or condoms are not available at the time social recognition that one is involved in sexual activities can create embarrassment adhering to condom use norms can lead to embarrassment in carrying or getting condoms for some the embarrassment norm is stronger than the condom use norm while for others the condom use norm seems to be stronger lust in one sense all of the reasons for condom use and nonuse that we have described can be seen as secondary issues in the sexual transmission of hiv the primary motivation leading people to have sex is that sex is a pleasurable and relationshipaffirming activity with lust as an underlying motivation lust is a motivation concerned directly with the sexual response often associated with a sense of urgency many reported objections to condom use seem to be related to anticipated reductions in pleasure and enjoyment often through ruining the moment or inhibiting spur of the moment sex other commonly reported complaints are that condoms do not fit well or are too tight or small they cause loss of erection and cause awkwardness technical reasons have also been cited as reasons for use such as a lack of confidence in own skill or the perception that condoms are not efficacious more general reasons for avoiding use of condoms are a dislike of condoms or an image of condoms as effeminate there are certain limitations to the literature we have reviewed first most studies examine only one or a small number of reasons so previous literature has given us little information on the relative importance of the many reasons for condom use or nonuse second few of the reviewed research studies offer a differentiated view of relationships with attention to variations in serodiscordant or seroconcordant statuses within populations and across relationships one study does analyze hiv participants and their view of responsibility when it comes to protecting sex partners though there is no confirmation of partners true status some studies of hiv persons distinguish between relations to hiv partners and relations with hivpersons however we did not find studies of condom use that compared hivpersons with hiv partners to hivpersons with hivpartners many interventions designed to increase condom use have been developed and implemented over the last 30 years since hiv became a global health concern however few of these interventions have focused on the hiv risk reduction motivations of the members of the target group members of the 93 evidencebased interventions described by the cdc in 2015 only 29 are geared to individuals of the 29 individuallyfocused interventions 22 focus primarily on sexual transmission of these 22 interventions all encourage safer sex practices using condoms detailed examination of these programs show that two specifically target hiv people with hivpartners four target hiv people with partners of unspecified status one targets hivpeople with hiv status five target hivpeople with partners of unspecified status two target people with negative or unknown hiv status and eight use nonhivstatus eligibility criteria for participants and their partners selecting for example people with a history of any std though as noted above there are five general motivations for condom use or nonuse it is hard to tell from program descriptions of the 22 promoted interventions related to condom use and sexual transmission which motivations are explicitly targeted for intervention in the research reported below we provide evidence on those motivations that sexually active persons themselves report as important specifically we examine the frequency with which participants report that they considered each of 46 reasons for condom use or nonuse because of the potential effect of hiv infection on withinrelationship motivations we distinguish and compare the reasons given by four types of relationship we study role 1role 2 relationships role 2role 1 relationships role 2role 3 relationships and role 3role 3 relationships hiv partners with hiv partners are not included in this discussion methods participants were recruited in a study designed to better understand the role of relationship dynamics and sexual behaviors in the prevention or transmission of hiv eligibility included being over 18 years of age having english speaking ability being cognitively competent having been sexually active with a partner in the previous three months not being transgendered and in the case of hiv participants not being diagnosed as hiv in the previous three months the last criterion was imposed to protect against psychological anxiety and disorganization from a recent diagnosis that might compromise the ability to give informed consent for this study 115 serodiscordant dyads were recruited together and 139 hivpersons were recruited because they had multiple sex partners dyads were referred through targeted mailings to hiv clients in a centralized database managed by the state department of health and informational flyers placed at hiv care sites multipartner hivindividuals were recruited through flyers posted and distributed at hiv testing sites these participants were recruited to permit examination of reasons for condom use outside of serodiscordant relationships a strength of this sampling design is that it provided a sample of role 2 participants many of whom reported both role 1 and role 3 partners the sample for the analyses reported here consists of 109 role 1role 2 serodiscordant dyads all but one of whom were recruited together in addition 12 of the role 2 participants described relationships with role 3 partners and 112 role 3 hivpersons described relationships with other hivpartners some of these relationships had incomplete data and are omitted from analyses most relationships with incomplete data involved oral sex only where condom use is seldom considered initial screening and interview procedures interested potential participants called the study coordinator who gave them a brief overview of the study and screened them for eligibility serodiscordant dyads were interviewed separately but simultaneously there was no requirement that dyads be either primary or longterm relationships as a result 17 of relationships were over 5 years in length while some 20 were no more than one month in length including five percent reported as one night stands within the sample 31 of participants were hiv by design of the study of the 218 participants reporting role 1role 2 dyads 63 were heterosexual and 31 were male and 6 were both of the 132 role 3 hivindividuals reporting role 3role 3 relationships 94 reported heterosexual relationships only while 5 reported malemale relationships only and 2 reported both participants were asked to name up to 10 sex partners and some demographic and relationship information was collected about all partners participants were asked in detail about up to three of these relationships initially participants were asked in detail about three relationships but early in the study this number was reduced to two because of respondent burden the 109 role 1 participants reported 127 relationships with hivpartners while the 109 role 2 partners described 112 relationships with hiv partners and 12 role 2 participants reported 53 relationships with hivpartners the 112 role 3 participants named 212 partners they believed to be hiv for those participants recruited as dyads special procedures were followed to guard against one participant coercing another to participate in the study male interviewers interviewed only men female interviewers interviewed men and women participants were told the purpose of the study the risksbenefits of participation the types of information to be collected and the time required to participate participants were also told that they would be tested for hiv at the end of the interview all individuals were encouraged to ask questions and were given a copy of the consent form study procedures were approved by a university institutional review board and all participants gave separate informed consent measurement sociodemographic information and attitude data for this report were collected via selfreport computerassisted personal interview where the interviewer posed questions and recorded responses participants were asked the number of sex partners in the previous three months and were asked general and partnerspecific attitudes and behaviors for up to three recent sex partners interviews generally lasted two to three hours depending upon the number of sexual partners named participants were remunerated 4000 for completion parking or bus transportation costs were also reimbursed reasons for condom use and nonusein order to understand motivations for condom use or nonuse participants were asked for up to three named sex partners to remember the last time they had made a decision with each about using or not using a condom with the partner for some participants this occurred recently for others this decision was in the distant past and had become a habit participants were asked the last time you and partner made a decision about using condoms did you think about… followed by 46 reasons that are the subject of this report to create this list we drew on existing scales citations omitted and brainstormed additional items most reasons were asked separately for each partner some reasons such as whether they knew how to use a condom or the reliability of condoms were considered global reasons and were asked only of the first partner and were assumed to apply to all partners some items were asked or asked differently depending on the hiv status of the participant and the partner for example hiv participants were asked about giving hiv and not about getting hiv thus hiv participants were asked about whether giving hiv would be shameful or would be gods will only hivparticipants were asked whether getting hiv would be shameful or would be gods will similarly hivparticipants were not asked about giving hiv when talking about their relationship with their hiv partners reasons relating to pregnancy were only asked for heterosexual dyads finally items about relationships were not asked about partners who were casual acquaintances or one night stands hiv testingat the end of the interview participants were given an oraquick© mouth swab to test for hiv to confirm their selfreported hiv status any participant who seroconverted was given a referral for confirmatory hiv testing posttest counseling and care all participants received cdc standard hiv counseling from an interviewer who had undergone training in hiv testing and counseling from the state department of health four individuals seroconverted at the end of the interview each of these knew that the partner was hiv but did not know that they had been infected there were five role 2 hivparticipants who believed that the hiv partner was hiv none of these seroconverted none of the multipartner hivparticipants seroconverted results the final sample contained 348 participants with data on condom use reasons counting only those relationships where participants were asked and gave complete responses about condom use participants described 503 relationships the 348 participants reported a mean age of 375 years of the participants 207 were male with 77 describing 103 malemale relationships and 130 describing 199 malefemale relationships the 141 women described 201 heterosexual relationships in terms of education 41 had some education after high school a large percentage of the sample selfidentified as african american with the rest identifying as white hispanic other and multiple the marital status of participants was mostly not married results are presented in table i for the most frequently cited reasons for condom use or nonuse the first column lists the ten most often cited reasons across all participants other columns distinguish reasons by role match each column is divided into reasons cited in at least 50 of relationships described by participants in that role and reasons cited in fewer than 50 of relationships but still among the ten most cited note that of the 46 reasons participants were asked about only 15 were named by at least a third of all participants who were asked another seven were named by at least a third of participants in at least one role and only 16 were among the ten most cited for any role care must be taken to interpret the combined results because some reasons were not asked of all participants for example role 1 hiv participants were not asked whether they thought about getting hiv of the hivparticipants only those who said they thought one of their partners might be hiv were asked about giving hiv to another partner role 3 participants were not asked whether it would be shameful to give hiv the combined column shows that self protection and partner protection were the most active motivations two relationship reasons were also among the top ten reasons overall the only major normative reason mentioned was that it would be shameful to give hiv the participants were greatly concerned with reasons that have to do with hiv but also almost as important were reasons that have to do with other stds as well examining our findings by role shows overlap in concerns it is expected that an hiv person having sex with an hivperson has some different concerns than an hivperson with an hiv partner an hivperson with a presumed hivpartner may be anticipated to have yet another set of motivations for condom use or nonuse the role 1 reasons for condom use or nonuse were distributed across four motivations these were partner protection and self protection and concern for relationship and social norms hiv reasons were of large concern to role 1s hiv giving hiv and whether it would be shameful to give hiv are the top three most reported reasons eight of the reasons were cited in over 50 of the role 1 relationships role 2s reasons to use or not use condoms in their relationships with role 1s were also distributed across four motivations but less evenly self protection was dominant followed by relationship they selected just one reason each for partner protection and lust role 2s showed considerably less consensus in their relationships with role 3s than in other relationships only three reasons were cited in more than 50 of these relationships two ambiguous references hiv and getting hiv were interpreted as a partner protection motivation for these role 2s who were in a relationship with role 3s hivpartner because the role 2s were exposed to hiv through their relationship with a role 1 the ten most frequently cited reasons were three self protection four partner protection and one each for norms relationship and lust reasons role 3s were most clearly and consistently motivated by self protection when deciding to use or not use condoms six of their 10 most reported reasons were concerned with protecting self from disease although more of them were concerned with nonhiv diseases than with hiv the next most frequent concern for role 3s was relationship ii for all of the 46 reasons that participants reported thinking about they are grouped in the table by motivation that each reason is thought most to represent in this list hiv is listed separately under the selfprotection and partner protection motivations unlike most prior research on reasons for condom use or nonuse except for global reasons we did not ask how important a reason is in generalwe asked participants whether they thought about the reason the last time they were making a decision about whether or not to use a condom with a particular partner some of the reasons were assumed to refer to all partners equally and we asked these reasons only once these reasons are denoted as global reasons in the table only two of the most important reasons in table i are global reasons reliability of condoms and whether it would be shameful to give or get hiv results are presented in table discussion and clinical implications in our study participants were asked about each of 46 reasons that they might have thought about when they were making a decision whether or not to use a condom with a particular sexual partner the sample consisted of 348 participants who described 503 sexual relationships in which they had penetrative sex where condom use may have been considered participants were asked about reasons for condom use or nonuse that are seen to reflect five motivations self protection partner protection social norms relationship and lust while many reasons for using condoms were role specific there were commonalities across roles as well self protection and partner protection were clearly the dominant motivations with six self protection reasons and two partner protection reasons given in over a third of relationships hivparticipants were most concerned about getting hiv and other stds hiv participants were most concerned about giving hiv but were also highly concerned about being infected by other stds presumably because their immune systems were already compromised by hiv the reliability of condoms was thought about by over a third of participants in all roles it is notable that only 15 of the 46 reasons were selected by more than a third of all three hiv status roles and only 22 were selected by a third of at least one of the status roles many motivations suggested by previous research as important in the decision of whether to use or not to use a condom were not frequently selected by our participants in this study some research mostly on adolescents and young adult samples has suggested that technical reasons may be important such as knowing how to use a condom or how easy or hard they are to use such technical reasons have been important in such samples but these reasons were not considered particularly important by our adult sample being mentioned by 10 or less of participants relationship power as a barrier to condom use was not supported in these data participants indicated some concern in 20 of relationships that the partner might not listen but only 15 were concerned that the partner might object or get angry if one wanted to use a condom among women these reasons were chosen by fewer than 33 a result that suggests that power may be of concern for a minority of women and a few men a moderate number of participants were concerned about the meaning of condoms in terms of how they represent caring in a relationship thus participants were much more likely to care about the partners wishes than to be afraid of a partners reaction in these data from an adult sample embarrassment was not selected as being a motivation to deter from condom use whether it came to getting condoms the act of buying condoms what people would think if they saw one buying condoms or just using condoms and issues they may present fewer than 12 of role 1s and role 3s reported that they were concerned about what friends and others thought about condoms the role 2s reported being concerned about their friends thoughts even less than role 1s and 3s embarrassment and other social norm reasons were not relevant to our participants other analyses have also suggested that norms do not have much impact on condom use only three of ten normative reasons for condom use were named by at least a third of any role shame for giving hiv was of substantial concern reported by 70 of participants who were asked it is of note that study participants did not select many of the lustrelated reasons for condom use or nonuse that are frequently mentioned by researchers and interventionists for example in this sample condoms affecting foreplay erections and condoms being disgusting were cited by fewer than a third of participants perhaps these reasons are more important for the active libidos of inexperienced adolescents but they do not provide major barriers for this adult sample similarly technical reasons like knowledge of how to acquire or use a condom were not of concern clinical implications recent pharmaceutical developments have improved choices for clinical interventions one that has developed as a limited alternative to condoms is the prep program for preventing hiv transmission unfortunately it is expensive and condoms are cheaper and more available another limitation of prep is that it is not effective for other diseases besides hiv so that most recommendations continue to suggest using condoms along with the program it may be of value to consider how various intervention strategies to improve condom use may be received depending on a persons hiv status and of the status of their partners differences in motivation indicated by differences in reasons selected for using or not using condoms suggest that public health interventions may have differential impact depending on the role of the targeted population role 1 as stated in the literature review only 2 of the exemplary individuallevel cdc prevention programs are explicitly targeted at hiv individuals with hivpartners nevertheless initial preventive efforts are usually initiated oneonone during posttest counseling results here suggest that it might be effective if such counseling included an exploration of the persons concern about the potential shame of infecting a partner furthermore the intervention may have a stronger impact if it is personalized toward each particular partner although shame is a global motivating factor the protection of a particular partner may be best motivated by the persons caring for that partner it may also be highly relevant that protecting the partner from infection of hiv also protects oneself from other stds which can be important in the context of a compromised immune system when discussing prevention with a role 1 person our results might suggest giving a focus of how condoms show care for a partner and protect the partner from contracting the same chronic disease our suggestions are based on the most common responses within our sample although twothirds of role 1s think about potential shame infecting another onethird do not report thinking of shame of course a competent counselor will attempt to find out what is important to the role 1 individual and create and discuss only relevant issues but the suggestions here may be helpful in guiding that discussion role 3 most of the 22 prevention programs endorsed by the cdc report focusing on hivnegative individuals with undetermined status partners our results concur with most intervention programs that the primary focus should be on self protection for role 3s role 3s report thinking slightly more about other stds than about hiv but hiv is still a major concern our role 3s all of whom reported multiple sex partners as a function of study design showed a high concern about their partners multiple partners and moderate concern for protecting their own partners at the same time role 3s lack of awareness of potential risk to the partner limits the scope of their concern for the partner relationship issues around caring trust and communication are an important potential avenue for intervention for 3040 of role 3s discussion about pregnancy with role 3s might be productive because pregnancy was reported to be of moderate concern insofar as a goal of pregnancy can conflict with condom use the only lustrelated reason that was slightly important to role 3s was how condoms affect pleasure but only a little more than a third reported this norms of condom use have a clearly secondary influence for role 3s but a fourth to a third at least think they are supposed to use a condom and anticipate shame at getting infected with hiv because one out of eight people with hiv are unaware they are infected and because a significant number who do know their status do not disclose it to the partner because of fear of being rejected there is a serious risk to having a sex partner of unknown hiv status one may argue that a major element in all hiv programs is to convince role 3 clients that they are really role 2s our results show that role 3s who do not think that they have an hiv partner have consistently lower levels of concern about hiv than role 2s although they have higher levels of concern about other stds for those role 3s who are complacent about the risk of disease it would probably be a beneficial approach to emphasize that a partner who could give them one std could also give them hiv and that the partner might not be inclined to reveal the information role 21 there do not seem to be prevention programs explicitly targeted at role 2s among exemplary cdc prevention programs it is clear that role 1role 2 relationships are more complex than role 3role 3 relationships in terms of the variety of motivations operating a prevention program directed at role 2s should be similar to one for role 3s because they report thinking about many of the same reasons and most role 3s will not know they are actually role 2s nevertheless this possibility can be successfully communicated then there are additional intervention strategies that can be invoked for role 2s it is important to emphasize the many consequences to the partner as well as to the self of not using a condom role 2s should be reminded to use condoms not only to protect themselves from hiv and other stds but also to protect any hivpartners from hiv and any hiv partners from nonhiv stds relationship issues are important for aware role 2s interventionists could emphasize how using a condom shows ones caring for the partner by providing role 2s with the knowledge that role 1s are most worried about giving hiv to someone and that they would feel ashamed if they did the role 2s can be encouraged to spare their hiv partner this shame a faithbased approach might be successful for a large minority of role 2s although this is a complex issue there is a tendency for many role 2s to be fatalistic about their risks but there is another 16 who think about whether god would protect them although it is possible that they mean that god will protect them it may be useful to raise the question whether god will in fact protect them role 23 role 2s in a relationship with a role 3 show different reasons compared to their relationships with a role 1 their choice of reasons indicates their awareness that they can transmit disease in both directions they are still heavily motivated by self protection but their concern about getting other stds is more like a role 3 the 33 who thought about protecting another partner are certainly expressing their concern for the hiv partner clinically it may be best to emphasize protecting themselves from stds like in the role 3 intervention those role 2s who are not monogamous with the hiv partner are aware of themselves as a vector of std infection to that partner it would be wise to remind them of their std threat to their role 1 partner these role 2s are equally aware of the threat they pose to their hivrole 3 partners thus they show high concern about hiv and the potential shame from transmitting it it is important with these role 2s to remind them that hiv symptoms do not appear for three months after contracting it so they should be concerned about the possibility of passing it to anyone who is hivbefore they may be aware of their own infection because multiple sex partner role 2s have the greatest current potential of transmitting hiv to others this is the group that most needs the importance of condom use emphasized strengths limitations and future researchthere are a number of limitations to this study the study did not recruit women who had sex with women nor did we include in our analyses those relationships that reported only oral sex as this was a study of condom use although this paper analyzes what reasons participants thought about when deciding whether or not to use a condom it does not explore the content of those thoughts or if the reason elicits a direction for condom use or nonuse or if it is ambiguous in addition we were unable to capture the decision at the moment it was made but had to help people try to recapture and report information that was in some cases years in the past this study contributes a few unique elements to understanding what people consider when they decide if they will use or not use condoms first in this study we distinguish roles based on the hiv status of both participants and their partners we also measure most reasons as they differ among partners interventions that treat all condom use reasons as global may create resistance among clients who make distinctions in their attitudes and behaviors toward multiple sex partners second we attempted to explore a relatively comprehensive set of reasons to use condoms thus our results make clear that many potential reasons are of concern only to small subsets of the population our emphasis here has been on messages that will have broad appeal to the maximum number of people within each role at the same time prevention workers may find knowledge of the less frequently selected messages also useful it may be that some uncommon reasons may be important for small subsets of clients if they can be identified

all procedures performed involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments of comparable ethical standards irb approval included a waiver of consent for named partners who were not themselves interviewed under condition that that their identifying information be treated with the same confidentially protections as interviewed participants informed consent informed consent was obtained from all individual participants included in the study

background health equity is the absence of unfair and avoidable or remediable differences in health among populations or groups defined socially economically demographically or geographically 1 health inequities refer to health differences that are unjust and avoidable differences in health that stem from some form of discrimination or lack of access to certain resources 2 and are therefore socially produced and mainly preventable 34 as such health equity is about the opportunities a person has to achieve good health as opposed to the personal decisions people make about their health 5 despite global improvements in health outcomes and increases in life expectancy in many countries regardless of their level of development inequities are widening and of increasing policy concern 67 these inequities manifest in the levels of health risks to which different population groups are exposed and in differential access to its resources 48 the need to address widening inequities is enshrined in the post2015 global development agenda and the pledge to leave no one behind 9 in regard to health it is particularly relevant to the united nations sustainable development goal goal 10 which aims to reduce inequality within and among countries and goal 3 that aims to ensure healthy lives and promote wellbeing for all at all ages 9 ongoing measurement evaluation and reporting are important aspects of promoting health equity since what gets measured often affects whether and how actions occur 3 monitoring health equity also helps to track progress and can serve as a warning system 10 many of the available health equity indicators however focus primarily on access to quality healthcare risk factors and health outcomes employment education housing and socioeconomic position 1112 furthermore while many surveys collect data on place of birth few surveys collect information on ethnicity aside from for aboriginal and torres strait islanders in order to capture health equity itself measurement indicators need to also focus more specifically and intentionally on other social determinants of health that drive outcomes these other determinants include those related to ethnicity culture and place and the institutional practices and policy decisions made outside the healthcare system 35 current measures used in australia as in many other places however rarely provide fine enough detail to identify intracity differences including differences between different ethnic groups or establish health differences along the social gradient 11 logan city where this study took place has however used disaggregated indicators for health in the immunisation blueprint 20132015 which measures childhood immunisation rates by geographical areas and australian bureau of statistics census data to report the socioeconomic factors including motor vehicle ownership income english language and overcrowding to identify inequities in immunisation whilst logan city council policy documents value equity community participation and recognise the importance of the social determinants of health aside from immunisation rates these attributes are not measured 13 the social determinants of health acknowledge that the health status of a population is improved by addressing the social inequities that impinge upon wellbeing 14 indicators need to provide a nuanced picture including reference to social determinants otherwise there is a risk of generating superfluous and ineffective policy responses by over simplifing reality for example single measures from a cross sectional survey on built and social environmental features can fail to capture changes in equity and the relational effects of inequalities 3 this is relevant when determining whether certain populations feel safe in the green spaces that are physically accessible to them also important is indicators use data that are verifiable and easily accessible and can be shared in an accessible and compelling manner to stakeholders 1516 in a wealthy country such as australia measuring the social determinants of health should mean going beyond the minimum requirements for physical health to include peoples ability to meet their full potential which requires a level of social and economic security for themselves and future generations 11718 this includes access to education and employment it also includes access to assets to enable meaningful participation in society it includes their ability to develop a sense of belonging in and a sense of autonomy over their own lives 5 19 20 21 22 while difficult to measure there is increasing recognition these conditions must be met to acieve full and healthy lives and there is a need for researchers practitioners and policy makers to make an explicit commitment to understanding the social determinants of health if we are to deliver practical results 23 in australia one population that experiences disproportionately large inequities across the social determinants of health are people of pasifika descent for the purposes of this paper the term pasifika refers to the peoples of melanesia micronesia and polynesia it is important to note that these terms all have origins from colonial contact and classification and are contested amongst their communities pasifika includes māori people who are the indigenous polynesian people of new zealand 21 using the term pasifika does not disregard the unique and diverse cultures and languages of each island nation but recognises there are sufficient commonalities in beliefs values and practices pasifika in australia in recent times a large proportion of the pasifika population in australia migrated via new zealand through the 1973 transtasman travel arrangement that allows citizens of new zealand and australia to freely visit and migrate to the other country available figures on the number of people from pasifika descent in australia are thought to be under reported as many are documented as new zealand citizens 24 according to the 2016 census however growth in the number of people claiming pasifika heritage continues both in absolute terms and as a proportion of the total population 25 for example those reporting pasifika ancestry has more than doubled over the past 10 years and as such this rapidly growing population warrants further investment in health equity 25 pasifika communities in queensland are well connected through a rich network of cultural civic religious and sporting organizations with a tradition of working collectively despite their unique strengths however many of those claiming pasifika heritage work in unskilled or semiskilled positions and casual job occupations and are therefore at risk of irregular employment and inadequate working conditions 2627 pasifika communities for example are more likely to be unemployed at almost double the rate of the general australian population 24 while accurate data on ethnicity of people processed through the australian criminal justice system are sparse available evidence suggests pasifika peoples are disproportionately represented 21 in 2014 samoanborn prisoners for instance had the second highest imprisonment rate in australia 28 changes to the transtasman travel arrangement in 2002 and again in 2017 have also negatively affected those who are new zealand citizens unlike other migrants to australia new zealanders are not considered under australias migration programme or able access benefits provided to other migrant populations this makes it harder for them to access social service support higher education loan programs permanent residency and thereafter australian citizenship 29 these changes can also negatively impact second and third generation pasifika peoples whom as legal residents but neither citizens nor permanent residents face exclusion and barriers to prevailing social protections residency and citizenship requirements are often difficult for people of pasifika descent to fulfil as the cost of applications are often prohibitive with almost half of pacific peoples residing in australia not citizens 24 this in turn contributes to disparities in the social determinants of health as well as adverse individual and population health problems due to delayed presentation at the primary care level 30 the proportion of pasifika people in australia with a bachelor degree or above for example is estimated to be three times lower than the general population 24 health data on this population in australia is scant available data however suggests low engagement with preventative primary health care and poorer health outcomes compared to the general australian population 30 south east queensland represents settlement of an estimated 102320 pasifika peoples comprising at least 24 of its population 21 south east queensland presents a rapidly growing highly urbanised and youthful population of pacific islanders with the majority of its population aged between 0 and 24 years 24 it has been identified by queensland health as a priority population requiring interventions across the social determinants of health if improvements in health are to be achieved 30 specifically young pasifika peoples have several risk factors that make them vulnerable to poor health outcomes including early sexual debut unprotected sexual intercourse high levels of interpersonal violence excessive alcohol consumption and use of marijuana low levels of physical activity and suboptimal health seeking practices 30 of concern suicide rates amongst young people are significantly higher than other ethnic groups in queensland 30 this paper develops proposals for placebased health and wellbeing equity indicators for pasifika youth the focus on young people is an important dimension of the paper with many scholars recognizing that young people are more affected by where they live than other demographic groups 3132 while we recognise pasifika peoples themselves are diverse and heterogeneous with each pasifika nation having its own set of cultural beliefs customs languages values and traditions as in new zealand there are also similarities within each pasifika community in australia including community and family connectedness a desire for selfdetermination and altruistic service which have allowed the research team and pasifika community to cultivate a discussion of health equity from a pasifika perspective within this paper 33 study setting the study was undertaken in logan city a local government area situated within the south of the brisbane metropolitan area in south east queensland australia the city is ethnically diverse with an estimated one quarter of logans residents born overseas according to the 2016 census samoa was one of the top five places of birth for logan residents and in the top four for places of birth for residents father or mother 34 after english samoan is the most spoken language in logan 34 it is one of the most disadvantaged urban areas in australia 3536 and has the largest pasifika population in queensland 30 representing nearly 19 of the total population of queensland in some schools pasifika children comprise more than 50 of the student population 37 logan has also been identified as one of twenty hotspots of high youth unemployment 38 as well as having areas of entrenched health inequalities and placebased risk conditions that require tailored evidencebased solutions 35 study design and methods the design of this study was influenced by pasifika values including reciprocity and relationships respect and inclusion stage one in developing the health equity indicators involved the lead researchers engaging with culturally relevant community stakeholders working within pasifika communities in logan to develop respectful and collaborative partnership processes within the community elders are held in high regard by virtue of age experience and position in the community and engaging with community stakeholders initially was culturally respectful this early engagement also helped in the second stage of recruiting peer researchers as well as helping us to begin to identify the opportunities and barriers young people faced in leading healthy lives these stakeholders however were not involved in the research design methods or subsequent draft indicators in the second stage consideration and understanding the views and lived experiences of young pasifika peoples was critical six young pasifika researchers were initially recruited through job posting on social media outlets and pasifika community stakeholder listserves and became integral to the planning data collection data analysis and dissemination of the research components the peer researchers lived in or had experience of living in logan queensland australia and were aged between 18 and 26 years old applications were shortlisted after review from the research team and community stakeholder partnerships and while our intent was to recruit four peer researches all those interviewed were recruited as peer researchers due to interview performance but also to give us a greater spread of ages and backgrounds within the team there were three female and three male researchers who identified specifically as either fijian tongan or samoan and the peer researchers were aged between 16 and 26 the peer researcher team was able to provide us with unique insights about the research design including sampling data collection and dissemination of the findings 3940 further to valuing this research methodology focusing on young peoples worth peer researchers were remunerated at the standard university hourly rate for commensurate with their tasks the peer researchers had no prior experience of organising or participating in a research project and workshops focusing on research methods and ethics training included an introduction to and practice with various qualitative techniques in data collection including indepth interviews focus group discussions and walkalong interviews prior to undertaking the research the peer researchers however felt more comfortable with the indepth interviews and also felt these would work best with young pasifika the peer researchers were also introduced to pasifika research methodologies and ways of interviewing and more specifically the talanoa approach talanoa is a polynesian word broadly meaning to talk or converse and emphasises the importance of communication to better understand a person a situation or an issue 41 based on pasifika worldviews it is a personal encounter where people share stories their lived experiences and aspirations 3341 it is almost always undertaken facetoface using unstructured storytelling to develop relationship between interviewer and interviewee with the researcher part of the research itself rather than an objective bystander 3342 it shares some characteristics of phenomenological approaches focussing on what the meaning of lived experience of the phenomenon has participants 42 it is also similar to narrative approaches to research particularly in the process used to acquire information a difference however is that in talanoa culture is a fundamental factor 42 for the peer researchers talanoa provided a way of talking things over with participants rather than following a rigid format and was one that they felt was most culturally appropriate for this research while the peer researchers organised the data collection themselves the entire team met regularly to debrief and seek solutions to any challenges during the research process the training and debriefing sessions were facilitated by academics and pasifika community stakeholder partners to genuinely codesign the research process methods this study used a culturally appropriate qualitative approach of pasifika peoples holistic models of health 43 and research methodologies as well as data collection by peer researchers using indepth interviews informed by the talanoa methodology 3342 and youth participatory action research youthled participatory action research is an approach to scientific inquiry of young peoples lived experiences is grounded in principles of equity 4445 young people are seen as collaborators in the methodological process which aims to identify change knowledge and practices to improve the lives of youth and their communities 45 the purpose was to give voice to young pasifika peoples lived experiences to develop an understanding of the drivers of health disparities and the social determinants of health in order to develop culturally responsive health equity indicators that will be further tested and refined and used to design programs measure change while meetings and relationshipbuilding with community stakeholders helped inform the research as the peer researchers grew in confidence consistent with youth participatory action research approach the peer researchers and the research team shared power through an iterative process as the peer researchers took more ownership in shaping and disseminating the research through community forums the research the data used to draft the indicators presented in this paper comes exclusively from the interviews with young people this approach helped to ensure young people were positioned as active and informed contributors with young pasifika peoples voices at the forefront the research methods of talanoa as well the youth participatory action research approach and peertopeer interviewing of people with shared cultural heritage ensured researchers knew the culture and context in which they were undertaking the interviews and were able engage and behave relevantly importantly the peer researchers and the use of talanoa achieved a levelling of power between researcher and interviewee in the ability to acknowledge the commonsense worldviews of participants since they existed in similar age and social levels in a created cultural space 42 sampling the pasifika community stakeholders whom our research team worked closely with throughout the research process were identified by relationships within the academic community as well as other groups that were referred through a snowball effect once word spread about this research the pasifika community stakeholders and peer researchers personal and affiliated networks were critical resources in disseminating electronic flyers for the opportunity to interview for this study the peer researchers also used a chain referral approach to sampling with each peer research inviting a potential participant from their community into the study and asking participants to introduce another potential participant to the peer researcher 46 this method is thought to potentially reduce volunteer bias and underreporting of socially undesirable behaviours 46 this method also maximised opportunities for a diverse sample with our recruitment of peer researchers coming from different social networks 46 respondents were then given an information sheet to read and a consent form to sign before an interview was conducted in this case purposive sampling was employed to recruit young pasifika for this research data collection the peer researchers conducted facetoface interviews ranging from 30 to 60 min on average with pasifika young people between 17 and 26 years of age who lived or had lived in logan queensland australia interviews took place in venues that were convenient for the participants and ensured confidentiality following the talanoa approach the interviews took the form of a conversation and exchange of ideas or thinking as the peer researchers and participants engaged in social conversation story sharing andinevitablythe cocreation of knowledge according to vaioleti 36 talanoa can only be effective when there is a good relationship between the teller and the listener as such the peer researchers began by introducing themselves including their background and responding to participants questions in a reciprocal relationship also sharing their experiences being of similar age experiences and ethnicity the peer researchers were able to quickly establish rapport and empathy with participants as was observed in an interview when a peer researcher was empathising in dialogue with participant we know the struggle we can relate to you the peer researchers worked in pairs for each interview for safety and for moral support as well as debriefing and feedback to each other each peer researcher conducted five interviews as the lead interviewer and five in the role of a support person with 30 interviews conducted in total questions related to the daytoday experiences of participants and factors that contributed to their wellbeing while the peer researchers developed a question guide for the interviews using the talanoa approach to conduct interviews also gave the participants the flexibility to focus on issues of concern to them allowing their voices to be represented as they engaged in learning about the daytoday experiences from conversations with other young people of pasifika descent while peer researchers had developed an interview guide with themes talanoa interviews were relatively unstructured and took the form of a conversation and exchange of ideas or thinking as the peer researchers and participants engaged in social conversation story sharing and inevitably cocreation of knowledge language used in interviews was defined by the peer researchers and interviewees themselves and peer researchers were given free license to adapt questions themes to suit their interview style as well as the ebbs and flows of the moment while interviewing interviews were recorded with recorded interviews professionally transcribed and checked by the peer researchers data analysis throughout the data collection and analytical process the research team met regularly to review learnings and data surrounding the lived experiences of young people of pasifika descent living in logan data was manually analysed by highlighting text on notes making notes in the margins and memoing of thoughts at a given stage in the analytical process and amended based on further reading of the texts to identify factors that participants felt enhanced their wellbeing and further defined and refined through discussion in workshops with the peer researchers abbreviated versions of participant responses were recorded coded and grouped into themes on paper and subsequently into excel further the fonofale model of pasifika health which provides a holistic framework of recognising family physical spiritual socioeconomic status service and other areas of cultural importance to pasifika health 43 influenced how our research team pulled themes and meaning from interviewee data and within the themes identified potential indicators through this process of reading examining and interpreting the data the analysis moved from a primarily inductive approach to a deductive approach 4748 while the analysis was largely undertaken by the lead researchers the data were also analysed together with the peer researchers themselves in order to identify key indicators reflecting areas of importance and meaning regarding their health at a future phase in our research we intend to develop these indicators in partnership with councils and young people who participated in this study ethics the research was approved by the university of queenslands human research ethics committee the concept of reciprocity was central to the research process this was apparent through the sharing of research findings with young people themselves through a community meeting and formal report as well as with participants of the interviews and multilevel community stakeholders results six key thematic areas of health and wellbeing were identified from interviews spiritual dimensions sociocultural dimensions place access to culturally responsive services economic and material dimensions and political dimensions these key areas will be discussed further throughout this section contextualizing their meaning and providing examples of young pasifika voices the young people interviewed were an almost equal mix of male and female ranged in age from 17 to 24 years of age and most identified being samoan other participants from tonga maori fiji cook islands kirabati tuva nuie and tokelau with several associating with more than one ethnicity they spanned a range of socioeconomic experiences either in school graduates dropouts university cultural committee members and church group affiliates in total 15 of the participants were born in new zealand 12 in australia and the remainder from one of the pacific island state named above analysis of the data demonstrated participants took a holistic view of health with spiritual cultural social economic and political processes intersecting in often contradictory ways to influence health and give meaning to pasifika young peoples lives these different but shared aspects of wellbeing provided a way of weaving together the different layers of health and wellbeing for young pasifika peoples in australia the following section discusses the observations of 30 peer researcher interviews with pasifika youth spiritual dimensions of health and wellbeing spirituality and a personal relationship with the christian god was seen as central to wellbeing the importance of spirituality was also linked to relationships and place participants explained how the church was a big part of who i am and a place where they could access social connections social support and meet their religious and cultural needs as well as develop leadership skills participants discussed how interwoven religion and spirituality were with their culture and their lived experiences associated with their identity as a pasifika person that churches were a way of participating in and maintaining cultural heritage and an important aspect of social capital according to one participant its a certain type of church commitment and this is the world this is our world this is of what is most value to us even with health health is in the back its more about your spiritual health thats more important another female participant explained how she and her brother moved to logan becausegod called us over to help serve every nation brisbane at the time and we knew that there was a need also there was a calling to be able to stay there we took the risk and obeyed god to be able to move over another person described how when she was considering suicide her faith stopped heri went through a massive phase of suicide and it was like pretty much the only reason i never fell through with it is because i wanted to see dad again and from my understanding of the bible and all the miracles that god had done through my journey that i knew for sure it wasnt some kind of hopes thing it wasnt some kind of fairy tale it was legit there is a god out there who loves and cares and then my understanding of his word and i wanted to make sure that i saw my dad in the end and so thats why i never ended it myself i just need to wait until its his time most participants belonged to christianbased religions and attended either multicultural churches or churches with a specific pasifika identity church and religion functioned for many of the participants as a source of social support and meaning reinforcing values that emphasize service and civic responsibility with several acting as youth leaders within the church the notion of social reciprocity and giving back or serving emerged with particular clarity in interviews it is important to note however of several participants mention their parents accepted practices of giving monetary contributions to the church could often create financial stress the financial stress arose when young people themselves are required by familial obligation to donate a piece of their own finances mainly from parttime jobs in this way many participants stated that whatever small personal income they do collect from parttime work or other avenues is often not their own coupled with fulltime schooling this can create overwhelming stress for young people as they are unable to save their own money for future pursuits and they house a fear of disappointing family if they reject giving sociocultural dimensions of health and wellbeing participant interviews suggested that cultural engagement and pasifika peoples cultural capital such as language proficiency acceptance by the pasifika community pride in identity and pasifika values were all important aspects having a sense of belonging young participants reflected their desire to participate in meaningful connections and reciprocity within the broader pasifika community indeed almost all of the young participants described themselves as being a pasifika individual as well as belonging to their specific cultural group many also described how this ethnic identity was central to who they were and to their health and wellbeing noted when one participant described that i just like the culturalness of being māori i just enjoy it i enjoy it another person reflected on the unique strengths of pasifika peoples and their forebears which provided strength and inspiration for facing current challenges our ancestors navigated the seas without any maps they used their instincts they used the stars they used the surroundings but it was the internal spirit of them to pioneer and to relentlessly fearlessly courageously go forward for our people one young person was proud to be samoan because it was how god created herim proud to be who i am because i believe thats who god created me to be a samoan a young female participant explained … when people ask me where im from i like immediately i say im from samoa just because thats my blood but then people are like no you were born here youre australian so i usually kind of identify myself as a samoan who was born here while many participants identified with one or more ethnic groups as one person said im tuvaluanfijian and another whitemaori while another said she was um an islander i well im norwayan cook island maori they tended to mix in groups with people of different backgrounds with one person friendship groups weresamoans tongans tokelauans and some were from new zealand some of my friends were from new zealand while a normative and positive way of defining themselves this also creates potential conflicts in regard to their identity as young pasifika and the traditional ways of their family as they negotiate their place in australia participants talked about shedding their pasifika identity in some contexts or being a poly with polys and an aussie with aussies as one second generation pasifika participant explainedso ways of being and ways of doing things at home is still more close to the culture and yet a majority of my time is spent in school in a different world again but if it comes close to home its the culture but there is that mix of here in the education system or in mainstream system where its a whole different philosophy or ways of thinking and being but for us that connection is because we draw from what is really close down because i guess thats closer to our very existence is the cultural elements so even though we come in to the space we still look different we feel different and we are different in a sense there is always that battle while relationships with parents family and the wider pasifika community was particularly important for young people they often also described feeling silenced by their elders young people also recognized that their families wanted them to do well but did not always know how to support them as they navigated different worldviews the notion of stigma recurred in several participant interviews due to being of pasifika descent and the othering stereotypes of pasifika peoples that stigmatized them implicitly or explicitly participants talked for example about being stereotyped as low socioeconomic and educational status school dropouts in trouble with the police and street kids one young person explained ill be walking through a shopping centre and an old lady i can see someone just grab their handbag and theyre like frightened and think im about to do something i feel like im stereotyped to be the bad criminal they dont know my story they dont know who i am and were not all like that another negative side of culture several participants spoke about was the amount of respect given to elders which often silenced young peoples voicesyou need to speak directly to the kids in regard to this facilitated a strong sense of community as well as the construction of a positive self and ethnic image and the pride that comes with belonging several also reported membership of a local community group or club and many mentioned being part of a sports team and having lots of opportunities within the neighbourhood to play sport and exercise participants also mentioned the importance of learning about language heritage and culture in developing a sense of identity access to schools churches dance groups fastfood outlets and the library were also frequently mentioned services that participants valued while many participants expressed strong attachment and bonds to logan participants also said they often felt marked by a blemish of place this was expressed as the result of negative stereotypes and pejorative media representations of logan in which logan is constructed as unsafe with high unemployment substance abuse delinquency and poor health due to bad lifestyle choices as one person explained the media has painted a picture and portrayed logan to be the unsafe place the ghetto in the sense of they see the crime rate and all this kind of stuff but for me myself being an islander and been living in logan for so many years im actually proud to say that im from logan because i feel im at home a female participant aged 23 who identified as samoan and had lived in logan all her life explained that while logan was often seen by outsiders as a poor place and potentially unsafe it for her it was a place where she felt safei guess a lot of people like to look at it that way like as the poor area its actually an area where i would say would be safe area for most polynesians youve got your people who dont work and stuff like that also with that as well in this specific area in where we are right now youve got the train station where the people who dont work the people who like to come out during the day and just bum around yeah i guess a lot of people like to look at it that way like as the poor area its actually an area where i would say would be safe area for most polynesians when asked if she would ever consider moving from logan she respondedeven if i was rich i would never leave logans always been home its just like if i was to live in i dont know new zealand new zealand will always be home but australia is always home and logan is always home several people talked about how this negative serotyping impacted on them when they went outside of logan or how on leaving logan you sort of have to shed your logan skin while this developed an attachment to logan it also potentially inhibited wider geographical and social engagement those who were able to go to university on the other hand were able to access a wider and more diverse set of social relationships one female participant described the reaction of university peers on what she had accomplished in terms of education when she said she came from logan another explained sometimes when i tell them im from logan they make fun like you know people say logan bogan the above quote helps to highlight the specific expectations or stereotypes associated with coming from logan and the perceived differences between we and the kind of people they are who come from logan another explained how she did not usually reveal her address at university or invite university friends to visit her in this way some participants who were at university used strategies of stigma avoidance by attempting to distance themselves from logan due to the expectation of being rejected for their ties to logan itself others also noted that since being in university they did not engage in much socializing with people from logan with university providing opportunities to explore beyond their home territory and extended their social networks despite experiencing stigma related to place few expressed the desire to move out of logan expressing solidarity and strong ties to logan in this way while many of the participants identify strongly with their pasifika identity and culture they also distanced themselves from it in some settings access to culturally responsive services the need for access to culturally responsive services was mentioned both by community stakeholders and young people with several noting people often did not use available services because they did not meet their cultural or spiritual needs regarding primary and secondary education in queensland children of pasifika descent are entitled to attend primary and secondary school participants expressed a mixture of reactions to their overall school experiences ranging from loved it to a bit tough given participants rarely talked about learning or school related activities their experiences were more often shaped by how they were treated at school similarly one young person explained the importance of developing meaningful relationships based on an understanding of the young persons worldview and ways of being like teachers they say oh theres not enough teachers and well we just have to train the teachers and its not about having more pasifika teachers but mainstream teachers understanding and being able to build the relationships the underlying value would be just the curiosity about who we are and not bringing the knowledge that they get from their academy and imposing itasking questions about our ways of thinking and our ways of beingbecause otherwise its just one way okay so i say how can i work in with what you know and how you see the world and often thats whybecause its like youre sitting there thinking oh okay fix me you think youre going to fix me and so its notand a lot of us are good at playing that game its like that like okay yeah yeah and then go away and yeah theres no change one female participant who was in her last year of high school noted that for some who found school really hard and could not engage with the teachers often dropped out with negative consequences including drug abuseso recently past few years ive noticed that my friends theyre also pacific islanders that theyve dropped out of school and theyve become your ordinary city bums so city bums what they do is they roam around logan they roam around the city and theyre taking drugs alcohol stuff that mess up with your head and theyre all like 14 15 few services were reported to be available for these young people apart from some services provided by the church but often the church fund it hard to engage with these people with many reported to end up being engaged in the juvenile justice system where again they found limited cultural support in different ways the lack of cultural concordance between young pasifika peoples and mainstream services can lead to their feeling misunderstood and that existing services do not meet their needs on the other hand more culturally respectful services could achieve good results one participant for example noted how an education program for teenage mothers enabled one young mother she knew to complete her education and subsequently go on to complete an undergraduate degree at university several participants also mentioned a teacher at school who while not of pasifika descent was able to demonstrate understanding and empathy another young female participant of 18 years old who was not doing well at school explained how she went to a multicultural service after school to get additional help poor mental health and lack of services was brought up in several interviews often linked to the elders views of mental health and the church as one 18yearold explained thats one thing thats real hard on a lot of polynesian kids that theres no understanding from their parents its something that i feel like they dont believe in it to try to explain it thats the one thing … i think from their upbringing it never really existed so they think that we shouldnt believe in it too if you believe in god as well then that poor mental health shouldnt be existing in your life as well which makes it quite hard and it gives them a reason to keep sweeping it away i know that a pacific islander were one of the highest rates of suicide nevertheless there were some classes that were offered free and usually provided by local cultural associations and several people thought there should be more of these especially as some people were disengaging from their cultural heritageits called language new language learning your own heritage and cultural backgrounds and thats a class that im taking which is a samoan language class that happens once a week and its for free so they have different ranges of groups so beginners intermediate and advanced and thats something that should be emphasised is the cultural and learning our language the generation now were lacking in our own language in our cultural language and also actually in the knowledge of our heritage and where were coming from and so these classes are very if we had more of them and free everything to do with that this participant also felt connecting to her identity would also improve her mental health and while she identified as pasifika she also wanted to represent herself as a tongansamoan woman yet felt she could not do this as she had no knowledge of the language or cultural as with many other participants she felt incorporating aspects of culture into the school curriculum would be a positive thing economic and material dimensions of health and wellbeing as well as exposure to social and cultural resources young people need access to material and economic resources priority concerns included higher education employment and ability to pay bills as well as affordable access to appropriate goods and services such as nutritious food access to safe housing was also identified as an issue with one homeless person explaining that he lived in an abandoned house with four other people and a few others dropping in and out in talking about young parents one young person explained how its difficult to access good foods healthy food they just cant afford it because theyre trying to pay the bills so because of that they dont eat well lots of difficulties with healthy eating they dont have multivitamins but a lot of those things they dont access i have a lot that have to see the psychologist because they just have so much anxiety its just from stress and depression from stress so they just need help with how can i get this and feed my family cheaply added financial pressure included expectations to provide for family members back in their home country for the church as well as supporting ones family in logan one female participant of 18 years old explained how like many other people she knew financial issues were criticalbeing the middle child after me its basically the little kids so my role in the family i work and i pay for their transport to school i pay for their school fees the older kids they pay for rent they pay for our savings and stuff like that so with our family its definitely financial she also went on to explain that she had been bullied at school and experienced anxiety and depression but using services made her more anxious because f the additional financial strain in her family a tongansamoan participant aged 22 years old explained how young pasifika often drove without a driving license because as we know i dont know the percentage but theres a lot of polynesians who are driving who dont have a learners licence or who are driving on a learners licence thats due to the fact that they probably cannot afford it at the time or dont have jobs or their parents just financially not stable at the moment and so they find other ways to drive some people also noted that unemployment was prevalent across the youth population and that job seekers services that would work with them not only on identifying their skills and potential work opportunities but also developing a sense of comradeship group motivation and support would be beneficial for young pasifika political dimensions of health and wellbeing the political dimensions of health and wellbeing identified by participants related to access to permanent residency and citizenship as well as the formal rights associated with this including access to services such as health care education social protection and labour markets several participants reported concern around the role of institutional stigma for those holding scvs and not australian citizenship or permanent residency for many the conditions of the scv made the costs of higher education unaffordable limiting aspirations and opportunities to work upper labourmarket segments its hard after school you study in australia and then you have all these things of university but study stops you because you cant afford it so you need to work and by the time you start working your life is all about that all about money you forget you get stuck in that and studying just becomes nothing because youre growing in age and everything just turns around as another participant explained he also had to look after his family as his older brother was in gaol and unable to get financial help to for higher study he explained how for him and some of his friendsits basically if rugby doesnt work out for them then theyre going straight to the factory their old man knows someone or their old mans working in the factory so their old mans gonna get them a job there they dont really go out there and want to be bigger than that being a permanent resident but not able to access social protection services available to other permanent residents was a common theme as one young single mother explained while she got some child support she was not able to access the dole and she pointed out how this political discrimination also contributed to crimeshaving multiple kids having huge families and the government doesnt help us with that they let us suffer and then they wonder why so many kids go out and steal and as much as i hate to say it its a lot of islanders that go out and theythey fight for food and they become very violent and they become fairly i guess depressed and brought up they do a lot of bad things to get money to get food they steal several of the young people in this study noted how aspirations within young people were constrained by their lack of access to resourceseven going back to uni the whole goal of pacific islanders i feel is to better themselves but they cant better themselves in the education system because theres not much help going out for the new zealand citizens in this way despite many pasifika peoples paying taxes government policy reinforces an insideroutsider distinction imposing specific constraints on their choices and positions in socioeconomic and power hierarchies for young pasifika born in new zealand this form of discrimination and disparities in the social determinants of health and health outcomes is systematic rather than accidental furthermore accurate data on pasifika health and participation in higher education and labour markets is scant with many often documented as new zealanders this renders people invisible in datasets and reports and is a form of institutionalized discrimination government policies also and leave them disenfranchised from higher education and employment opportunities this would bring limiting their aspirations and field of influence discussion within this research participants understandings of health and wellbeing were reflective of pasifika models of health that include family beliefs and cultural values and the spiritual physical mental and other aspects of life that form the connections between family and culture often represented metaphorically by pulotuendemanns fonofale model 49 the study suggests that pasifika young people feel positive about their membership within pasifika groups quantitative surveys in new zealand have also shown that pasifika youth typically report high levels of ethnic pride 5051 membership of the broader pasifika community also enabled participants to construct a positive ethnic identity affirm a sense of self and forge supportive networks in an otherwise marginalizing social structure the fonofale model study underscores how individuals experience the places in which they live and their importance in shaping young pasifika health and wellbeing as well as their perceptions of the opportunities open to them 52 participants in our research for example expressed a strong emotional attachment to logan and the diverse communities that help to define logan they expressed feeling safe in logan and often attachment to place is closely associated with feelings and perceptions of safety 53 positive affirmation of ethnic identity and attachment to place can be health protective and serve the motivational need to belong it can also build social capital which can also be protective of health and act as a buffer to some of the negative effects of low socioeconomic status on health 54 55 56 the type of social capital revealed in this study related to what has been called bonding capital and relates to the close reciprocal relationships between family and associations based on a shared social identity 56 while important the potential of these networks in linking young people to social capital resources outside of their more immediate family and placebased networks was confined within their specific cultural or placebased networks furthermore in some cases these ties were potentially detrimental to health and placed financial stress on some people a similar finding was observed in a study of aboriginal australians living in urban areas 57 for those who were at university however there was evidence that they were being linked to richer social networks both within the broader pasifika community as well as bridging ties to nonpasifika peoples this study also revealed the presence of stigma at both the individual and institutional level including spatial stigma and the australian citizenship processes that acts as a barrier to the pasifika community who hold new zealand citizenship under the government policy new zealanders deserving permanent residency and citizenship are those who have the resources to manage the administrative hurdles bureaucratic complexities and high costs making it beyond the reach of many pasifika families in this way migration policy helps determine different levels of power wealth access to certain services or prestige due to their migration status positions is an important issue for health equity 58 participants also often mentioned how being of pasifika descent andor from logan were often defined by their deficiencies such as low socioeconomic status and low educational attainment and their health risk factors as obese and smokers such negative labelling can lead people to respond with passive acceptance acting as barriers to socioeconomic political and cultural capital outside of the immediate community and reducing civic participation and sense of belonging 5960 on the other hand many of the participants in this study managed stigma through emphasizing the positive aspects of their culture and logan access to culturally responsive education and tertiary education access to transport spaces for playing sport and celebrating culture social capital positive employment arrangements and basic income security as important to young pasifika peoples health and wellbeing and have been documented as lacking for this population a common theme was that services especially for mental health were not culturally responsive to the needs of young pasifika and did not always support and strengthen the relational aspects of care one way of addressing this is to look at ways in which young pasifika peoples can be directly involved in the conception planning and delivery of services rather than simply receiving services that have not been designed with their input placing serviceusers as experts has been found elsewhere to improve use of services improve service effectiveness and efficiency and help reduce risk factors 61 62 63 such an approach would also recognize the diverse capabilities and talents of young pasifika peoples and would allow them to engage in collaborative rather than paternalistic relationships with service users while contributing to health equity this study highlights how health equity indicators need to go beyond healthcare services and prevention to include a focus on the social determinants of health it emphasizes the need to understand the multiplicity of placebased factors that interact in complex ways to shape health inequities this includes understanding the dynamic interactions between the material features of place as well as its psychosocial elements including the meanings people ascribe to places and how political institutions shape the environments 1664 as the places where people live are constructed not only by their material and physical aspects but also by how people experiences and interact with these aspects research and health equity indicators need to account for the contextspecific differences in social processes such as power and cultural expression and the ways people interact with their environments this view of health means urban health equity indicators need to move beyond measuring health outcomes or features of the built environment such as amount of bicycle paths to understanding the economic social environmental political and cultural dimensions that drive wellbeing 1665 monitoring the social determinants of health and wellbeing can also help to identify which of the determinants are the most responsible for producing inequities in populations of pasifika young people over time thereby creating entry points for interventions 452266 this research suggests policy makers and service providers need to ensure policies and programs support health equity through a focus on policies to promote equal opportunities for all people residing in australia promote social inclusion and address the individual and systemic discrimination with interventions aimed at the media school children universities healthcare professionals medical students and employers this study also suggests common measures of health and wellbeing used in australia are missing important information related to the factors that shape young pasifika peoples health and wellbeing and particularly the impact of place on health and political decisions that limit access to basic services available to other residents to redress inequities experienced by pasifika peoples we suggest health equity indicators related to the key themes revealed by our research these include the spiritual sociocultural place material and economic and political dimensions of health and wellbeing with examples of potential indicators listed in table 1 while we have presented research from literature and interviews to support the abovementioned indicators they require further development via codesign efforts with key participants representative of all those involved from design to service delivery to be operationalized furthermore in partnership with pasifika communities and local councils it would be of value to select priority measures that represent the larger equity issue being addressed the intent of these indicators is to generate a set of measures that can be combined to monitor progress against the drivers of health inequity ideally indicators should be able to be expressed as proportions and rates so that they can be compared across different jurisdictions within southeast queensland with large pasifika populations a challenge however could be having sufficient data to provide meaningful comparisons between jurisdictions as well as to examine associates with health and wellbeing outcomes 67 nevertheless advances in mobile information technology are creating new opportunities for placebased data collection 3 capturing this information in respectful and meaningful ways however will require participatory approaches to inquiry that include both quantitative and qualitative data against the indicators as experienced by people to understand how these different dimensions are constructed and contested the next step of this work will be to refine and pilot the proposed indicators to ensure they are relevant and feasible and meet the needs of both policymakers and pasifika young people we will use the indicators to develop and test hypotheses about how these features of place interact and influence specific aspects of health in pasifika young peoples lives over time in working with policymakers the intent is also to align our proposed indicators with existing government indicators and to evaluate progress over time including the effectiveness of policy and programs in promoting health and wellbeing for this population furthermore the current paucity of available data relating to pasifika peoples across a range of socioeconomic indicators including health education and labour force participation will assist in increasing visibility of pasifika young peoples through this work we also hope to be able to gain a better understanding of unmet needs while hard to measure and detect given the lack of robust data in this respective area such information would be invaluable in informing policy and programs and closing the socioeconomic gap in health outcomes this could include for example participatory mapping of the physical and social place in which people live and visualization activities to imagine and advocate for the changes needed to promote wellbeing in rio de janeiro brazil a youthled digital mapping program implemented in partnership between unicef and a brazilian nongovernmental agency generated data from mapping placebased observations as evidence for health promoting interventions and policies 68 limitations this paper contributes to our understanding of pasifika young peoples experience of living in logan and its influence on health and wellbeing a limitation however is that the study was based on experiences in one city and we recognize that pasifika peoples live in other cities in australia in which diverse experiences of health equity may occur piloting and implementing the indicators in other areas with large pasifika populations may provide a more nuanced understanding of how health equity can be expanded in addition the indicators were policies that promote health across sectors and promote socioeconomic and cultural inclusion selected based on the subjective experiences of young pasifika peoples and while this makes them valid they are open to interpretation and will be revaluated as we work with local councils and pasifika young peoples through further research initiatives furthermore the proposed indicators were derived from the interview data which did not specifically ask participants to identify and rank the indicators and therefore require further refinement with young pasifika and with other stakeholders to ensure it is also feasible to collect data on the final selection of indicators as such limitations of insider research are acknowledged however this method of research appears to be an important component of youth participatory action research as well as the cultural relevance of the project design itself 4469 ultimately the test of the indicators will be whether they promote awareness and action by different actors across the system not just within the health sector 38 based on their work in richmond and nairobi however corburn and cohen 38 reported increased participation in nonhealth care specific sectors following the introduction of indicators that focused on the social determinants of health furthermore while the proposed indicators focus on the social determinants that contribute to inequality we do not mean to sidestep the importance of measuring and disaggregating by population groups socioeconomic outcomes this simply cements the need for a comprehensive approach to analysis of inequity much of this data is collected by various household surveys and implemented by federal and state governments but is rarely disaggregated by ethnicity or place conclusion while the experiences of pasifika young peoples living in australia may differ depending on context this study is important in demonstrating how health inequities experienced by pasifika populations are produced and strongly linked to place as well as economic social and cultural position while we have shown that connection to culture place and strong bonding capital can be health protective the study also suggests these can have some negative effects many of the participants demonstrated unique strengths and the social and cultural skills to navigate between their pasifika culture and mainstream culture however barriers to health equity were often underpinned by discrimination and unequal access to economic and social opportunities overcoming these barriers requires policies to address discrimination and stigma and recognise the strengths of pasifika peoples while this requires attitudinal changes within mainstream australian society and the australian government beginning to measure and provide policy makers with information against the social determinants of health is a first step towards addressing health inequities abbreviations help higher education loan programs scv special category visa authors contributions jd ls conceived the initial idea and design of the study nf af cz em tt je uu st contributed to the design data collection and initial analysis of the data jd conducted additional analysis and wrote the first draft of the manuscript all authors contributed to and approved the final version of this manuscript consent for publication not applicable competing interests the authors declare that they have no competing interests

background health equity is a priority in the global sustainable development agenda available health equity indicators often focus on health outcomes access to healthcare risk factors and determinants such as income education and gender less attention has been given to other social determinants including those related to place and ethnicity measures such as income education and gender however may not provide policymakers with sufficient information to redress inequities in this paper we begin to develop health equity indicators for young pasifika peoples in logan queensland australia while health data on pasifika young people in queensland is scant available data suggests significant inequalities the purpose of the study was to develop an understanding of the drivers of these disparities through the lens of the social determinants of health to create health equity indicators methods following meetings with community stakeholders to develop respectful and collaborative partnership processes we took a youth participatory action research approach six peer researchers 3 male 3 female were recruited from the logan area for the project following training the peer researchers undertook 31 qualitative interviews with young pasifika 1624 years old data was manually analysed coded and grouped into themes to develop the draft indicators interviews used the culturally appropriate talanoa storytelling approach results six key themes were identified from the interviews and were used to develop example indicators related to spiritual and sociocultural dimensions place access to culturally responsive services economic and material dimensions and political dimensions the results demonstrate health inequities experienced by pasifika populations are strongly linked to place and their economic social and cultural position conclusions this study emphasises the need to understand the multiplicity of placebased factors that interact in complex ways to shape health inequities for young pasifika peoples it highlights health equity indicators must go beyond healthcare services outcomes and a limited number of objective determinants to include a more holistic focus starting to measure health and wellbeing via the lens of the social determinants of health will help to identify where policymakers and programmes can intervene to begin to more adequately address inequities

introduction in western culture higher education institutions ideally aim at ensuring equality of opportunities that is selecting impartially the more competent students independently of their social class however they ironically tend to reproduce social inequalities selecting preferentially the higherclass students as a matter of fact in comparison with continuinggeneration students firstgeneration students are 68 less likely to earn a college degree after 4 years of college this social class graduation gap has been documented in european union as well as in switzerland it is notably explained by a lack of fit between the values of firstgeneration students and that promoted by universities most often scholars seem to consider firstgeneration students as unconditionally disadvantaged and continuinggeneration as privileged in the educational system yet one might argue that they only look at one side of the coin reasoning in terms of personenvironment fit the degree of ones sense of fit may indeed differ according to the context for instance although lowerclass students have a lower likelihood to graduate from more competitive colleges fields or departments some evidence suggests that higherclass students are less likely to succeed in less competitive ones additionally firstgeneration students are underrepresented in less prestigious departments toptier colleges and elite institutions but conversely continuinggeneration students are underrepresented in less prestigious fields secondtofourthtier colleges and secondrate institutions one might argue that these findings translate differences in terms of fit as a function of both social class and academic competition with most research describing firstand continuinggeneration students asrespectivelynot fitting in and fitting in in absolute terms we propose a more evenhanded approach raising the possibility of a relative lack of fit specifically we suggest a categorical and contextdependent lack of fit might impair the level of endorsement of two academically adaptive achievement goals namely the desire to learn and that to perform within a more competitive department firstgeneration students may experience a lower studentinstitution fit hindering the pursuit of these goals contrariwise within a less competitive department continuinggeneration students may also experience a lower fit hindering the endorsement of these same goals a contextindependent view of social class and studentinstitution fit let us first consider the relationship between social class and studentinstitution fit independently of the academic context that is the mere correspondence between personal and environmental characteristics in addition to economic and social factors psychological reasons might account for the social class graduation gap for instance bourdieu and passeron argued that students from lower social class could experience a discontinuity between their habitus and the higherclass habits promoted by universities such a discrepancy would result in lower achievement more recently stephens et al specified the effects of social class on studentinstitution fit on the one hand authors showed that firstgeneration students regulated their behaviors in keeping with interdependent values they endeavor to adjust themselves to the context to be connected to others and to respond to others interests on the other hand authors showed that continuinggeneration students regulated their behaviors in keeping with independent values they try to influence the context to be distinct from others and to satisfy their own needs preferences and interests yet higher education institutions most often convey independent norms according to which students are expected to work independently to strive for personal achievement and to express their own views in these contexts firstgeneration students therefore tend to experience a low sense of studentinstitution fit whereas continuinggeneration students experience a high fit in a series of articles stephens and her colleagues reported that such a reduction in terms of academic fit led firstgeneration students to feel more stressed to obtain lower grades and to achieve lower academic success a contextdependent view of social class and studentinstitution fit let us now consider the variations in the relationship between social class and studentinstitution fit as a function of the academic context most of the studies showing firstgeneration students lack of academic fit were conducted in highranked competitive universities yet although most higher education institutions and departments are highly competitive some others are less competitive moreover whereas the former promote independent values the latter might promote different values orat leastless independent ones as a matter of fact stephens et al reported that university administrators of highly competitive institutions characterized the values promoted by their university as being more independent than the ones of mildly competitive institutions in the first instance we will draw on these observations and develop the idea that more vs less competitive departments differ drastically regarding their institutional culture institutional practices and institutional identity then we will argue that the relationship between social class and studentinstitution fit depends on these differences competition and institutional culture as a function of academic competition departments convey different cultures in terms of excellence and individualism in more competitive departments students are encouraged to develop their idiosyncrasies and critical judgment as an example skelton urged higher education administrators to promote the enhancement of the individual students personal character and the development of the individual students autonomy conversely in less competitive departments the pursuit of collective goals rather than individual ones is emphasized for instance vansteenkiste et al reported that education students were more oriented toward helping others than toward wealth competition and institutional practices as a function of academic competition departments rely on practices fostering different representations of selfand othercompetence in more competitive departments where a numerus clausus can be established between the first and the second year only few of the candidates will pass their final exam in such environment the higher the likelihood that others are selected the lower the chance one has to succeed students enrolled in more competitive departments therefore perceive the competence of their classmates as necessarily coming into conflict with their own competence in other words others and selfcompetences are viewed as negatively correlated it is less the case for students enrolled in less competitive departments who view others and selfcompetences as uncorrelated competition and institutional identity as a function of academic competition departments imply different changes with regard to social identity that is the attitudinal and behavioral adjustments to comply with new institutional norms more competitive departments are associated with superior reputation and attractiveness than the less competitive ones as a matter of fact the more competitive a department the higher its students future earnings and socioeconomic status thus for lowerclass students being enrolled in a more competitive department involves a larger upward social mobility process this was notably found to predict psychological discomfort conversely for higherclass students being enrolled in a less competitive department may involve social immobility or downward social mobility process which could result in status insecurity academic competition social class and studentinstitution fit what conclusion regarding social class and studentinstitution fit can be reached from the fact that institutional culture practices and identity depend on academic competition on the one hand in more competitive departments firstgeneration students values of positive interdependence should be more incongruent with institutional individualistic culture and more negatively interdependent practices than continuinggeneration students values moreover they should experience a stronger feeling of incompatibility between their sociofamilial identity their new institutional identity as well as with their future possible identity on the other hand in the more specific case of less competitive departments continuinggeneration students values of independence might reciprocally appear as more incongruent with institutional collectivistic culture and less negatively interdependent practices than firstgeneration students values it is also legitimate to think that in this case their sociofamilial identity might conflict with both their institutional identity and their future socioeconomical identity such a lack of identityrelated fit would occur to the extent that students perceive themselves as being engaged in a downward mobility process in the present study we will specifically focus on students endorsement of academically adaptive goals as a function of such a contextand categorydependent lack of fit studentinstitution fit and achievement goals regulation achievement goals theorists distinguish two nonexclusive reasons for engaging in competencerelevant behaviors namely mastery and performance goals mastery goals relate to the desire to personally progress to surpass oneself whereas performance goals pertain to the desire to relatively succeed to surpass others mastery goals predict persistence after failure intrinsic motivation and taskcommitment performance goals predict performance be it in experimental or field settings in the late 90s adopting a multiple goals perspective judith harackiewicz and her colleagues showed that an elevated degree of both mastery and performance goals corresponded to an adaptive pattern of achievementrelated behaviors endorsed conjointly these goals allow the maintenance of optimal degrees in task interest and performance mastery and performance goals are not merely stable traits but may also be regulated in response to environmental factors as a matter of fact students enter in higher education holding high mastery goals but these goals tend to decline over the course of the curriculum such a decline is explained by the fact that many of the students become aware of the distance between their idealistic expectations and the reality of the courses however performance goals tend to remain more stable although similar discrepancy between ones resources and task demands predicts their decline hence it does not come as a surprise that studentinstitution fit is predictive of the maintenance of an elevated degree of mastery and performance goals generally speaking the incongruence between students beliefs and the perception of their environment was found to deplete motivation various kinds of needs and the level of goals endorsement more specifically a higher sense of match between individual preferences or values and environmental requirements or culture sustains task commitment a mastery goalrelated outcome as well as a high level of relative performance a performance goalrelated outcome overview and hypotheses as suggested in the opening paragraphs firstgeneration students are less likely to succeed and to be represented in more competitive academic environments whereas continuinggeneration students are less likely to succeed and to be represented in less competitive ones it reflects the fact that firstgeneration students may experience a discrepancy between their and the more competitive institutions culture practices and identity as a theoretical extension the same might be true for continuinggeneration students in less competitive departments in the present article we argue that this relative lack of studentinstitution fit as a function of social class and competition should predict the decrease in the endorsement of mastery and performance goals we therefore formulate two hypotheses in a more competitive department firstgeneration students should report lower mastery and performance goals in the third than in the first year it should not be the case for continuinggeneration students conversely in a less competitive department continuinggeneration students should report lower mastery and performance goals in the third than in the first year it should not be the case for firstgeneration students materials and methods the study used a 2 × 2 × 2 crosssectional design first the sample included undergraduates from a more and a less competitive department in the former namely life sciences the firsttosecond year passage appears to be more selective in the latter namely civil engineering the selection is weaker second firstgeneration students were distinguished from continuinggeneration students lower social class students were those having no collegegraduated parent whereas higher social class students were those having at least one collegegraduated parent finally both firstand finalyear bachelors degree students were surveyed in order to observe the evolution of their achievement goals the questionnaire assessed both mastery and performance goals that is both the will to learn and to outperform others participants and procedure three hundred and eightyeight undergraduates from a frenchspeaking swiss university filled in a paperandpencil questionnaire presented as a research on the motivational profile of students ten observations were excluded due to missing values the final sample was composed of n 378 students 153 females and 222 males with a mean age of 2001 years academic competition was operationalized through a difference in the selection process between two departments of the university civil engineering and life sciences such a difference is both objective and subjective first the two departments vary in terms of examination passing rates the firsttosecond year average success rate for the five academic years preceding the study was more than half for civil engineering whereas it was less than half for life sciences 1 as compared to the average success rate of the whole epfl that of civil engineering was higher indicating a less competitive environment and that of life sciences was lower indicating a more competitive environment second a pilot study aimed at confirming that students perceived life sciences as being more competitive than civil engineering sixtyone secondyear undergraduates mainly students of other departments but from the same institution as that of the main study were surveyed seven missing observations and two outliers were excluded from the analyses the final sample comprised n 52 students 23 women and 29 men on a scale ranging from 1 to 7 participants were asked to evaluate the extent to which civil engineering was a selective department promoted betweenstudent competition and enrolled competitive students the same three questions were repeated for life sciences the order between the two sets of items was counterbalanced the two scales showed a satisfactory reliability regression analyses tested the difference in terms of perceived competition between civil engineering and life sciences participants academic affiliation as well as order of item presentation were statistically controlled as expected results revealed that the two departments were perceived as differently competitive b 056 se 022 f 645 p 0014 η 2 p 012 life sciences were judged as being more competitive than civil engineering in other words the two departments were objectively and subjectively perceived by students of the epfl as different in terms of competition change in achievement goals was appraised using a crosssectional design we surveyed both firstyear and thirdyear students as mere social class was not found to significantly predict freshmens mastery and performance goals students having just entered university constituted a control group as identifying interpreting and responding to lack of studentinstitution fit are longterm processes students in their final year before bachelors degree graduation constituted the group in which changes were expected data were collected in agreement with the swiss psychological societys ethical guidelines3 no experimental manipulation was performed no incentive was given for participation participants were informed that the questionnaire was anonymous and that they could refuse to do it and withdraw from participation at any time variables social class participants reported the highest educational level attained by their parents using genouds sevenchoice scale4 as in prior research participants were categorized as firstgeneration students when neither of their parents had a college degree and as continuinggeneration students when at least one of their parents had a college degree table 1 shows the number of participants as a function of the three independent variables considered achievement goals participants reported their goals using the french validation of elliot and mcgregors achievement goal questionnaire on a scale ranging from 1 to 7 three items measured their masteryapproach goals and three others performanceapproach goals a summary of descriptive statistics and correlations is presented in table 2 results overview of the regression analyses multiple linear regression analyses were conducted with the department the academic year as well as the social class as independent variables with mastery and performance goals as dependent variables complete analyses of covariance was conducted in preliminary stage with gender and meancentered age as including these terms did not produce significant effects on any of the outcome variables they were not retained in the analyses the final model contained seven predictors the department the academic year the social class and all interactions a summary of the results is displayed in table 3 mastery goals analyses revealed a significant interaction between the department the academic year and the social class on mastery goals b 192 se 060 f 1043 p 001 η 2 p 003 it indicated that the interactive effects between the academic year and the social class depended on the department this interaction was decomposed by first examining the more competitive department and then the less competitive one first in the more competitive department the interaction between the academic year and the social class was significant b 099 se 040 f 625 p 0013 η 2 p 002 results confirmed that firstgeneration students reported lower mastery goals when in the third year than when in the first one b 116 se 033 f 1218 p 0001 η 2 p 003 in other words within the more competitive department firstgeneration students mastery goals tended to decrease from the university entrance to the final year of study in line with the existing literature these results suggest that firstgeneration students experience a particular discrepancy between their self and the competitive academic environment impairing their willing to learn conversely the effect of academic year was not different from 0 for continuinggeneration students b 018 se 021 f 1 continuinggeneration students mastery goals did not decrease between the first and the third year second in the less competitive department the interaction between the academic year and the social class was also significant b 093 se 044 f 437 p 0037 η 2 p 001 compared to the previous analysis the results were reversed indeed in this department firstgeneration students mastery goals endorsement did not decrease between the first and the third year b 010 se 036 f 1 as firstgeneration students maintained an elevated degree in such a context it conveys the idea they may not be unconditionally disadvantaged in the educational system conversely continuinggeneration students reported lower mastery goals when in the third year than when in the first one b 082 se 026 f 973 p 0002 η 2 p 003 in the less competitive department continuinggeneration students mastery goals tended to diminish from the university entrance to the last year this result leads into thinking that in less competitive environment continuingrather than firstgeneration students are those who face the motivational consequences of a lack of studentinstitution fit taken together such findings sustain both ideas that firstgeneration students might not always have to struggle at university and that continuinggeneration students might not always be favored by the academic context indeed continuinggeneration students could also experience a discrepancy between their self and the less competitive environment which can deplete their desire for improvement and learning performance goals for performance goals analyses did not reveal a significant secondorder interaction between the department the academic year and the social class b 026 se 081 f 1 contrary to our second hypothesis the interactive effects between the academic year and the social class did not depend on the department however the firstorder interaction between the department and the academic year was significant b 105 se 041 f 660 p 0011 η 2 p 002 as can be seen in figure 2 in the less competitive department performance goals were lower in the third year than in the first one b 099 se 030 f 1056 p 001 η 2 p 003 regardless of social class for students enrolled in the less competitive department performance goals decreased from university entrance to the final year of study in the more competitive department such an effect was not observed b 016 se 027 f 1 indeed whatever the social class performance goals did not change between the first and the third year as the endorsement of performance goals is indicative of a more competitive environment these findings confirmed that life sciences were characterized by a more elevated degree of betweenstudent competition than civil engineering discussion most research on social inequalities in higher education described firstgeneration students as not fitting in and continuinggeneration ones as fitting in independently of their academic environment such a weighed tendency might be due to two reasons firstly most academic contexts are highly competitive therefore specifically impairing the lack of fit of firstgeneration students secondly most social scientists goals are to reduce social inequalities therefore willing to bolster up the lack of fit of firstgeneration students however universities being heterogeneous in terms of culture practices and identity the studentinstitution fitbased approach implies that in less competitive contexts continuinggeneration students might also experience comparable selfinstitution discrepancies the present study aimed at testing the effects of such a categoryand contextdriven lack of fit on the endorsement of two academically adaptive achievement goals 5 congruent with our first 5 in this article we refer to mastery and performance goals in their approach form as we aimed at focusing on the academically adaptive achievement goals however these goals might include an avoidance component and become more maladaptive it is worth noting for the sake of transparency that three items assessing masteryavoidance goals and three performanceavoidance goals were added for exploratory purpose we carried out the same analyses on masteryand performanceavoidance goals the results revealed only two significant effects namely two main hypothesis in a more competitive department firstgeneration students reported lower mastery goals when in third than when in first year it was not the case for continuinggeneration students conversely in a less competitive department continuinggeneration students reported lower mastery goals when in third than when in first year it was not the case for firstgeneration students however incongruent with our second hypothesis such an interaction effect was not observed for performance goals let us see how these results contribute to connecting the literature on social inequalities and that on achievement goals by first considering mastery goals and then performance goals we will then discuss some practical implications theoretical contribution regarding mastery goals in the more competitive department over the course of their bachelors study firstgeneration students mastery goals were found to diminish to a greater extent than those of continuinggeneration students yet we have seen that at university mastery goals actually relate to dropout intentions hence taking low mastery goals as a dropout risk factor such a result might provide a goalbased explanation for the fact that firstgeneration students are much more likely to leave from more competitive institutions than continuinggeneration ones more generally it might account for the lack of social class diversity in more competitive universities negative effects of academic years on the former b 091 se 016 f 3091 p 0001 and on the latter goals b 039 se 018 f 454 p 0034 both the importance of masteryand performanceavoidance goals diminished in the third year compared to the first year in the less competitive department over the course of their bachelors study continuinggeneration students mastery goals were found to diminish to a greater extent than those of firstgeneration students once again taking low mastery goals as a dropout risk factor such a result might provide a goalbased explanation for the disappearance of the social class attrition rate in less competitive institutions moreover it might explain why continuinggeneration students tend to flee from less prestigious colleges and to transfer to another institution when their needs are not satisfied or when they can benefit from an informal career opportunity requiring no given level of education theoretical contribution regarding performance goals as compared to the more competitive department in the less competitive department performance goals showed a steeper firsttothird year reduction generally speaking it pertains to the fact that structural competitionin that it fosters social comparisonfavors the endorsement of performance goals whereas the perception of a climate not emphasizing relative performance predicts their diminution however social class was not found to influence the effect of academic competition on performance goals regulation revealing unexpected variations in the relationship between studentinstitution fit and achievement goals yet we have seen that performance goals are related to higher academic grades hence taking low performance goals as a lowgrade risk factor such a null finding may echoe the inconsistent effects of social class on grades in sum from a goalbased perspective these findings seem to suggest that the social class graduation gapbe it contextdependent or independentmight be explained by a misfitdriven lack of learningfocus rather than a misfitdriven lack of successfocus as a matter of fact the social class graduation gap is accounted by a series of epistemic causes namely lower interest in extracurricular activities lower timeinvestment or lower selfefficacy research should be undertaken to test the specific role of mastery goals in explaining the effects of competition and social class on dropout and on grade practical implications in the last years scholars proposed various recommendations andor developed several interventions intended to reduce the misfitdriven social class achievement gap some of them are institutionfocused that is at a macrolevel such as needbased financial aids however some others are studentfocused that is at a microlevel such as personal value affirmation how do our results inform on the goalrelated potential consequences of these two approaches amongst the institutionfocused approaches as the social class achievement gap is notably attributed to the increasing competitiveness among prospective students some scholars urged faculty members to reduce competition extending the present results one might suspect that change in structural policies aiming at lessening competition might have ironical effect although reducing competition could be beneficial for the maintenance of firstgeneration students mastery goals it could impair that of continuinggeneration ones in a way spencer and castanos results can be linked to this rationale indeed by minimizing the evaluative dimension of a task authors demonstrated that lower class students experienced less threat but that upperclass students experienced less challenge yet the hypothesis of the potential perverse role of competition reduction on goals in that it could undesirably impair mastery goals within the dominant group remains to be formally tested before that additional empirical data confirm or infirm it relying on studentfocused approaches aimed at ensuring social equality between firstand continuinggeneration students might be less hazardous as a matter of fact stephens et al s differenceeducation interventionin which students learn about the potential consequences of social classwas found to eliminate firstgeneration students disadvantage without affecting continuinggeneration students limitations two limitations of the present study should be acknowledged first the crosssectional design of our study does not allow to formally distinguish whether a selection process or a socialization one accounts for the results in other words it is not possible to determine if students oriented toward mastery goals drop out when suffering from a lack of fit or if the ones suffering from a lack of fit abandon their mastery goals over time however as observable in table 1 the firsttothird year diminutions of the number of firstgeneration students are virtually similar from one department to the other indicating that different attrition rates could less parsimoniously explain the effect than a genuine change in goals the same reasoning might apply to continuinggeneration students although the diminutions are somewhat more different still given the crosssectional nature of the present study together with the fact that the number of observations in some cases is rather small the present findings need to be replicated future research might employ a longitudinal design to more directly measure the evolution of students achievement goals alternatively scholars might be willing to use publicly available largescale data sets to examine whether structural competition indeed moderates social class graduation gap second the use of different departments of the same academic institution as a proxy of competition creates a weakness for internal validity yet it must be stressed that in addition to structural differences in terms of selection the pilot study showed that life sciences were indeed perceived as being more competitive than civil engineering such a difference was confirmed by the fact that thirdyear students enrolled in life sciences reported higher performance goals than those in civil engineering however one cannot exclude that the results could be due to a confounding variable indeed the present study should be considered as a singlesite case study future research should manipulate competition in order to exclude possible confounds and draw causal conclusions conclusion adopting an evenhanded approach this article reports preliminary evidence of a contextdependent effect of social class on mastery goals on the one hand firstgeneration students were argued to suffer from a particular lack of fit when enrolled in more competitive domains which was found to prevent the maintenance of an optimal level of mastery goals on the other hand continuinggeneration students were argued to suffer from a particular lack of fit when enrolled in less competitive domains which was foundhere alsoto impair their mastery goals in other words firstgeneration studentsin addition to having lower degree aspiration might be less likely to be learningoriented and to persist when engaged in more competitive institutiondriven upward mobility conversely continuinggeneration studentsin addition to having higher degree aspiration might be less likely to be learningoriented and to persist when engaged in less competitive institutiondriven downward mobility a promising avenue for future scaledup research would be testing whether these two complementary dynamics contribute to maintain the transmission of social inequalities from one generation to the next conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

as compared to continuinggeneration students firstgeneration students are struggling more at university in the present article we question the unconditional nature of such a phenomenon and argue that it depends on structural competition indeed most academic departments use harsh selection procedure all throughout the curriculum fostering betweenstudent competition in these departments firstgeneration students tend to suffer from a lack of studentinstitution fit that is inconsistencies with the competitive institutions culture practices and identity however one might contend that in less competitive academic departments continuinggeneration students might be the ones experiencing a lack of fit using a crosssectional design we investigated the consequences of such a contextand categorydependent lack of fit on the endorsement of scholastically adaptive goals we surveyed n 378 firstand continuinggeneration students from either a more competitive or a less competitive department in their first or final year of bachelors study in the more competitive department firsttothird year decrease of mastery goals ie the desire to learn was found to be steeper for firstthan for continuinggeneration students in the less competitive department the reversed pattern was found moreover firsttothird year decrease of performance goals ie the desire to outperform others was found to be steeper within the less competitive department but did not depend on social class this singlesite preliminary research highlights the need to take the academic context into account when studying the social class graduation gap

introduction transgender and gender variant youth experience multiple stressors that negatively affect their health and wellbeing transgender youth are adolescents and young adults with a selfidentified gender different from their sex assigned at birth while gender variant youth are those whose characteristics traits or identities do not neatly align with societal expectations of traditional male and female roles gv youth may include youth who identify as transgender neither being transgender nor gv implies that a youth is also a sexual minority as gender identity and sexual orientation are distinct transgendergv youth experience stigma due to negative cultural beliefs about gender variance and most gv youth report higher levels of verbal and physical victimization than their gender normative peers harassment violence discrimination and childhood abuse are particularly well documented for transgender youth these youth experience elevated risk within many domains traditionally associated with positive youth development for example family networks may be unsupportive if parents reject children who disclose a transgender identity and schools can be inhospitable as coming out to peers teachers and staff can result in bullying or verbal and physical harassment these compounding risk factors have welldocumented effects on health and wellbeing for transgendergv adults experiences of stigma are linked with mental health difficulties including depression anxiety reduced quality of life and attempted suicide transgender youth are diagnosed with depression and anxiety at rates that surpass cisgender peers and experience up to three times the rate of suicidal ideation nonlethal selfharm and suicide attempts as cisgender youth violence stigma and discrimination are tied to elevated rates of hiv infection among transgender women rates of hiv are disproportionately high among transwomen with population averages ranging from 15 to 40 among adults and 522 among youth age 1625 years approximately 27 of young transmen and transwomen in one study reported having had gonorrhea chlamydia andor syphilis in the past year given the compounding effects of risk encountered by transgendergv youth researchers should consider what helps prevent poor health and wellbeing literature on adolescent development suggests that strengthening protective factors among atrisk youth is an important intervention strategy protective factors are characteristics conditions and behaviors that enable individuals to avoid or decrease negative health consequences associated with risks and hazards bronfenbrenners socioecological model provides a useful framework for conceptualizing protective factors within individual relationship community and societal levels public health scientists have historically used this model to map protective factors among subgroups of adolescents such as those at risk for violence those who identify as sexual minorities and those in developing countries consideration of protective factors within this model highlights the dynamic relationship between factors at each level and how they collaboratively influence health and wellbeing this dynamism enables researchers to identify important missing links between factors and outcomes in need of future study and allows practitioners to specify multilevel pathways through which interventions may best improve adolescent health while some emerging scholarship about protective factors that reduce risk and improve health outcomes among subpopulations of transgendergv youth exists empirical study of this topic remains underdeveloped the purpose of this systematic review is to map the empirical literature on protective factors among transgendergv youth within a socioecological framework to advance scientific inquiry in this area we summarize the existent empirical research on transgendergv youth and protective factors organize evidence within the socioecological framework and 3 identify theoretical and methodological gaps this conceptual overview should help researchers design future studies of protective factors and transgendergv youth methods to identify and categorize protective factors we developed a conceptual guide a priori via a nonsystematic scan of peerreviewed and gray literature that we organized using the socioecological model and adolescent development theories factors were integrated into the conceptual guide if we found evidence that they were theoretically or empirically described as a protective factor for any health outcome among any population of adolescents or young adults we subsequently organized these factors by socioecological level and types of factors within each level this conceptualization guided the development of search terms and data extraction figure 1 offers a visual representation of this socioecological conceptualization of protective factors we identified relevant articles via a systematic review of 19 english and 13 spanish databases using keywords from three core domains to create the search strategy inclusion required at least one search term from each of the three core domains we also performed manual database searches and reviewed reference lists of included articles to identify additional relevant articles inclusionexclusion criteria to meet inclusion criteria articles had to be published in a peer reviewed journal in english or spanish between 1999 and2014 analyze data collected from a sample or subsample of transgender or gv adolescents with a mean age between 10 and 24 years present research conducted in north america europe australia new zealand or latin america and examine at least one theorized protective factor in relation to a health or behavioral outcome for quantitative studies this final criterion was met by statistical testing of at least one pathway between a theorized protective factor and a health or behavioral outcome health and behavioral outcomes were not limited to specific topics or types of measures however they did exclude risk factors like victimization and experiences of harassment quantitative relationships with a p value of 05 were considered significant qualitative studies had to report at least one authoridentified theme that connected a protective factor to a healthpromoting pathway studies that explored these relationships in a sample that did not disaggregate transgender youth from their cisgender peers were excluded from the synthesis as we could not interpret the unique effects of theorized protective factors for transgendergv youth articles meeting inclusion criteria were included regardless of study quality with the exception of retrospective studies of adults older than 24 years reporting their experiences as youth abstract screening and data extraction three coders screened the abstracts of all potentially relevant articles identified in the literature search to determine intercoder reliability an initial subset of abstracts was screened by all coders intercoder agreement on this subset was 95 at that point remaining abstracts were divided among the coding team to be screened any articles assessed as unclear with respect to inclusion or exclusion criteria by individual reviewers were brought back to all coders to discuss until consensus was reached after identifying abstracts of interest two researchers independently reviewed and summarized the full text articles meeting inclusion criteria using a standardized extraction form extracted data included study background information sample characteristics protective factors organized by ecological domain outcomes and a summary of the relationship between protective factor and outcome discrepancies concerning protective factors or outcomes were discussed among coauthors until consensus was reached data analysis to map this literature we catalogued articles by sampling strategy raceethnicity and sex or gender composition within the sample and terminology used to categorize transgendergv youth we organized protective factors extracted from articles within the socioecological framework totaled the number of factors observed or tested as protective at each level and distinguished between factors as qualitative or quantitative we noted any factor examined in more than one article or in relationship to more than one outcome and flagged any theorized protective factors with nonsignificant or risk relationships to health and behavioral outcomes we then clustered factors by thematic type within each level of the socioecological framework to highlight any existing empirical trends results study characteristics the systematic search retrieved 2337 records after removing duplicates we screened 1956 unique records of those 50 abstracts met criteria for fulltext review and an additional 15 articles were found through review of reference lists and manual searches after full text coding 21 articles met our inclusion criteria including nine that were quantitative nine that were qualitative and three that were mixedmethods all included articles were crosssectional and written in english and the great majority described research conducted in the united states because articles that reported data from the same study but examined different factors or provided separate quantitative and qualitative analyses were included results are presented in summative tables by unique article rather than data source participants ranged from 11 to 26 years of age and were racially and ethnically diverse five articles included exclusively youth of color seven articles included 50 youth of color seven articles included 50 youth of color and two articles did not report information on race or ethnicity while all articles used convenience samples participants were recruited through multiple recruitment strategies including community or venuebased recruitment online recruitment and schoolbased recruitment fifteen articles recruited participants in urban areas seventeen articles had samples that exclusively comprised transgendergv youth while four articles included both transgendergv and cisgender youth but examined protective pathways in a transgendergv youth subgroup see table 2 for article characteristics a wide range of terminology was used to categorize gender identities of participants eleven articles categorized transgender participants within a gender binary labeling participants as maletofemale or femaletomale nine articles further disaggregated the transgender umbrella using a variety of researcherassigned and participantidentified gender identity labels such as genderqueer genderfluid or mahu one article utilized diagnostic criteria to identify participants experiencing clinically significant distress or impairment due to the difference between their lived gender and assigned sex protective factors we found 27 unique protective factors with nine factors at each of the individual relationship and community levels of the socioecological model no articles examined factors at the societal level table 3 provides a complete list of factors organized by socioecological level and details specific qualitative and quantitative findings quantitative findings are further disaggregated into protective nonsignificant and risk associations individuallevel protective factors beliefsperceptionsfive factors capturing beliefs and perceptions for transgender youth demonstrated some protective associations with health and wellbeing selfesteem body esteem religiosity positive sense of self and selfefficacy in quantitative articles higher selfesteem was protectively associated with less engagement in high risk sex among young transgender women however nonsignificant associations were found between selfesteem and various mental health outcomes including depression qualitatively youth reported that increasing their selfesteem helped them avoid suicide in quantitative studies two dimensions of body esteem were associated with fewer attempted suicides but no association was found with a third body esteem dimension religiosity was measured by religious attitudes and practices strength of formal religious practice had a protective association with sexual risk for transgender youth while religious attitudes was not associated with sexual risk youth suggested that increasing their sexual selfefficacy allowed them to better negotiate healthy relationships and sexuality and that a clear and positive sense of self helped them cultivate feelings of pride and empowerment skillscompetenciesfour factors had some support as protective skills or competencies for transgender youth personal mastery ability to use internet or social media for information or support problem solving skills and selfadvocacy skills personal mastery was associated with a lower risk of depression and fewer symptoms of mental trauma but was not associated with other internalizing and externalizing disorders and an overall measure of mental health problems in qualitative studies youth discussed using problem solving skills to challenge or change their families antitrans feelings and to find more inclusive spaces selfadvocacy skills helped youth stand up for themselves when facing harassment youth also reported using the internet and social media to find resources educational materials and health information and to connect to role models who shared their gender and racial identities relationshiplevel protective factors parents and familiesfamily cohesion and parental support exhibited some support as protective family cohesion was associated with higher selfesteem higher sexual selfefficacy and later age of first intercourse for transgender youth but was not related to number of sexual partners substance abuse behaviors incarceration and prostitution parental support was protectively associated with fewer depressive symptoms perceived burden of being transgender and improved life satisfaction in qualitative studies transgender youth discussed how support of friends and family improved their mental health and sense of self and how family support improved their selfdefinition of marginalized gender and racial identities transgender girls and young women with at least one supportive parent discussed using condoms more consistently than participants without such support and some reported developing a new kinship as woman through supportive relationships with their mothers trusted adultsthree factors supportive educators and staff transgender role models and helpful service providers were assessed as protective having a relationship with a supportive educator was associated with less school absenteeism for transgender youth and feelings of safety at school in qualitative reports transgender youth relayed that the presence of school staff who advocated for them including teachers made them less likely to drop out even if they experienced victimization and harassment faculty who were aware and supportive of transgender issues also improved these youths academic experience transgender youth also reported that adult advocates were critical to the successful navigation of structural barriers in the school system that adult transgender role models improved their educational and career aspirations and that adults at social service agencies aided them in obtaining housing health insurance and changes to their legal name or lived gender and were sources of emotional support and mentorship peerspeer support and networks had some evidence for being protective in a sample of youth diagnosed with gender dysphoria those who reported higher quality peer support also reported fewer psychological symptoms qualitatively transgendergv youth claimed support from friends and peers improved their positive sense of self and helped maintain their mental health transgendergv youth who increased their friend networks and peer support reported fewer of the negative effects of depression felt more comfortable opening up and discussing issues and felt less isolated and lonely youth with transgender friends also reported having a more positive sense of self and being better able to find information about transgendersupportive social services finally for some friendship networks acted as a family of choice after rejection from families of origin generalized social supportgeneralized social support demonstrated mixed effects for young transgender women high levels of social support were associated with a reduced likelihood of engaging in unprotected anal intercourse and with fewer symptoms of depression and fewer problems with internalizing behaviors but had nonsignificant associations with externalizing behaviors symptoms of trauma and an overall measure of mental health problems conversely one crosssectional article found high levels of social support to be associated with a greater likelihood of engagement in sex work among young transgender women romantic or sexual partnershipshealth protective communication was associated with less unprotected anal intercourse for young transgender women young transgender women also qualitatively reported that open communication informed sexual health decisionmaking with their main partner these women reported that they discussed and confirmed through testing both their own and their partners hiv status before stopping condom use and continued to use condoms with casual partners outside the primary relationship to reduce the risk of hiv infection communitylevel protective factors school policiesschool policies against bullying and lgbt inclusive curricula demonstrated some evidence of being protective mcguire et al created a composite measure of school protective factors high scores on this measure were directly associated with a greater likelihood of transgender youth expressing a connection to an adult at school and indirectly associated with increased feelings of safety however they were not directly associated with increased feelings of safety additionally school policies against bullying and harassment and an lgbt inclusive curriculum were each independently associated with less absenteeism among transgender students organizational resourcesgsas alternativecharter schools and transgender health and social services were three organizational resources with support for being protective the presence of a gsa was protectively associated with reduced absenteeism for transgender students transgender students qualitatively reported that joining a gsa helped them to develop selfadvocacy skills and that having a gsa improved school climate transgender youth also discussed alternative and charter schools as a critical educational resource when traditional schools did not provide a hospitable climate the availability of transgender health and social services in schools and neighborhoods was cited as important for finding emotional support for and tangible assistance with legal and medical transitions for homeless transgender youth access to safe lgbtfriendly youth centers was important to building support and feelings of safety community visibilityschool diversity oncampus activism and a visible transgender community showed some support for being protective transgender youth reported that the presence of visible lgbtqq communities and allies in school improved school climate and contributed to their development of selfadvocacy skills and resilience youth also expressed feeling more comfortable with their racial and gender identities when they attended schools with diverse faculty and student bodies transgender youth also appreciated opportunities for oncampus activism and found they led to increased knowledge about rights and feelings of empowerment finally transgender youth qualitatively shared that finding community with other transgender people was positive and improved their academic experiences while involvement in the transgender community was not associated with engagement in sex work discussion across the 21 included articles 27 unique factors were related to positive health and wellbeing for transgendergv youth but only seven of these factors demonstrated protective relationships in multiple quantitative and qualitative studies while the frequency with which factors appeared as protective in the evidence does not indicate the magnitude of their effects on health it does indicate which have the most preliminary support as protective for transgendergv youth at the individuallevel selfesteem was the only factor with support as protective for transgendergv youth across both qualitative and quantitative articles while selfesteem was mostly protective for youth in this review other studies indicate that selfesteem has no effect or even risky effects among lgb and nonlgbt youth groups as such evaluating how selfesteem functions similarly or differently within different populations may help to understand its utility as a potential protective factor for transgendergv youth at the relationshiplevel support of parents peers and trusted adults emerged as central to the wellbeing of transgendergv youth the importance of parental support echoes research on all youth and on lgb youth in particular furthermore this finding is consistent with what has been observed among transgender adults where support from family members has been tied to reductions in suicidal behavior and thus appears to be a protective factor critical to the health of individuals with stigmatized identities the benefits of peer support to the mental health of transgendergv youth also aligns with trends observed for all youth however because parent and peer relationships are frequent sources of harassment and victimization for transgendergv youth questions remain about how to strengthen these connections other adults are sometimes the only sources of support available these extrafamilial trusted adults may be resources to help families and peers better understand gender variance at the community level schools can also play an important role in the lives of transgendergv youth both through supportive teachers and staff and through the resources they provide schoolbased gsas emerged at the community level as a potentially protective resource for transgendergv youth with protective associations across studies the protective benefits of gsas have been documented for lgb youth and their protective effect for transgendergv youth is promising although questions remain as to how gsas might be better designed to meet the needs of lgb and transgendergv youth simultaneously absent from the literature and consequently this review were articles evaluating societal level protective factors leaving questions as to the protective effects of laws and governmental policies on transgendergv youth unexpectedly one article found that a traditional health protective factor the relationshiplevel characteristic of social support was associated with a greater likelihood of engaging in sex work however this may not imply direction of causality or reflect real world risk the connection between social support and sex work was explained by article authors as potentially resulting from either a lack of measurement clarity or a reflection of the unique social support transgender women engaged in sex work offer each other additionally this review highlights patterns within the scientific study of protective factors among transgendergv youth first there is little consistency as to how researchers measure and classify transgendergv youth identities an academic discussion of how best to measure transgender identities in survey research is ongoing with movement toward standardized use of a twostep approach this review reveals some tardiness as to its uptake as more researchers employ this method comparing protective relationships among transgendergv youth across research studies and examining within group differences will become more possible second all the articles included in our review used convenience samples with wellrecognized limits to their generalizability however using convenience samples to access hard to reach populations is consistent with early work on lgb and other marginalized populations and likely indicates the novelty of this field of study researchers should consider novel methods such as combining venuebased sampling with quotas to insure adequate racial and gender diversity or timespace sampling of community venues to control for sampling bias derived from recruiting the entire sample at one point in time respondentdriven sampling using key informants from hardtoreach subpopulations of transgender gv youth may also increase diversity in the sample and can help to capture the experiences of youth who do not actively frequent community venues in addition longitudinal research would facilitate examination of the pathways between factors theorized as protective and health outcomes furthermore the quantitative and qualitative findings in this review provide the reader with complementary but distinct implications for continued research on this topic factors which demonstrate some protective effects in quantitative data such as personal mastery and supportive educators would benefit from continued study specifically further assessment of the protective factors in this sample with additional untested health and behavioral outcomes would enable researchers to understand the full range of these factors protective effects while replication of previously observed relationships between protective factors and their outcomes within surveys using the methodological advancements suggested above would enable a more robust understanding of these factors generalizability qualitative findings unrepresented in the quantitative data such as selfefficacy and transgender health and social services may be used to guide measurement and survey development for quantitative analysis testing qualitative pathways quantitatively in welldesigned surveys could also establish the generalizability of these factors as protective for transgendergv youth although intervention research was not included in this review two types of interventions did appear in initial search results and showed beneficial effects on both protective factors and health outcomes medical interventions such as pubertal suppression and gender reassignment surgery appear to improve selfconcept and reduce negative mental health outcomes among youth who elect these procedures additionally peerbased interventions for transgendergv youth appear to strengthen communication skills and support networks these findings support possibly adapting positive youth development interventions that increase protective factors and improve health and wellbeing of other groups of marginalized youth for transgendergv youth some additional limitations of this review should be noted first the articles included in this study are limited by our search criteria while we aimed to be inclusive of all transgendergv identities articles that did not include the chosen search terms might have been missed second our results may be limited by publication bias while this review provides a thorough summation of the peerreviewed science on protective factors and transgendergv youth researchers particularly interested in innovative methods might choose to supplement it with a scan of the gray literature conclusions overall our findings affirm that research on transgendergv youth and protective factors is in a nascent stage as the first comprehensive mapping of protective factors for transgender gender variant youth the results of this review may provide an introduction for scientists and practitioners who are new to this field mapping factors from quantitative and qualitative studies within the socioecological model provides a theoretically driven guide for identifying protective factors that have received adequate attention and those in need of continued empirical investigation because scientific inquiry into this topic is relatively new expansion of the research base through novel recruitment strategies that include diverse and representative transgendergv youth and through longitudinal studies evaluating the effects of protective factors over time is needed schools and other communitybased organizations may use the information on protective factors provided here to inform programs and interventions that strengthen the health and wellbeing of transgender gv youth body esteem externalizing problems internalizing problems internetsocial media use transsexual college students considered the internet a good tool for finding resources educational materials and connecting with other transsexuals transgender youth of color reported using social media to connect to role models who shared their gender and racial identities as well as to find information about transgender social and medical experiences problem solving skills transgender youth demonstrated problem solving skills by taking steps to better their situation some engaged in dialogue to change opinions of family members who were antitrans others sought out inclusive spaces in which to live selfadvocacy skills transgender youth of color discussed how their selfadvocacy skills helped them stand up for themselves relationship romantic or sexual partnerships communication with sexual partner highrisk sex young transwomen discussed communicating with their steady partners that they would not use condoms with each other but use condoms with commercial or casual partners to prevent hiv infection this was usually done alongside hiv testing parents and families parental support depressive symptoms transgender college students reported that support and acceptance by family improved their mental health and contributed to a positive sense of self the types of support that were perceived as positive were asking questions to understand transgender experience assisting with affirming participants transition perceived burden life satisfaction transgender youth discussed how support from family increased their sense of racialethnic and gender identity young transwomen with strong parental support reported their mothers helped them to develop a new kinship as woman affirming their gender identity social support highrisk sex ie unprotected anal nonsignificant author manuscript transgender youth of color shared that interactions with other lgbtqq youth of color in school or community organizations built up their resilience trans youth participants named that support from transaffirming communityallies on campus helped facilitate their resilience and selfadvocacy skills diverse faculty staff and studer body female transgender students of color reported feeling more comfortable when others with their gender and racial identities were present on campus oncampus activism transspectrum youth reported that engaging in oncampus activism helped them to feel empowered and know their rights no protective factors were identified at the societal level of the ecological model j prim prev author manuscript available in pmc 2019 june 01

transgender and gender variant gv youth experience elevated risk for poor health and academic outcomes due mainly to social experiences of stigma and discrimination to supplement the growing evidence on health risks encountered by transgendergv youth we identified factors theorized to be protective for these youth across all four levels of bronfenbrenner s socioecological model individual relationship community societal we conducted a systematic search of peerreviewed research the articles included in this review were published in peerreviewed journals in english or spanish between 1999 and 2014 analyzed data from a sample or subsample of transgender or gv participants with a mean age between 10 and 24 years and examined the relationship of at least one theorized protective factor to a health or behavioral outcome twentyone articles met inclusion criteria transgendergv youth in included articles ranged from 11 to 26 years of age were raciallyethnically diverse and represented varied gender identities within these articles 27 unique protective factors across four levels of the ecological model were identified as related to positive health and wellbeing selfesteem at the individual level healthy relationships with parents and peers at the relationshiplevel and gaystraight alliances at the community level emerged as protective factors across multiple studies our findings underscore the relative lack of research on transgendergv youth and protective factors novel recruitment strategies for transgendergv youth and better measurement of transgender identities are needed to confirm these protective relationships and identify others growth in these areas will contribute to building a body of evidence to inform interventions

introduction in mental health settings there is no place more social than where people smoke tobacco patients and healthcare professionals alike much as many social activities in other settings even nowadays yet mental illness is associated with higher levels of social anxiety those who suffer are doing their coping and may appear to be doing better than the others but in fact may need special attention for smoking cessation because they are still smoking more than other patient populations objectives to reflect on tobacco smoking and social anxiety methods pubmed search using terms tobacco and smoking and social anxiety social anxiety disorder results social anxiety 1 is associated with higher smoking initiation and progression to dependence 2 is more frequent in smokers 3 is used as a coping mechanism for distress caused by social interactions and may alleviate negative affect and thus serve as negative reinforcement 4 may be associated with higher nicotine dependence 5 has not been definitely associated with heavier smoking 6 may differ in its effects according to gender 7 may be associated with less quit attempts 8 may hinder success in quitting smoking and may be associated with higher rates of relapse conclusions identifying and treating social anxiety may lead to better outcomes in smoking cessation in a subgroup of patients who present elevated social anxiety with or without social anxiety disorder patients with mental illness especially serious mental illness will likely present with higher levels of social anxiety which may represent a significant factor contributing to an increased difficulty in quitting tobacco smoking in this patient population disclosure of interest none declared epv0019 sexual motivations for engaging in chemsex behaviours introduction the intentional use of drugs before or during sexual intercourse is a phenomenon of special importance in the msm population due to its impact on mental physical and sexual health sexual health issues related to chemsex practice have been described such as difficulties in achieving sober sex erectile dysfunction or problems with sexual desireobjectives the objective of this study was to understand the sexual motivations for chemsex practice o a group participantes of a sexual health program for chemsex users in two drug substace use disorder clinics in madrid methods qualitative research approach we analyze an anonymous survey with chemsex users with open answer questions about the motivations for chemsex practice data analysis was based on thematic analysis of content introduction the emergence of new psychoactive substances has had a substantial impact worldwide nps mimic the effect of existing drugs and are specifically manufactured so that the new substances fall out of regulatory frameworks although the structural changes might be minimal nps often have marked differences in potency and subsequent harm the population of the azores archipelago has been particularly affected by the rapid growing and changing nature of this phenomenon mainly caused by the introduction and spread of the newly synthetic cathinones as a inexpensive and easily available street drug before any educational public health and socioeconomic policy changes be proposed to accurately tackle the problem the basic step of knowing how these substances have been affecting their users specially their neuropsychiatric effects must be taken objectives this project aims to characterize the neuropsychiatric side effects caused by the acute intoxication of nps with a psychostimulant profile namely synthetic cathinones methods description of the neuropsychiatric symptoms of intoxicated users of stimulant nps that present to nongovernmental organizations specialized in addictions and also to the psychiatry emergency department in sao miguel azores review of the forensic records of the deaths by suicide in 2021 in sao miguel looking for evidence of recent abuse of nps or previous history of nps use disorder nonsystematic review of the recent and relevant scientific literature on this topic results the desired effects are increased energy mood enhancement euphoria mental clarity improved concentration improved sociability increased talkativeness empathy inducing effects amplification of sound and colour and prosexual effects nevertheless in the case of intoxication the frequent neuropsychiatric side effects tend to be agitation agressiveness irritability altered consciousness brief psychosis with paranoid delusion visual and auditive hallucinations transient mania enhanced sensorial experiences headaches dizzyness seizures confusion and amnesia usually the acjute intoxication period tend to be followed by a crash with depression craving anxiety panic suicidal ideation and behaviours a third of the deaths by suicides in sao miguel island in 2021 7 out of 21 were in stimulant nps active or recent users conclusions review of the neuropsychiatric effects of new psychoactive substances with a psychostimulant profile further studies of this population of synthetic cathinone users in the azores are due namely studying their socioeconomic background looking for risk and protective factors and also the longterm side effects disclosure of interest none declared epv0021 subject characteristics of medical requests to the addiction liaison psychiatry unit 12 years in hospital del mar introduction addiction liaison pychiatric units are frequently requested by other medical services due to the high prevalence of medical pathologies in substance use disorders we intend to know patients characteristics in order to improve the approachobjectives to describe patient characteristics of all medical request to the addiction liaison pyshicatric unit from january 2010 to december 2022methods study data will be obtained from all patients that were referred to the addiction liaison psychiatric unit to assess addictive disorders and withdrawal symptoms related to drugs during 12 years in hospital del mar demographics and clinical data were obtainedresults the results will be presented as soon as all data is obtained we will explore covid19 pandemic implications

montenegro is a country in southeastern europe podgorica the capital and largest city covers 30 of its total population of 621 000 and around 80 of patients enrolled in buprenorphine treatment buprenorphine was registered in montenegro in may 2017 buprenorphine is an opioid partial agonist its a safe and an effective option for the treatment of opioid addiction buprenorphine may be abusable its abuse potential however is lower in comparison with that of opioid full agonists objectives benefits of buprenorphine treatment suppress symptoms of opioid withdrawal reduce illicit opioid use help patients stay in treatment buprenorphine maintenance keeps the person stable while they make positive changes in their lives health problems are reduced or avoided especially those related to injecting such as hiv hepatitis b and hepatitis c viruses skin infections and vein problems crime behavior reduction methods clinical study results we followed the patients who were enrolled in the buprenorphine substitution treatment for a period of five years to be more precise in the period from may 2017 august 2022 in may of 2017 only 33 patients were enrolled in program the number of patients were gradually increased to 193 patients in december of 2017 until the december of 2018 the number of patients was increased to 203 in december of 2019 numbers of patients were increased to 291 at the end of 2020 numbers of patients were 348 in december of 2021 numbers of patients were increased to384 and in august of 2022 numbers of patient were 426 conclusions health problems are reduced or avoided crime behavior was reduced for 65 over five years period a total of 124 new cases of hcv infection were discovered from the beginning of study to the end of july of 2022 doses are required only once a day for most adults with opioid use disorder maintenance therapy with buprenorphine is the most effective treatment approach

introduction according to a 2022 report the rate of divorce in indonesia is the highest in asia and africa with twentyeight percent of its marriage ratio 1 although the proportion is slightly lower in aceh at fifteen percent with 6448 divorce cases compared to 42213 nikāḥs in 2021 2 the rate continues to climb our critical analysis of the increased fragility of marriage is shaped by both normative and socioempirical approaches it is normative as we look at the islamic legal principles regarding marriage and divorce stipulated by both the qurān and the hadīth tradition as well as at relevant regulations of indonesian falling out of love divorce of three acehnese ubanan couples 1871 asna husin doi 1022373sjhkv7i319433 this ratio at nearly eleven percent 7 with unicef estimating that 1220900 girls were married before the age of eighteen in 2018 8 this makes indonesia to have the seventh or eighth highest rate of child marriage globally 9 theory on the impact of modernization on marriage is conflicting some scholars assert that easy dissolution of family cohesion and traditional values is related to social changes and employment transformation brought by modernity the improvement of education technological advancement and economic growth makes a deep impact on society and the family higher female literacy and women engagement in the labor force are some of the positive consequences of this transformation however a few studies also show the opposite consequences analyzing marriage and divorce in six countries of the gulf cooperation council 10 researchers find that social transformation brought by modernity affects family structures and marital stability plaguing the region with high divorce rates since the values of men and women are mostly paternal 11 the advances in the status of women may contradict social norms traditions customs and expectations 12 upsetting the very foundation of the traditional family structure that certain societies are not prepared to abandon indonesia is also experiencing great pressures of modern life on the family laila setyawati arifin and others assert that modern lifestyle has shifted gender roles from the traditional configuration where wives were mainly responsible for maintaining the household and rearing children while husbands worked outside statistics that one in four americans who gets divorced is aged 50 and above researchers provide conflicting arguments for reasons causing the dissolution of the family after years in marriage some argue that the three key life turning points that are emblematic of later adult lifean empty nest retirement and chronic health conditionsaffect family stability as children move away from home to attend college or start work their absence…removes a potential barrier to divorce children are the glue holding some couples together this study finds that an empty nest is related to a higher risk of divorce among the middleaged 18 similarly retirement allows couples to share more time together 19 and health problems 20 can fundamentally alter marital dynamics affecting family stability and heightening the chances for divorce for some families other researchers find that these three key life turning points are unrelated to the likelihood of ubanan divorce 21 and assert that these life events can actually bring families closer together they maintain that risk factors traditionally associated with divorce among younger couples are also salient for older adults including marital duration marital quality and economic conditions and are strongly connected to the divorce of ubanan couples as well as to that of younger adults thus gray separation is most likely to occur among couples who are socially and economically deprived the remarriage family is more vulnerable to divorce than the first marriage union 22 furthermore low marriage quality is directly linked to an older couples family breakup marriage quality demonstrates the reciprocal love respect and understanding between spouses making them trust each other and honour each others realistic expectations in the past couples might have remained in unhappy marriages rather than get divorced but things have changed perceptions of marriage and expectations for personal fulfilment have reduced the stigma of divorce the high value placed on this institution suggests that divorce is a better way out of a bad marriage 23 as divorce has become more common people are more marriage and divorce in islam law one of the most important commandments of islam is that of marriage it is a divinely inspired institution enjoining union between a man and a woman with clearly prescribed laws and principles legitimizing action within the marriage this action is a manifestation of rights and responsibilities of the two marriage individuals as they live as husband and wife marriage in islam is a contract between a man and a woman and thus not a sacrament it is described in a number of āyāt of the qurān and modeled after the life of the prophet muḥammad pbuh one verse states and of his signs is that he has created for you spouses from among yourselves so that you might take comfort in them and he has placed between you love and mercy indeed in that are signs for those who reflect this verse adorns almost all marriage invitations in contemporary aceh including my own in 2000 and those of my family members the verse describes that women and men are created of the same substance implying equality and intimacy it also states one purpose of marriage is to bring emotional peace and spiritual tranquillity due to love and compassion implanted in the heart of husband and wife the same closeness between the two asna husin doi 1022373sjhkv7i319433 is also echoed in the following verse they are your garment and you are theirs this highlights the attachment and closeness of the couple as that of a person to their clothes this image of the garment underscores that husband and wife are required to play the same role in the relationship 25 the function of clothing is to conceal blemishes and to protect the person from the harm of heat or cold and thus husband and wife serve as each others protection and sanctuary if one is lacking in certain things it is the responsibility of the other to ensure that this is not exposed to others outside their union if one spouse is feeling vulnerable the other is there to wrap their partner in comfort and support 26 as khadījah bint khuwaylid the beloved wife of the prophet comforted him after his receiving the first revelation in 610 garments also function as a beautification to augment each others physical appearance and spiritual growth therefore marriage is a sanctuary for trust and confidence the sunnah of the prophet and his traditions also emphasize the essentiality of marriage the messenger of allah said o young men whoever among you can afford it let him get married for it is more effective in lowering the gaze and guarding chastity and whoever cannot then he should fast for it will be a restraint for him another tradition of the prophet states marriage is part of my sunnah and whoever does not follow my sunnah is not of my group these two traditions emphasize that there is no celibacy in islam and thus the union of a man and a woman is an important act of religiosity as followers of muḥammad pbuh other ḥadīths recognize the human need for physical and sexual fulfilment through legal and spiritual union thus marriage is a form of protection to preserve men and women from illicit sex and from being unchaste furthermore the traditions acknowledge that legal enjoyment of physical attraction and corporal intimacy within a marriage is an act of faith 27 the importance of this pleasure is stated in another ḥadīth the whole world is pleasure and the best pleasure of the world is the righteous woman the above traditions also acknowledge the significance of reproduction as the natural outcome of marriage it serves to prolong human existence and to multiply the population of the world oh doi 1022373sjhkv7i319433 mankind have consciousness of your lord who has created you from a single soul from it he created your spouse and through them he populated the land with many men and women thus alghazālī thinks of procreation as one of the five advantages of marriage 28 like any act in islam marriage is also enjoined so that husband and wife help one another to be closer to their creator the qurān and the ḥadīth also speak about divorce yet islam discourages it we saw that marriage is an agreement between a man and a woman to provide the two with emotional peace and spiritual tranquillity based on love and compassion mutual trust and confidence however not all marriages meet these expectations and many actually fall apart due to numerous reasons islam provides an escape for falling out of love between the husband and wife by means of divorce according to islamic law or sharīah divorce is the legal dissolution of a marriage in a procedure that is either initiated by the husband known as ṭalāq or by the wife termed khul there are a variety of opinions regarding family dissolution depending on the legal school and reflecting cultural influences in indonesia the shāfiī madhhab with local interpretations is generally followed and before we discuss a few points of interest on the issue of marriage and divorce law in the indonesian context we shall first review some qurānic verses and prophetic traditions on the matter the qurān speaks of family breakup in this way if you divorce women…give them a suitable compensationthe rich according to his means and the poor according to his a fair compensation is an obligation on the gooddoers qs alṭalāq 651 states o prophet instruct the believers when you divorce women then divorce them with concern for their waiting period iddah and count it accurately and fear allāh your lord do not force them out of their homes nor should they leaveunless they commit blatant misconduct these are the limits set by allāh and whoever transgresses allāhs limits has truly wronged his own soul verse 2 of the same chapter says once they have almost reached the end of their waiting period either retain them honorably or separate from them honorably and call two of your reliable people to witness either way for allāh there are other important provisions about divorce in the qurān but for our purpose here these three verses are sufficient to highlight key regulations about ṭalāq it stipulates the rights and responsibilities of men who are the initiators of divorce first the āyāt regulates the permissibility of ṭalāq many ḥadīths also describe permissibility and regulations regarding divorce second as contract breakers husbands must provide a reasonable provision to women as they have to observe the waiting period of iddah to ensure paternal certainty although there are various views about this among jurists they base their arguments among others on the following verse divorced women shall keep themselves in waiting for three menstrual cycles and it is unlawful for them … to hide whatever allāh might have created in their wombs numerous prophetic traditions also prescribe the iddah third during this waiting period the husband and wife can decide to either reconcile thus reconfirming their marriage or finalizing their divorce either way it has to be conducted with respect and decency finally whatever their decision might be it has to be recorded and witnessed by two sensible witnesses in another verse the qurān encourages the conflicting parties to appoint arbitrators one representing him and the other representing her if they both desire reconciliation regarding the divorce initiated by women termed khul the qurān states divorce may be retracted twice then the husband must retain his wife with honour or separate from her with grace it is not lawful for husbands to take back anything of the dowry given to their wives unless the couple fears not being able to keep within the limits of allāh so if you fear they will not be able to keep within the limits of allāh there is no blame if the wife compensates the husband to obtain divorce these are the limits set by allāh so do not transgress them and whoever transgresses the limits of allāh they are the true wrongdoers the section that refers to khul is so if you fear they will not be able to keep within the limits of allāh there is no blame if the wife compensates the husband to obtain divorce another verse is and if a woman fears from her husband contempt or evasion there is no sin upon them if they make terms of settlement between them and settlement is best and present in human souls is stinginess but if you do good and fear allāh then indeed allāh is well aware of what you do and among the prophetic traditions about khul is one narrated by ibn abbās as recorded in ṣaḥīḥ albukhārī hadīth 5273 describing jamīlah the wife of thābit bin qays29 who complained to the prophet that she cannot endure to live with him the prophet pbuh requested that she return the garden given her as a dowry by her husband thābit accepted his gift back and divorced her right away both the qurānic verses and the hadīth stipulate that a wife can request separation from her husband by returning the dowry which in the case of thābit bin qays was a garden note that in the matter of ṭalāq the husband does not normally take back the dowry he has given her 30 in islamic jurisprudence it is also possible that the wife may not return anything she received from him during their marriage if the two make such an agreement or if the judge decides so depending on circumstances 31 the first one is khul or divorce for compensation in which women ransom their own freedom 32 while the second one is known in islamic jurisprudence as faskh 33 traditionally there are several grounds on which a woman can apply for a judicial dissolution of her marriage failure of maintenance violence prolonged physical abandonment that she was married without her knowledge or consent and that her husband is afflicted with a dangerous disease and a few others 34 jurists discussed the qurānic notion within limits of allāh which most take to mean the rights and responsibilities of husbands and wives prescribed by god in the qurān and the traditions of his prophet despite high moral grounds for divorce stipulated in the qurān and ḥadīths with special concern for decent treatment of women muslim jurists were of the opinion that in the case of ṭalāq the husband possesses a unilateral right of repudiation of his wife without her consent 35 similarly standard interpretations of shāfiī legal doctrine in indonesia is that a husband can terminate his marriage unilaterally and without explicit grounds by simply uttering the word of talak 36 women on the other hand are instructed to follow strict procedure if they seek to obtain a divorce in practice however wives have enjoyed a good deal of flexibility in obtaining divorces on favourable terms due to sympathetic judges or other bargaining strategies 37 yet the husbands unrestricted divorce right and the asna husin doi 1022373sjhkv7i319433 high rate of family dissolution has given the impetus for reform to marriage law in many muslim countries since the twentieth century 38 articles from the edited volume by michael feener and mark cammack islamic law in contemporary indonesia ideas and institution provide an excellent overview of the history and the debates surrounding legal thought and practice and law reform in indonesia culminating with the adoption of the 1974 marriage act this book highlights the internal dynamics and insights into indonesian legal thought and judicial institutions the 1974 marriage act has since been improved including the alteration of the legal age for marriage from 16 and 18 years old for girls and boys respectively to 19 years of age for both sexes at the insistence of women and other concerned scholars some other positive changes have also been made to the law through legal interpretations executive and legislative revision and clarification with the most important being the promulgation of the 1991 kompilasi hukum islam through the presidential instruction the compilation for example restricts husbands unfettered exercise of their right to talak with the requirement that such stipulation must be presented to the religious court with clear reasons it further provides equal right for women to file a divorce through the court the reform has surely given easier access to womens filing for a separation although there is a strong argument that the rate of divorce in indonesia is in decline the statistics continue to increase year by year quoting cammack 39 laila setyawati arifin highlights that in the 1950s fifty percent of indonesian marriages ended in divorce 40 more study is needed to assess cammacks findings especially with regard to aceh province snouck hurgronje in his classic work achehnese states that family separation of pasah in aceh was rare as compared to other areas of the region similarly the divorce of ṭalāq of a woman by her husband is also of less frequent occurrence in acheh than in other parts of archipelago 41 he provides a number of reasons for the comparative rarity of the ṭalāq including the high position of women in acehnese society men marrying women of their own social standing greater freedom of action for women their knowledge and sound understanding of their own affairs and the tradition of husbands living with their wives family after marriage 42 the fact that a great number of achehnese … are practically monogamists 43 might have also contributed to family stability even the higher rate of divorce in other areas described by hurgronje should have not been as high as 50 if that was the case he would most likely have said so what happened between 1891 and the 1950s with regard to family cohesion that made the institution of marriage so fragile it is beyond the scope of our study to pursue this question as for aceh it is plausible that the divorce rate continued to be low until our time so our review of ubanan family breakdown may shed some light on this worrying trend acehnese ubanan couples falling out of love the three older couples 44 interviewed for this piece have the following characteristics one couple kaka and firdas 45 were married for twentyfive years before they separated in 2012 together they have two children a son ismi 34 years old and a daughter nasrin aged 30 ismi himself is a divorcee with a girl child while nasrin has three children kaka was born in aceh and firdas in bandung kaka was married previously to another man who was not only abusive but also polygamous this marriage lasted for just three months five years later she met firdas and the two were married in 1987 firdas completed a threeyear electrical college education before working for an american company operating in aceh while kaka finished a twoyear college in accounting firdas came from a wealthy family originally from south aceh while kaka from east aceh she is a homemaker with business interests the family lived in three different cities in indonesia before settling down in banda aceh kaka believes they had a good life together firdas was a kind husband and a caring father he was generous and trusted me entirely with financial management by handing over his full salary to me for proper distribution and spending however kaka also noticed early in their marriage that he had a kelainanabnormality he was temperamental and became angry easily his will was extremely strong he arranged everything in our house by impulse if i suggested differently he got angry kaka learned not to contradict him to maintain peace however his uncontrolled emotion caused him a serious stroke in 1993 when he was just 40 years old while kaka was 30 he received good treatment through his company and was given a sick leave for seven months 42 c snouck hurgronje the achehnese p 371 43 c snouck hurgronje the achehnese p 360 44 at their request all names and current places of residence have been altered in order to safeguard their identity i am grateful to all our respondents for their willingness to be interviewed for this study 45 interviews with kaka and firdas february 2022 and march 2023 phone interview with kaka may 2023 interviews with ismi march with nasrin april 2023 asna husin doi 1022373sjhkv7i319433 with full pay when he returned to work our life became once again more normal firdas took an early retirement ten years later receiving a generous retirement package as compensation he was then just fifty years old the family made good use of the funds to purchase a house a car and a piece of land while saving a certain amount of cash for their expenses they continued to live a decent happy life as a family however firdas retirement gave a new dynamic to their existence his impulses and episodes of anger became exacerbated as the house became his only center of experience we created a room for his technical and machinery interests but his control of the entire house became a problem it was difficult because kaka was also concerned about his health if he became excited regularly when their money was running out and their assets were sold one by one for their sustenance childrens education and failed businesses they initiated their middle class family life was sliding down putting an additional stress on their marriage kaka turned to home cooking for income and sold food for private orders while extending her upper house for rental to students and young professionals life became very hard but our children must finish their college states kaka the family struggled with one misfortune after another in 2010 firsdas suffered another stroke that impeded his movement a year later kaka was diagnosed with breast cancer that made my world as if came to an end i was scared yet encouraged by the outpouring of support and love from family and friends she highlights i could not discuss my illness with him because he was incapable of understanding besides he is a sick man himself kaka reflected what kind of trial allah had inflicted on them she and her husband were sick their children were still in college and they had no money to pay for medical bills ismi and nasrin must finish their education was the repeated thought coming to her mind as she reflected on her condition kaka wanted to go to malaysia for surgery but how 46 firdas wanted to sell the house the very last asset they have but she disapproved where would we live if we sell it thinking about her illness she cried how would i get the money yet i never lost hope i believe allah would not let me down she mumbled kaka was right her parents sisters and brother together collected about 4000 dollars for her treatment giving her a renewed hope 47 before she left for malaysia there was a fight between kaka and firdas over money during which the latter suggested a divorce that was the first time the idea of separation came to my mind utters kaka when i asked firdas about it he states no i did not mean it i was upset and could not control myself kaka stayed in malaysia for one month and returned to indonesia with a piece of advice from 46 most acehnese do not trust their medical facilities and service thousands went to penang and kuala lumpur every month for medical treatment kaka was one of the many 47 aceh and indonesia have recently introduced a free health care but its quality is still not very good besides it is only applicable if one gets treatment in the country asna husin doi 1022373sjhkv7i319433 her doctor you are going to go through chemotherapy and you must be calm and free of stress sitting on the airplane to return home the doctors counsel you must be calm and free of stress kept coming to her mind i asked myself repeatedly and the idea of divorce became the most viable candidate kaka reflected on it for weeks and when she finally decided she told her parents they were not prepared but kaka was determined it would give me ketenangan he can no longer control my life despite being crippled by strokes his sexual drive was still very strong i could not handle it and i did not want to be sinful berdausa for not fulfilling his corporeal needs i told him to marry another woman when ismi and nasrin were informed about her plan for separation they both said whatever is good for mommys health we support it nasrin adds we saw how our mother struggled all these years for our family she truly needs ketenangan firdas cried when kaka and her parents informed him about divorce yet he accepted it for her health he explains my love for her is unconditional despite being separated she is my love in this world and in the next this familys misfortune persists yet kakas strength is remarkable after separation and the completion of her treatment she moved to jakarta to run a restaurant while firdas and the children continued to live in their house along with the tenants on the upper level kaka worked there for five years and then returned to live once again in the same house with firdas and her children we have no other place to go it is both his house and mine she explains ismi and nasrin graduated from the university in the same year and began to work however the job market in aceh and indonesia was not good and thus they were unable to find decent jobs they soon married and had children unfortunately ismis family life was shortlived we fought a lot over little things we did not have enough means to support our young family in contrast nasrins husband had a successful business and was financially stable until covid19 it destroyed our livelihood she says in 2019 firdas suffered from another stroke that put him in the hospital for a month since then he endured four more attacks with the most severe in early 2023 this last one was so grave it impaired his ability to speak and placed him completely on his back firdas went back and forth to the hospital and kaka faithfully took care of him with the help of a caretaker he is no longer my husband and i cannot touch him so i hire someone to come regularly to clean and bath him i have to turn my brain to find money for it when asked the reason for her taking care of her former husband her response he has no other place to go and if i do not look after him he will be on the street besides he is the father of my children then in late 2022 kaka herself had another health crisis her breast cancer returned and she had it treated with mastectomy she is truly remarkable i saw her two months after this surgery as she was cooking food for sale i have to make money she utters at around the same time nasrin returned home to give asna husin doi 1022373sjhkv7i319433 birth to her third child in the care of her mother now the house is completely full firdas ismi nasrin with her husband and three children as well as kaka as the breadwinner in spite of her repeated misfortunes kaka maintains her optimistic attitude and positive energy she is now working with her son running a small coffee shop in a commercial area of banda aceh our second couple are mita and musa 48 the two were married in 1981 and divorced on mutual agreement in 2022 after fortyone years of their union the family has two boys and one girl isa aged 40 dema 38 and their babygirl afra 34 two are happily married themselves with children while dema is about to get married his parents divorce has affected demas plan according to isa and afra mita was originally a teacher from west aceh and left her teaching position at the request of her husband musa came from a humble background in pidie but became a very successful entrepreneur they met in jakarta during college and were very happy together for many years states musa however mita has a different view we were happy from the outside he was very controlling and thought he was always right we could not have a conversation with him about anything without being snapped at later in their married life they quarrelled a great deal because mita could no longer stand to be just a yes woman their agreement to get separated did not make their divorce easier the problem came on how to divide their fortune besides mita learned that musa has a second family in jakarta and his polygamy became a real trigger for their family breakup musa currently lives in both banda aceh and jakarta while mita resides in banda aceh and medan regarding his first marriage musa asserts we were fortunate to have a good life good health and healthy children god gave us provision rizq we should be grateful without denying his description mita utters we had money and he turned all his money into assets as for me and the children he set a minimum limit ketket of allowance he was not generous to us mita also recognizes that she had a very comfortable existence yet it was not a satisfying one i had no say in whatever he decided his decision be it right or wrong was final no discussion isa and afra agree that their father was a bit domineering and stingy to our mother however he was generous to us especially as we got older when musa was asked about his lack of generosity toward mita his response she had everything she had a big house an expensive car with a driver we travelled around the world what more did she want isa explained to his father bunda resisted that you never gave her sufficient cash you controlled her life you would rather give her things inkind instead of cash you never gave her an opportunity to decide you always asna husin doi 1022373sjhkv7i319433 decided for her laughing musa responds she did not need to why did she need to decide she should just accept and be grateful mita emphasizes that was the real problem he denied my humanity by controlling everything in our life i could not be myself mita continues when we travelled he did not give me any cash i had to beg for money even for a menial need such as a cup of juice for children he was very stingy and controlling i was tired of being consumed under his wings afra defends her father saying yes he was controlling and at times rude but he was not a bad father or husband we live plentifully berkecukupan she adds i understand why bunda was not happy she was not allowed to do what she wanted or to express her interests he decided what is good for her i guess i would have reacted in the same way if i were to be placed in that situation when they decided to separate mita and musa discussed their hareuta sihareukat by any acehnese standard they had a fortune by law and custom all assets accumulated throughout their marriage are shared equally 49 mita wanted that tradition to be observed musa disagreed strongly he argued that he was the one who worked hard while mita was only terima beres yet they did not want to pursue an ugly divorce process through court we wanted to separate honourably we have children and grandchildren utters mita and musa agrees they settled the issue outside the court and mita accepted about one fifth of their accumulated assets she received a big house in banda aceh an even bigger one in medan three pieces of land of 3000 meters in total including one piece in jakarta she also kept her fancy car precious stones and cash of about 75000 this settlement was finalized by the judicial decision outside aceh to become final and formal musa states about this settlement she got a lot more than what she needs with it she could live a comfortable life for the next fifty years when asked if he really wanted to be separated from mita he responds no but she wanted to he feels that mita was a real contract breakerabout his own polygamy musa maintains islam allows the man to have more than one wife if he is able and just i did not do anything wrong if she cannot accept it is her problem not mine he quickly adds however i do not want my daughter afra to be a cowife i am glad that she and her husband have a better understanding about marriage life that mita and i were lacking mita is grateful with the settlement she is also very happy with her new found freedom to once again become a real person with thought ideas and decisions i am very content i plan to spend the rest of my life dedicated to community service my family children and grandchildren asna husin doi 1022373sjhkv7i319433 our third couple is my dear friend dinda 50 and her husband jamil 51 the two were married in 1985 and separated in 2019 after 34 years in marriage jamil has since remarried and has two young children with his new wife tuti dinda was 25 years old and jamil 32 when they were married the latter born and raised on the outskirts of banda aceh gained a twoyear college certificate in accounting and worked for the government until his retirement in 2013 at the age of sixty dinda received a threeyear college education and was a stayhome mom with cooking talent this skill helped her make money in times of need dinda was born in meulaboh and grew up in a number of towns in the province with a police father and a stayhome mom they moved around regularly following the deployment of her father they lived in the barracks and always struggled financially we experienced many juvenile crimes around our barracks 52 and my brother and i promised each other to work hard and be successful dinda describes her childhood i did not realize my dreams for i failed to finish college their four children boys alfa azra and girls nasha rifa are now married with children except the 32 year old rifa who is still single i will only marry a kind man who is economically stable utters rifa the three married children struggle financially and are concerned about the stability of their own families recounting her marriage life dinda states at the beginning of our marriage i was happy i think i accepted his unkind treatment of me and his preference for his own family dinda did not mind that he cares for his parents siblings and their children but she wanted him to be more balanced i think he had money but i did not even know how much he made every month he was very stingy to me and our children because of our scarcity i got into a catering business i made sufficient money to support our family jamil explains his devotion to his family i have to help my parents and siblings because i am the only son in the family they have no one else to turn to regarding his lack of spending on his own children he states i wanted them to be frugal and spent less on unnecessary items such as clothes and shoes i taught them to share with their needy cousins when asked if he was kind to his children his response of course i was kind to my children i supported their education and got them married yet he admits that i did not spend sufficient time with my children 50 dinda was my best friend during high school in beureunuen pidie i lost contact with her after graduation but we met again in banda aceh after the 2004 tsunami since then we have kept intouch and at one point i tried to mediate her marriage without success 51 interviews with dinda march 2022 february april 2023 phone interviews with jamil may and june 2023 group interviews with alfa azra nasha and rifa march 2023 the four call me cek asna or aunty asna 52 indonesias police and military barracks were then known for their juvenile crimes involving the anggota children and other young gang members asna husin doi 1022373sjhkv7i319433 when they were growing up or help them with their home work i was extremely busy with my work i entrusted that to their mother dinda agrees that taking care of their young children was her responsibility but i did not have much time and tried my best i had to do catering to earn money dinda continues had he given me enough to pay for our childrens needs i did not have to work in the kitchen i could just be a good mom and caring wife their four children concur with their mother our father was not a very generous man we did not have a good role model in our life of course we love our father states azra his siblings agree and nasha adds as kids we were not very proud of our father we were hurt seeing our mother struggling we disliked her catering business because she forced us to work we did not have time to play with our friends azra also remembers when other kids spent their after school time in diniyah or les 53 we were either helping our mother in the kitchen or playing football with local kidsalfa recalls we did not like our cousins because our father spent money on them while we ourselves were in need nasha highlights we have since reconciled with them as we have with our father the siblings learn from the experience of their parents and we do not want to repeat the mistakes on the way they raised us states azra rifa who has been quietly listening recounts cek asna we are not talking just about money our father never spent time with us when we needed him he never had good words of encouragement either to our mother or to us he did not care if we failed or progressed rifa continues if i get married my husband and i will spend time together we share the burden of the household and childrearing and this is how you make a marriage work when i asked if rifa has had a candidate smiling she utters insha allah please pray for me these four siblings supported their mother when she felt that she had enough time to quit the final straw was that their father secretly lent their only savings to his sister when dinda herself was in need of funds to renovate the house nasha underlines we knew our mother was not happy with our father nor he with her unfortunately our father has not changed even after marrying auntie tuti luckily she has her own income rifa adds hopefully she will stay with him for the sake of her children we wish the best for our father his new wife and children our mother and all of us are on good terms with them 53 diniyah is an afternoon or an after school islamic class to teach the qurān and basic knowledge and practices of islam to young kids aged five to fifteen or a little older it is run by mosques and other community centers for a small fee while les is a tutoring course for certain school subjects such as english or mathematics also in the afternoon or early evening to help children catch up with subjects they are behind in les is often run privately for children of all age asna husin doi 1022373sjhkv7i319433 multifaceted reasons for divorce the examples of our three couples indicate that falling out of love is an extremely complex series of life events with multifaceted factors in some cases there are clear triggers while in others things are not so obvious the final straw for our families are quite pronounced polygamy for mita giving away their savings for dinda and a severe health crisis along with poor character for kaka yet the real factors instigating their separation are the interlink of many causes with one clear fact that their marriage quality was very low health crisis and retirement contributed to the deterioration of kakas union while family influence to that of dindas mitas sense of the denial of her humanity and the impossibility to be a real person with her own thoughts dreams and decisions was a significant factor for the lack of cohesion in her family she did not find the postchildren experience of her marriage to be personally satisfying and fulfilling all these contributed to their low marriage quality and eventually led to divorce thus our findings demonstrate a combination of reasons causing gray divorce factors related to the three key life turning points emblematic of later adult lifean empty nest retirement and health chronic conditions especially the last twoare saliently demonstrated in our study yet the risk factors traditionally associated with divorce among younger adultsmarital quality and economic conditionsare also strongly exhibited in the marriage dissolution of our ubanan families in all three cases economic conditions played a role although only kaka was truly deprived while mita with her husbands fortune could not touch it until her divorce and dinda was somewhere in the middle her family probably had money but she was not aware and it was not decently shared as her former husband had a different priority eonomic deprivation is an important element causing the family to be ribut terus menerusquarrelling continuously 54 one of the underlying reasons for continued squabbling in the family is the lack of means as shown in our study when a household cannot earn enough to cover basic necessities such as food shelter and childrens education life becomes socially and economically insecure insecurity leads to personal social and family problems reducing marriage quality jobs are a necessary condition for healthy individuals and the country the government must create good jobs beyond merely filling the ranks of pegawai negeripublic servants in order to give young adults opportunities for steady decent income to raise a family this is a serious problem for in spite of the low unemployment rate presented by government statistics of about six percent in 2022 55 the real unemployment 54 republika kasus perceraian di aceh capai 6823 perkara didominasi istri gugat suami 7 december 2022 55 raden jihad akbar anisa aulia pengangguran di indonesia diramal makin banyak 2023 ekonom ungkap pemicu utamanya 26 december 2022 asna husin doi 1022373sjhkv7i319433 fulfilment raising a family it means that they contributed to the perpetuation of their family and the human race when love disappears and we are no longer a garment to each other it is time to get out life is not worth it if we have too many quarrels in the family states mita in spite of their failure they consider marriage to be an extremely important institution that needs preservation and protection dinda and mita would remarry if they were still young but as now they are too old for it kaka on the other hand would remarry if she finds a good match he must be willing to accept me and my family and be able to support me financially in short their islamic understanding about marriage and divorce also colours the already complex reasons causing their separation modernization bringing social transformations to our life must also be properly understood as it affects traditional values and gender roles as women become more educated they gain the freedom to work outside the house contributing to the wellbeing of their family and society their cognitive and professional gains have not gone handinhand with the cultural outlook of their society especially their male counterparts while respecting womens professional careers many acehnese men have not shown the willingness to share household and childrearing tasks in order to lighten womens doubleburden this attitude compromises family cohesion the other side of this equation is that as wives work outside the house they become more independent without a new understanding and constructive communication between husbands and wives the latters freedom may become a source of family tension in short modernization has changed women while most men continue to live in social vestiges although this condition may affect more of the younger adults its manifestation can also be glimpsed in the life of our participating families dinda for example had to both take care of the children and make money kaka has to work while also maintaining the household in her current conditions and this includes providing care for terminally ill firdas a new form of partnership between wives and husbands must be forged in order to safeguard the institutions of family and marriage the issues of an empty nest and the general tolerance of divorce also need attention the former is quite irrelevant to our three cases all three families host their adult children before and after their divorce one of mitas children isa and his family live in her house along with the unmarried son dema this is a common form of extended family practiced in aceh her daughter afra with her family live nearby with their children spending most of their time in mitas house especially during the day when both afra and her husband are at work mitas elderly mother also lives in this house similarly dindas married daughter nasha and her family live at her mothers home along with the unmarried rifa unlike mitas family with two maids and two nannies dindas has none in asna husin doi 1022373sjhkv7i319433 fact she functions as both babysitter and caretaker for nashas children and she does so with happiness it is my hiburan likewise kakas home is residence of her two children ismi and nasrin along with their father firdas although nasrin is the main caretaker of her three children since she is a stayhome mom kaka often helps regarding the general tolerance of divorce the impact of parents separation is immense researchers argue that divorce is socially contagious and a study shows that couples are 75 more likely to become divorced if a friend is divorced and 33 more likely to end their marriage if a friend of a friend is divorced it further states so divorce is contagious…and you can catch the divorce bug from your friendseven from a friend of a friend57 equally if a family member is divorced other members of the household are vulnerable to the same fate in the case of kaka we have already seen that ismi has been separated three of dindas married children alfa azra and nasha all are concerned about the stability of their own unions unfavorable economic conditions are a critical issue for all three for none of them earns a decent living so far they are able to keep their family intact and struggle to raise their children with love and care yet we do not know what the future holds is we are aware that our marriage quality is tidak baikbaik kali states azra similarly alfa and nasha express their concern about following the example of their parents we work hard to make our marriage work likewise mitas unmarried son dema already expressed his concern for a failed marriage before he even enters it according to afra demas attitude toward women has changed since our parents divorce on the one hand he is afraid of being like our father toward bunda and on the other he is also concerned that women are undependable they are for our fathers money not for him unlike dema both afra and isa feel that their marriage is solid and insha allah we will be together as family beyond children and grandchildren ie til death states isa likewise kakas girl nasrin feels that she and her husband are strongly connected god willing we will be together forever so the concern of some of these children about a fragile marriage is undeniably strong because divorce is like a bug that can be easily transmitted conclusion our research on divorce of the three acehnese ubanan families has confirmed the many earlier studies indicating the multifaceted nature of falling out of love the risk factors associated with gray divorce and those that are traditionally viewed to connect to the family dissolution of younger adults are both prominent in our study the issues of retirement and chronic health problems are relevant to understanding the marital fragility of our participating families these two reasons become high risk factors when they are met with economic deprivation all contribute to low marital quality which is an essential factor against the stability of the marriage other complex series of life events triggering divorce are also important first a better comprehension about the impact of modernization on family life and the transformation of gender roles is necessary this includes the acehnese mans attitude toward household tasks and childrearing which are also critical for the wellbeing of his family and for strengthening marriage quality second family experts suggest that communication is key to a successful family union thus the negative impact of egotistic lakilaki aceh character on marriage has to be spelled out explained and confronted directly especially for young acehnese males and our children acehnese women may no longer accept unkind treatment from people they love and thus more families will breakup without good communication and understanding between acehnese wife and husband in the case of ubanan divorce the key turning points during later life must also be comprehended older couples must be aware of their consequences and be prepared to constructively cope with them furthermore the government and religious institutions must initiate a prenuptial course and make it a requirement for young tobe married adults a similar course should also be organized for the gray middleaged couples especially in response to a prediction that ubanan divorce is increasing at a rapid rate this policy should be accompanied by nationwide meaningful and wellfunded government programs to salvage the marriage institution in indonesia marriage in our contemporary reality is difficult to survive with meager means and lack of sustenance thus policy for job creation must be encouraged since decent income directly impacts on family cohesion finally we are mindful that the result of our study on gray divorce cannot be generalized given that our sample is extremely small it could open the door for future research in this area studies on the impact of modernization on the family and closer attention to the lakilaki aceh character must be promoted this will enhance our understanding not only about marriage and divorce but also about the wellbeing of our future generations asna husin doi 1022373sjhkv7i319433 rests in the fact that fiftynine percent of indonesian workers during this same period work in informal sectors 56 a large section of them are unable to earn a reasonable living as we saw with kakas and dindas children if a great many young married adults and ubanan couples continue to experience economic deprivation the divorce statistics will continue to climb the government must do something meaningful and wellfunded if they seek to salvage the marriage institution in indonesia the attitude of our three main males character is typical of the old type of lakilaki acehacehnese men controlling insensitive to needs of their wives and thinking of themselves to be always rightalthough in the case of firdas it may be due to his abnormal temperament such a character is often associated with an irascible and irritable personality with whom calm discussion is impossible nor open communication easy some men demonstrate such a character at all times while others display it only when dealing with their intimates such as wives siblings children and close confidants it seems that the attitude of the lakilaki aceh played a major role in making the marriages of our respondents poor in quality as indicated earlier marriage quality is a condition in which husband and wife exhibit reciprocal love respect and understanding for each other making them trust one another and honour each others expectations and dreams we have seen that these requirements were missing in the experience of our participating families especially in the later part of their marriage existence dinda kaka and mita were often frustrated and stressful because they could not share their expectations and mutually discuss problems they stayed in marriage while raising children and quit thereafter their understanding of islamic injunctions about marriage and divorce also influenced our couples decision to tie the knot or to separate they were married because they were attracted to each other musa and jamil met their wives in college while firdas and kaka were introduced to each other by her family quoting the sunnah of the prophet five of the six viewed marriage as following the practice of the prophet and completion of their islamic faith all six also think that marriage is their protection from dausa of illicit sexual acts and zina mata with mita and jamil adding the emotional components of mutual support and emotional growth these two also brought the qurānic image of the garment regarding the closeness of husband to wife all six also express their happiness of being parents and now grandparents with women overemphasizing this role musa and dinda speak of children our family line continues they imply that their marriage was their early life asna husin doi 1022373sjhkv7i319433

the most hated of permissible things to allāh the exalted is divorce this prophetic tradition is narrated by abū dāwūd and ibn mājah yet divorce is now on the rise in aceh where islamic sharīah is supposedly being implemented there were 6823 divorce cases in the province during the first ten months of 2022 with most proposed by young couples this study examines divorce in mature families aged fifty and above who have been married for many years in the perspective of islamic law we analyze their marriage and the nature of their life leading to divorce the reasons for falling out of love and the impact of separation on their wellbeing and on their loved ones we review the islamic sources and academic literature about marriage and divorce the government and media reports for statistics and we interview three couples along with several of their children in order to obtain insights into their experience we uncover the complexity surrounding marriage and divorce as well as religious social and personal reasons guiding their action or nonaction the study recommends that governments and religious institutions implement premarital courses as a condition of marriage so that divorce rates can be reduced such policies must be accompanied by meaningful and wellfunded national government programs to save the institution of marriage and be able to maintain family cohesion in indonesia

in the past few decades changes in industrial structure and economic crises have led to an increase in the proportion of employment contracts other than standard employment 1 these nonstandard types of employment contracts comprise temporary employment parttime employment disguised employment and employment arrangement via digital platforms 2 in particular the informalisation of employment was accelerated by the recent covid19 pandemic the covid19 pandemic caused an economic crisis and brought changes to the industrial structure resulting in companies increasing their proportion of nonstandard employment 3 temporary employment temporary employment is widely known for its negative effects on workers health for example workers with temporary employment are at risk of fatal occupational injuries 4 and musculoskeletal problems 5 so far several studies have investigated the effects of temporary employment on workers mental health temporary employment can cause mental health problems because of the resulting subjective job insecurity for workers 6 previous studies found that temporary employment is associated with psychiatric distress and depression 7 8 kim et al reported that daily labourers had a higher risk of depressive symptoms compared with fixedterm or permanent workers in korea 9 furthermore one previous study argued that temporary employment is associated with a higher risk of suicidal ideation 10 however only a few studies have examined the relationship between temporary employment and risky health behaviours such as alcohol consumption although some researchers maintained that temporary employment was associated with alcohol misuse 11 and increased mortality owing to alcoholrelated diseases 12 others found no significant relationship between alcohol use and temporary employment 13 job dissatisfaction along with temporary employment job satisfaction is also a major determinant of workers mental health job dissatisfaction is a wellknown cause of burnout 14 and reduced wellbeing 15 of workers previous longitudinal and metaanalytic studies have reported that decreased job satisfaction is closely related to the poor mental health of workers 1617 for example cumulative years of job dissatisfaction were found to be associated with depressive symptoms 18 and anxiety 19 on the other hand the effect of job dissatisfaction on alcohol use is not unknown although one crosssectional study found an association between job dissatisfaction and alcohol misuse among young male workers 20 another study found that job dissatisfaction did not mediate the relationship between work stress and alcohol use disorder 21 association of temporary employment and job dissatisfaction with mental health problems recently there has been growing social interest in protecting workers mental health alcohol use disorder and depression are major causes of suicidal thoughtsbehaviour and can induce various physical illnesses such as liver diseases and obesity 22 impaired mental health is harmful not only to workers themselves but also to their organisations as problematic alcohol consumption and depression negatively affect an individuals work performance 2324 currently there are no studies that focus on the importance of job satisfaction for mental health problems in the context of temporary employment in general temporary employment has been reported to be closely correlated with low job dissatisfaction 25 nevertheless the relationship between temporary employment and job satisfaction depends on the characteristics of the worker for instance a decrease in job satisfaction was observed only in individuals who worked involuntarily in temporary employment and in the case of voluntary temporary workers no significant relationship between employment type and job satisfaction was found 26 also an interactional analysis by hammarström et al found that the health effect of temporary employment varied according to individual characteristics such as education level 7 thus it could be hypothesised that the impact of temporary employment on the mental health of workers could be moderated by job satisfaction consequently identifying how temporary employment and job dissatisfaction interact would provide new insight into the effect of temporary employment on workers mental health to sum up the effect of temporary employment and job dissatisfaction on alcohol use disorder has not yet been identified in addition to the best of our knowledge the combined effect of temporary employment and job dissatisfaction has not yet been reported therefore our study will contribute to the literature by exploring the association of temporary employment and job dissatisfaction with alcohol use disorder and depressive symptoms using a longitudinal dataset consisting of a nationally representative study sample finally we aimed to discover social determinants affecting workers mental health and provide evidence that could be used for policy development method study sample this study used the korea welfare panel study dataset the koweps is an ongoing annual panel survey conducted by the seoul national university social welfare research centre and the korea institute for health and affairs since 2006 to collect nationally representative households in korea the koweps used twostage stratified cluster sampling based on the south korea population and housing census in this sampling method the census enumeration district was employed as the primary sampling unit and the household was employed as the secondary unit the survey was conducted by trained interviewers using oneonone computerassisted personal interviews as the questionnaire regarding alcohol use disorder was introduced in 2009 study participants from 2009 to 2021 were included in this study out of a total of 23 692 participants with 204 336 observations we limited our sample to those aged between 19 and 64 years because 65 years is the retirement age in korea leaving 14 703 participants with 107 591 observations next we limited our sample to employed workers leaving 9922 participants with 55 770 observations after excluding 3131 observations with missing values our final sample included 9611 participants with 52 639 observations ethics statement the institutional review board of yonsei health system approved this study the requirement of informed consent was waived by the irb because of the retrospective nature of this study main variables employment type employment types were classified as permanent workers fixedterm workers and daily labourers permanent workers were employees who worked under a labour contract period of ≥1 year fixedterm workers were employees who worked under a labour contract period of ≥1 month to 1 year daily labourers were employees with a labour contract period of 1 month or those who were paid daily job satisfaction job satisfaction was measured on a fivepoint likert scale we then classified workers job satisfaction as dissatisfied neutral or satisfied alcohol use disorder the alcohol use disorders identification test was used to classify alcohol use disorders in this study the tenitem audit developed by the world health organization 27 is a validated screening tool for identifying individuals with alcohol use disorder and has been widely used in epidemiologic studies each question is measured on a fivepoint likert scale ranging from 0 to 4 so the total scores ranged from 0 to 40 according to previous studies those with a score of ≥16 were considered to have a high level of alcohol problems and required clinical intervention and monitoring 27 thus the same value was used in this study for classifying those who had alcohol use disorder depressive symptoms depressive symptoms were measured with the 11item centre for epidemiologic studies depression scale a short version of the original 20item cesd the validity of the cesd11 was confirmed in a previous korean study 28 each question was measured with a fourpoint likert scale ranging from 0 to 3 so that the sum of the scores ranged from 0 to 33 the total score was multiplied by 20 and then divided by 11 we defined those with a score of ≥16 as having depressive symptoms because the cutoff value of the 20item cesd is 16 29 covariates gender age household income education marital status occupation weekly working hours workplace size and survey year were considered as the confounders in our study the age groups were classified as 30 3039 4049 5059 and ≥60 years household income was classified into quartiles education level was classified as having completed college high school or below chronic disease status was classified as having at least one chronic disease being treated or taking medication or not smoking status was classified as current smokers or pastnonsmokers marital status was classified as married unmarried or other occupation was classified as blue collar service and sales worker and white collar according to the korean standard classification of occupations the korean standard classification of occupations classifies managers professionals and clerks as whitecollar workers service workers and sales workers are classified as service and sales workers also agricultural forestry and fishery workers craft and related trades workers plant workers machine operators and assemblers and elementary workers are classified as bluecollar workers weekly working hours were classified as ≤40 or 40 h according to the number of employees in the respondents organisation workplace size was classified as 30 workers 3099 workers or ≥100 workers in addition we also considered wavespecific effects by including binary dummy variables for each survey year in the fully adjusted models statistical analysis for descriptive analysis the χ 2 test was used to compare the prevalence of alcohol use disorder and depressive symptoms according to the socioeconomic features of the study participants for regression analysis we initially performed pooled crosssectional logistic regression and a generalised linear mixed model with a logit link in the next step to estimate the odds ratios and 95 confidence intervals models with random intercepts by individuals were used in the mixedmodel analysis to analyse the repeatedly measured survey data for model comparison log likelihood and akaike information criterion values were calculated for individual i and year t the model specification is as follows logit ¼ β 0 þ β 1 e1 it þ β 2 e2 it þ β 3 s1 it þ β 4 s2 it þ þ u i þ ε it where y denotes mental health outcomes e1 and e2 denote employment type s1 and s2 denote job satisfaction u i denotes participantspecific effect and ɛ it denotes the error also to clarify the temporal association we explored how the changes in employment status and job satisfaction affect mental health outcomes by applying a 1year lag time to each independent variable for measuring the combined effect of temporary employment and job dissatisfaction the two variables were grouped and newly classified into nine groups employment type job satisfaction to employment type job satisfaction the relative excess risk due to interaction was calculated to assess the supraadditive interaction between temporary employment and job dissatisfaction we estimated the reri by using the following equation reri ¼ odds ratio odds ratio odds ratio exposure to only bþ þ 1 the 95 confidence interval of reri was calculated by using the delta method 30 a reri of 0 suggests supraadditive interaction between two variables a pvalue of 005 was considered statistically significant and pvalues were twotailed all statistical analyses were performed with r for windows the r package glmmtmb was used to fit generalised linear mixed models results table 1 shows the socioeconomic features of the study participants based on pooled observations among the total observations 297 and 135 were fixedterm workers and daily labourers respectively the highest prevalence of alcohol use disorder was observed among daily labourers followed by permanent workers and fixedterm workers the prevalence of depressive symptoms was 46 for permanent workers 83 for fixedterm workers and 140 for daily labourers moreover among those who were dissatisfied with their jobs 87 and 182 of the workers had alcohol use disorder and depressive symptoms table 2 shows the association between temporary employment and job dissatisfaction and alcohol use disorder the fully adjusted generalised linear mixed model showed the best model fit in the fully adjusted generalised linear mixed model employment type and job satisfaction were associated with alcohol use disorder fixedterm workers did not show a significantly higher risk for alcohol use disorder compared with permanent workers however being a daily labourer was associated with alcohol use disorder regarding job satisfaction those who were neither satisfied nor dissatisfied or were dissatisfied with their jobs were associated with an increased risk for alcohol use disorder compared with those who were satisfied table 3 shows the association between temporary employment and job dissatisfaction and depressive symptoms the fully adjusted generalised linear mixed model has the best model fit in the generalised mixed model employment type and job satisfaction were associated with depressive symptoms being a fixedterm worker or daily labourer was associated with depressive symptoms compared with permanent workers additionally those who were neither satisfied nor dissatisfied or were dissatisfied with their jobs were associated with an increased risk for depressive symptoms figures 1 and2 show the combined effect of temporary employment and job dissatisfaction on alcohol use disorder and depressive symptoms this effect became stronger for those who were concurrently exposed to temporary employment and job dissatisfaction for instance daily labourers who were dissatisfied with their jobs showed the highest risk for alcohol use disorder and depressive symptoms the reri was estimated to assess the additive interaction between temporary employment and job dissatisfaction the reri for fixedterm employment and job dissatisfaction was 036 for alcohol use disorder and 037 for depressive symptoms the reri for daily employment and job dissatisfaction was 091 for alcohol use disorder and 347 for depressive symptoms suggesting a supraadditive interaction between the two variables finally table 4 presents the effect of the sequential experience of employment status and job satisfaction on outcomes the results show that the shift to daily employment and the retention of daily employment for two consecutive years are significantly related to alcohol use disorders and depressive symptoms in addition deterioration of job satisfaction and experience of job dissatisfaction for two consecutive years are also related to alcohol use disorders and depressive symptoms discussion our study provides evidence of the detrimental health effects of temporary employment and job dissatisfaction we investigated the effects of temporary employment and job dissatisfaction on alcohol use disorder and depressive symptoms we confirmed that temporary employment and job dissatisfaction were associated with an increased risk of alcohol use disorder and depressive symptoms furthermore our study suggests that the effects became stronger when temporary employment and job dissatisfaction were combined in addition the reris between daily employment and job dissatisfaction were 0 for alcohol use disorder and depressive symptoms indicating a supraadditive interaction between the two variables our findings are consistent with previous research showing that insecure employment is associated with alcohol use disorder 3132 and depressive symptoms 933 but contradict the finding that there is no significant association between temporary employment and alcohol use disorder 13 although fixedterm employment was not associated with alcohol use disorder daily labour was significantly associated with an increased risk of alcohol problems than permanent employment in addition daily labourers had higher odds ratios for alcohol use disorder and depressive symptoms compared with fixedterm workers suggesting that a shorter duration of an employment contract is associated with an increased risk for mental health problems along with temporary employment our study also found that job dissatisfaction was significantly associated with alcohol use disorder and depressive symptoms our results support the findings from previous studies that alcohol use disorder and depressive symptoms are affected by workers job satisfaction 18 19 20 additionally the more that workers became dissatisfied with their job the stronger the effect for example those who were dissatisfied with their job had higher odds ratios than those who were neither satisfied nor dissatisfied to the best of our knowledge our study is the first to suggest that workers show greater risks for alcohol use disorder and depressive symptoms when they are simultaneously exposed to temporary employment and job dissatisfaction according to previous studies the job demandcontrol model 34 and the effortreward imbalance model 35 explain workers stress job dissatisfaction reflects imbalances between job demand and control 36 and job effort and reward 37 additionally insecure employment reduces workers perceived rewards causing an imbalance between effort and reward 38 thus temporary employment and job dissatisfaction are more stressful when they are combined moreover the combined effect of temporary employment and job dissatisfaction was greater than their sum earlier studies have tried to identify the possible mechanisms by which temporary employment and job dissatisfaction affect workers mental health 3940 the detrimental effect of temporary employment and job dissatisfaction on mental health problems could be explained by elevated work stress among employees employment insecurity and job dissatisfaction increase workrelated stress 41 and anxiety 19 among workers which in turn increases the risk for mental health problems one previous study revealed that stressrelated mental health problems could be induced by job dissatisfaction 39 similarly tatsuse et al found that lack of job satisfaction significantly predicted depression 42 moreover to cope with work stress triggered by job insecurity and dissatisfaction employees may turn to risky healthrelated behaviours such as cigarette smoking substance misuse and alcohol misuse 40 for example stressful psychosocial work environment such as effortreward imbalance can act as a trigger for heavy alcohol consumption 43 physiological mechanisms also explain the relationship between temporary employment and job dissatisfaction and mental health problems according to previous studies work stress and accumulated insecure employment induce dysregulation of the hypothalamicpituitaryadrenal axis 4445 overactivation of the hpa axis is closely related to heavy alcohol consumption 46 and major depression 47 thus dysregulation of the hpa axis may mediate the relationship between temporary employment and job dissatisfaction and alcohol use disorder and depressive symptoms further indepth studies are needed to elucidate the exact mechanism of the effects of temporary employment and job dissatisfaction on workers mental health our study has some limitations first the koweps questionnaire regarding job dissatisfaction measured workers overall job satisfaction thus detailed aspects of the work environment such as job demand and control hazardous physical and psychological threats and perceived insecurities could not be identified in this study because of a lack of information second as health outcomes in our study were selfreported social desirability bias and recall bias should be considered one previous study reported that survey respondents tended to underreport their alcohol consumption 48 thus there is a possibility that the overall prevalence of alcohol use disorder might be underestimated in this study third although we employed a generalised linear mixed model to fig 2 the combined effect of temporary employment and job dissatisfaction on depressive symptoms using a fully adjusted generalised linear mixed model investigate the association between job characteristics and mental health problems the possibility of reverse causality should be explored in future studies for example the mental health problems of workers could negatively affect their employment status 49 and job satisfaction 18 despite these limitations our study has several strengths first we used mixed models adjusted for the personal traits of the survey participants personal traits can confound the relationship between job satisfaction and mental health problems for example workers with high levels of neuroticism have been known to report more job dissatisfaction and mental health problems 50 from this perspective our study overcame the limitations of previous crosssectional studies next the koweps study participants were selected through a systemic sampling method therefore the participants represented households in korea thus our study has strength in terms of its generalisability in summary our current study found that temporary employment and job dissatisfaction have detrimental effects on alcohol use disorder and depressive symptoms these effects became stronger when temporary employment and job dissatisfaction were combined policy makers should implement appropriate actions to ease job insecurity among temporarily employed workers and to improve job satisfaction data availability the raw korea welfare panel study data are available online the raw koweps data do not comprise personal information declaration of interest none

there has been growing interest in protecting workers mental health identifying social determinants that affect workers mental health could play an important role in preventing psychiatric diseaseswe investigated the effects of temporary employment and job dissatisfaction on alcohol use disorder and depressive symptomsthe korea welfare panel study dataset 20092021 was used and 9611 participants with 52 639 observations were included generalised linear mixed models were employed to estimate odds ratios and 95 confidence intervals the relative excess risk due to interaction reri was calculated to assess supraadditive interactions between temporary employment and job dissatisfactionincreased risks for depressive symptoms were observed among fixedterm workers odds ratio 112 95 ci 100126 and daily labourers odds ratio 168 95 ci 144195 daily labourers were associated with an increased risk of alcohol use disorder odds ratio 154 95 ci 122195 job dissatisfaction was associated with alcohol use disorder odds ratio 178 95 ci 152208 and depressive symptoms odds ratio 488 95 ci 4 36546 this effect became stronger when workers were concurrently exposed to temporary employment and job dissatisfaction daily labourers with job dissatisfaction showed the highest risks for alcohol use disorder odds ratio 299 95 ci 221403 and depressive symptoms odds ratio 900 95 ci 7361102 reris between daily employment and job dissatisfaction were 0 for alcohol use disorder 091 95 ci 006176 and depressive symptoms 347 95 ci 180514 indicating a supraadditive interactionwe revealed that temporary employment and job dissatisfaction had detrimental effects on alcohol use disorder and depressive symptoms

introduction substance use is increasing over the last 3 years among a national sample of students with 8th graders showing statistically significant increases in any illicit drug use population density matters among young adolescents as 8th graders residing in large metropolitan statistical areas are using illicit drugs at higher rates compared to youth in smaller msas and nonmsas in particular urban youth are vulnerable to early substance use and consequently future problematic use of both illicit drugs and alcohol many of these youth are disproportionately exposed to trauma which increases vulnerability to substance use to adequately understand individual development and change among urban adolescents the interplay of social and geographical niches in which the individual is embedded must be considered ecological models of behavior can be applied to investigate the social intrapersonal and environmental influences on risky health behaviors of adolescents such as substance use however researchers seeking to understand adolescent health and risk behaviors continue to struggle with systematic approaches of observing distinguishing and interpreting the vital ecological properties associated with the multiple environments that constitute modern adolescent development capturing the developing person in context as he or she engages with family peers and community members within a dynamic activity space and the accompanying psychological social and healthrelated experiences of these locations is extremely challenging an important construct that assists in the application of bronfenbrenners ecological developmental approach is activity space activity space can be defined as comprising all the locations that an individual has direct contact with as a result of his or her daily activities more broadly activity spaces are the manifestation of our spatial lives serving as an index representing routine locations and all the accompanying psychological social and healthrelated experiences of these places multiple approaches to measuring activity space have been used to capture location data within a given timeframe such as travel diaries structured interviews and using geographic information system research has shown that youth and urban adolescents in particular spend their time in a variety of geographically dispersed locations that are not delimited by conventional geographic boundaries such as census tracts zip codes political wards or even home neighborhood neighborhood characteristics are known to influence adolescents perceptions of safety and risk and are associated with substance use and mental health outcomes underscoring the importance of this construct for understanding urban youth research on activity spaces has also suggested that the places a person frequents outside the home may expose him or her to a variety of psychological social and geographic factors that likely influence substance use but that may not be observed within the home a large literature supports that relations with parents is critical to the emotional and behavioral health of young adolescents and that this relationship has been shown to influence adolescent peer relationships even when controlling for gender age socioeconomic status and peer effects relations with parents has shown specific protective effects on health and wellbeing clearly the adolescent parent relationship is one of many familybased constructs that effect adolescent emotional and behavioral health and is supported by a large body of research of particular interest is an empirically informed theoretical parenting model named the social contextual model of parental influence which posits that attributes of the family environment such as parenting directly affect attributes of the peer context a direct pathway from nurturant and active parenting reduces risk for deviant peer affiliations during adolescents thus providing a protective processes to increase emotional and behavioral health outcomes parents who actively engage in their childrens lives through nurturing and support will simultaneously guide their children into prosocial peer networks and away from risky peer environments there is evidence that positive parenting reduces deviant peer affiliation among african american youth living in disadvantaged urban settings and that this effect persists through childhood into adolescence social networks have been identified in the literature as a robust predictor of substance use extensive research has shown that peer context predicts tobacco alcohol and drug use peer networks establish group norms that define peer culture for both prosocial as well as antisocial behavior even when controlling for genetic and shared environmental differences peer network substance use predicts future individual substance use with stronger effects occurring within highintensitybest friendships thus the need exists to study peer networks capturing both risk and protective dimensions as part of a 24 month longitudinal study we report results from the first year of data collection we tested a moderated moderation model to examine the interactive influence of relations with parents peers and activity space risk on substance use involvement with young adolescents we developed this model based upon 15 years of work with urban adolescents identifying risk and protective factors associated with peers activity space and substance use in order to integrate a temporal dimension into our models we used the relations with parents variable the peer network variable the activity space variable and substance use involvement variable as illustrated in fig 1 the first part of the model examines whether peer network will moderate the association between relations with parents and substance use we hypothesize that peer network will moderate this direct pathway such that relations with parents will be of greater influence on subsequent substance use for youth with particularly risky peer networks as compared to youth with more protective peer networks the second part of the model includes activity space as a moderator to understand whether risk and protective environmental attributes interact with peer network characteristics we hypothesized that the moderating effect of peer networks on the pathway between relations with parents and substance use will itself be moderated by activity space such that the moderating effect of peer networks will be greater for youth who spend time in riskier as compared to safer environments this hypothesis is based upon the social contextual model of parental influence which maintains that parents living in high risk environments may exert increased protective parenting efforts such as influencing the peer network composition of their children eg in order to buffer against risky settings this hypothesis is also grounded in our work with urban adolescents where we posit that peer networks are an important mechanism by which the urban environment exerts its influence on protective or risk enhancing behaviors if activity space moderates the association between peer network and substance use it is also likely that peer networks will conditionally influence the strength of the direct association between relations with parents and substance use specifically we hypothesized that peer networks will moderate the direct effect when activity space is risky but not protectivedemonstrating a pattern of moderated moderation between our study variables method recruitment this study examined 12 month outcome data from the socialspatial adolescent study a longitudinal study of the interacting effects of peer networks activity space and substance use participants for the study were recruited between november 2012 and february 2014 the majority of participants were recruited from an urban adolescent medicine outpatient clinic at a large academic medical institution in richmond va this ambulatory care clinic provides comprehensive primary and adolescentspecific specialty care services to over 3000 patients annually between ages 12 and 22 years the present study is part of an urban youth and family initiative that seeks to test brief interventions in health care settings ageeligible adolescents presenting to the adolescent clinic for routine or acute care were approached and invited to participate in this study by a research assistant while in the clinics waiting room or pending arrival of the physician into the patients exam room after nurse triage participants were also recruited from richmond city health district satellite clinics these clinics located within citysubsidized housing developments offer limited primary care and adolescentspecific health programs to adolescents and families at little or no cost these participants were recruited by referral to the study team from the primary patient advocate at each of the satellite clinics the patient advocate provided information about the study to all teens presenting to the satellite clinic who met the age criteria the name and phone number of interested teens was then provided to the studys project manager for followup by phone over 400 adolescents and parents were either approached at the outpatient hospital clinic or referred from the satellite clinics of these 57 enrolled in the study enrollment and data collection procedures were the same across sites all procedures were completed in one visit all participants completed the 30min baseline survey on a study laptop participants completed followup surveys upon receiving a text message and email with an imbedded url link to complete a webbased followup survey chi square tests revealed no significant differences in age sex or race of participants between the recruitment sites data collection procedures were the same across sites adolescents who met eligibility requirements were recruited to participate written informed consent was obtained from all parents and adolescent participants prior to conducting any research activities the first authors university and the richmond city health departments institutional review boards approved the research protocol and the study received a federal certificate of confidentiality from the national institutes of health at enrollment participants completed an initial survey in a private room separate from parents and any clinic staff participants received nominal incentives for their time and effort ecological momentary assessment procedures ecological momentary assessment methods collect realtime data within participants natural settings using repeated measurements of momentary states and behaviors which characterize participants realworld experiences over a given period of time we collected ema data to characterize adolescents moods behaviors and activities of their close friends all participants were given a smart phone for the duration of the study with unlimited texting data and limited voice minutes participants were trained during enrollment on responding to the ema surveys on their phones participants received a text message with an embedded url where upon clicking they were directed to the secure webbased ema survey our use of ema data collected in brief yet dense periods of time enabled us to specify young adolescents activity space by utilizing global positioning system generated longitude and latitude coordinates derived from adolescents phones every 2 months for 12 months participants received ema surveys beginning on thursday through sunday with between 4 and 6 emas per day for a total of 18 per month this time parameter allowed for the capturing of both weekday and weekend ema surveys thereby providing a more representative characterization of adolescents lives each survey took less than 60 s to complete and participants provided windows during the week days that they were available to receive surveys following typical ema procedures participants were given an 8 min time window in which to complete each survey with an additional 1 min grace period before a survey was marked as missed at the 7 min mark a reminder text message was sent to any participant who had not yet completed the current survey the gathered data included the ema survey responses along with timestamps noting when each survey was begun and finished survey data submitted beyond the designated time window was still gathered with timestamps used to differentiate outofwindow data as needed geospatial data procedures each ema survey automatically generated location data at the moment of ema data capture using gps embedded within the phone and recorded as latitude and longitude coordinates gps can vary substantially in accuracy over time according to the geometric configuration of the gps satellites that provide location information and related factors particularly in urban environments where structures can inhibit communication between the gps receiver in the phone and the gps satellites fortunately the gps receiver embedded within the phone also provides a measure of location uncertainty for each coordinate position recorded for the current study we used participants ema response coordinates with a location uncertainty less than 300 feet which provides location data at an accuracy sufficient for linking each activity space location to other geospatial data describing socioeconomic disadvantage and neighborhood disorder as described below measures demographics participants reported on their age sex and race during the initial survey at enrollment age was not used in our models due to the lack of variation gender was coded as 0 girls 1 boys race was recoded as dichotomous because the sample was 88 african american substance use substance involvement was measured using the adolescent alcohol and drug involvement scale the aadis has good internal consistency and is highly correlated with selfreported measures of substance use clinical assessments and subjects perceptions of the severity of their own drug use problem we used the aadis to characterize alcohol and drug involvement and problem severity total score as dependent variable scores above 37 indicate likelihood of meeting a substance use disorder diagnosis we also used the drug use history section of the aadis to measure the frequency with which participants engaged in use of tobacco alcohol and marijuana for descriptive purposes frequency of use of substances were coded as 1 never used 2 tried but quit 3 several times a year 4 several times monthly 5 weekends only 6 several times a week 7 daily 8 use several times per day scores range from 1 to 8 for each substance measured relations with parents relations with parents were measured with the behavior assessment system for children relations with parents scale relations with parents construct is defined as the perception of being important within the family unit the perceived quality of the childparent relationship and the degree that the child experiences trust and concern the ten item scale had a cronbachs alpha of 084 in our sample higher scores indicate positive adjustment atrisk scores indicate disturbed relations with parents and clinically significant scores indicate severe family problems peer network characteristics peer network data were gathered using the adolescent social network assessment the asna captures information on each subjects close personal contacts which constitute their personal or egocentric peer network because our study focused on the influence of close peer networks we aligned the number of nominated close to friends to three as this is within the range commonly reported for close peer network size and because close friends have more influence on substance use than general peer networks adolescents were asked to think of up to three close friends respondents provided information about each of their close peers substance use influence on behavior and types of activities specifically subjects were asked about negativerisky activities such as whether they know if each nominated peer uses substances if the peer is a daily user and whether the subject has been directly or indirectly influenced to use or not to use substances by each peer as well as participating in illegal violent or dangerous behaviors in addition subjects were also asked about positiveprotective activities with their peer affiliates such as receiving help with school or transportation or providing support by talking through problems these items create a total score for each peer and are based upon a weighted scoring procedure with scores ranging from 14 to 14 weights are based upon our previous research that has shown for example that risk for substance use increases with one substance user in a network and risk for mental health problems is elevated with one daily substance user in a network given these data we developed the following weighted scoring procedures risk quality substance user 1 daily user 3 negative activity 4 influence to use 6 and protective quality nonsubstance user 4 absence of negative activities 4 influence not to use 6 each peers score is summed assuming three peers per participant total network quality scores range from 42 to 42 higher scores indicate greater peer network protection and lower scores indicate increased network risk the asna has favorable internal reliability and correlates significantly in the expected direction with selfreported measures of substance use with selfreported alcohol use and with selfreported marijuana use activity space the activity space for each participant was captured using each participants gps coordinates encoded from the set of their ema responses over the 1 year period of data capture we used geographic information systems software to join these ema response coordinates to other geospatial data to develop a measure of relative environmental risk and protection afforded by each participants activity space environmental risk was characterized via an index of neighborhood disorder which we derived from a set of variables commonly for this purpose and which we acquired from the us census bureaus 20082013 american community survey at the tract level these variables included indicators of educational attainment residential stability housing infrastructure poverty employment and race we also included a crime variable a census tract level index of assaults normalized to the national average using gis each ema response was attributed with these variable values according to the tract within which that ema response occurred following sampson et al we employed principal components analysis to identify a smaller number of components that expressed the variation in these highly collinear environmental variables such an approach is often used to develop theoretically meaningful variable constructs in models of neighborhood effects pca identified a single factor with eigenvalue 4 that explained 66 of the variance in seven of the 12 neighborhood disorder variables we used a single component representing four protective dimensions median household income percent housing units owner occupied percent employed percent with a bachelors degree or higher and three risk dimensions percent living below poverty line percent receiving public assistance income and the assault index score the continuous factor value from this analysis was used as a variable to represent relative environmental risk and protection associated with the location of each ema response higher values of the variable represent an increase in protective environmental influences and lower scores represent an increase in risk the activity space variable for each participant was then calculated as the mean neighborhood disorder component value for all ema responses for each participant analytic plan we began our analysis with a regression model that examined the direct effects of all predictor and demographic variables on substance use involvement in order to confirm all variables hypothesized contributions within our moderation models missing data was handled using multiple imputation procedures in spss v 21 missingness for selfreported data ranged from 0 to 15 a littles mcar tests was subsequently conducted indicating no systematic missingness imputed data were then combined using methods described by rubin to test the hypothesis that peer network characteristics moderates the relationship between relations with parents and substance use we created a moderation model with demographic variables as controls and also including the predictor variable the moderator variable and then the interaction term peer network × relations with parents to facilitate interpretation of results we meancentered peer network activity space and relations with parents variables next to test the hypothesis that activity space will moderate the moderating effects of peer network on relations with parents influence on substance use we conducted a 3way interaction analysis we then estimated the conditional effect of relations with parents on substance use as a function of peer network using an inferential test to better interpret the interaction specifically we tested the conditional effects on the 3way interaction with activity space interacting with peer network moderating relations with parents influence on substance use this allows the moderation of relations with parents effect on substance use by peer network characteristics to depend on levels of the degree of activity space risk 1 standard deviation below the mean the mean and 1 sd above the mean we conducted all analyses using ibm spss and the hayes and preacher conditional process analysis program results the study sample was 57 female 88 african american 9 other or unknown and 3 white the mean age was 134 years old ranging from 13 to 14 years old the mean aadis score was 84 with a range of scores from 1 to 64 lifetime substance use is provided in order to compare our samples use of tobacco alcohol and marijuana to the us national survey on drug use and health 8th grade 2012 data our samples lifetime tobacco use is 161 compared to 103 nationally alcohol use is 137 compared to 204 nationally and marijuana use is 112 compared to 78 nationally the peer network mean score was 22 with a range of scores from 23 to 38 relations with parents mean score was 282 with a range of scores from 7 to 38 the mean activity space principal component value for this sample was 00 with a range from 199 to 234 as a first step towards building our moderation models we regressed substance use involvement on the three predictor variables relations with parents peer network activity space and the two control variables race and gender table 1 shows that all predictor variables relations with parents peer network activity space significantly predicted substance use involvement in the expected direction where positive relations with parents and protective peer networks and activity spaces are all associated with lower substance use neither of the demographic variables significantly predicted substance use involvement and consequently were dropped from further analyses we hypothesized that peer network would moderate the association between relations with parents and substance use supporting the hypothesis the direct effect between relations with parents and substance use was significantly moderated by peer network figure 2 provides a graph of this interaction complete model coefficients for all variables are provided in table 2 we hypothesized that the association between peer network and substance use would be stronger for adolescents with higher levels of environmental risk associated with their activity space than for adolescents with less risk results indicated that the interaction term between peer network and activity space was significantly related to substance use figure 3 provides a graph of these interactions complete model coefficients for all variables are provided in table 3 in order to specifically assess the conditional effects model reported in table 3 the moderating effect of peer network on relations with parents influence on substance use involvement was examined at three values of activity space risk 1 standard deviation below the mean the mean and 1 sd above the mean this addresses the question of what level of activity space risk is significant in moderating the effects of peer network findings revealed that the interactive effect of peer network with relations with parents influencing substance use involvement was observed when activity space risk was high and moderate but not low thus the moderation by peer networks is itself moderated by activity space such that the moderating effect of peer networks on the relationship between parental relations and substance use is greater for teens with riskier activity spaces discussion an important contribution of the present study was integrating geographic social and psychological data to better understand young urban adolescents microsystems and subsequent substance use involvement over the course of 12 months this study adds to a very limited literature on the longitudinal interplay of parentadolescent relations peer networks activity space and substance use among a predominantly african american urban sample utilizing location specific activity space data and characterizing the risk and protective attributes of these dynamic data provides insight into the effects of place for these urban youth our study confirms previous research that has found protective family peer and placebased effects for youth related to substance use and other behaviors in addition we found that peer networks moderated the association between relations with parents and substance use involvement for these young urban adolescents peer networks moderated the relations with parents influence on substance use such that the adolescentparent relationship influence is greater for adolescents with riskier peer networks than for those with protective networks one reasonable interpretation is that when these variables are examined without regard to contextual factors such as activity space the interaction between relations with parents and risky peer networks exerts a greater riskenhancing effect on adolescents without taking into account the environmental influences conclusions regarding social interactions and subsequent health behaviors are restricted or narrowed these adolescents are situated within an urban context that produces important interactive effects with both peers and parents as is evidenced in our second hypothesis below our findings support our second hypothesis with activity space interacting with peer networks such that the moderating effect of peer networks on the relationship between parental relations and substance use is greater for teens with riskier activity spaces indeed results indicate that the effect of relations with parents on substance use is amplified for teens with particularly risky peer networks and risky activity spaces in other words the riskier a teens social and environmental contexts the more influential are the teens parents in mitigating substance use this finding is a placebased conditional effect that supports the social contextual model of parenting and leads us to speculate that parents in our sample may increase efforts at communicating caring trust and concern when their child is active in highrisk settings this conditional effect finding also supports lloyd and anthonys work where positive parenting reduces deviant peer affiliation among african american youth living in disadvantaged urban settings while our data precludes us from identifying specific parenting practices that may have changed over the course of our study from the adolescents perspective increases in positive qualities such as feeling important in the family trust concern and improved quality of adolescentparent relationship may serve as a proxy for positive parenting finally these results support our work in utilizing spatial social and psychological data in addressing substance use urban adolescents by providing confidence in the utility of collecting comprehensive and nuanced data relative to substance use involvement there were limitations in this study that should be considered when interpreting these findings first our sample was an urban almost entirely african american sample and therefore our findings may not apply to other populations while this is an important population to study due to historic underrepresentation replications with more diverse ethnic and geographic populations are needed second we used only selfreport measures for the substance use outcome obtaining biological specimens would increase confidence in these results third purchasing smart phones for participants inherently limits the scalability of such research future research is needed that uses existing phones of participants in order to test realworld data collection strategies finally a convenience sample was used for this study limiting the generalizability of these results this study supports the assessment that social influences are not aspatial but rather are embedded within place and in fact play an important role in creating adolescents experiences of place through the social interactions that occur at particular locations by examining the influence of peer networks within the context of activity space a placebased approach illuminates an interactive dynamic among peer networks place and health outcomes we acknowledge the challenges associated with incorporating microsystems such as place and peers into longitudinal models as stated by bronfenbrenner in 1979 nevertheless without systematic investigations of the complex and more realistic models of urban adolescents dynamic social and spatial lives we are severely narrowing our lenses that seek to observe and understand risk and protective factors for vulnerable populations conceptual model of the direct effect of teenparent relationship on substance use moderated by peer networks which is moderated by the risk and protective attributes within adolescents activity spaces moderating effect of peer networks on relations with parents influence on substance use moderating effect of activity space on peer networks moderation of relations with parents influence on substance use

limited research is available that explains complex contextual and interactive effects of microsystems such as family relationships peer networks and placebased influences have on urban adolescent substance use we contend that research into these complex processes is improved by integrating psychological social and geographic data to better understand urban adolescent substance use involvement accordingly we tested a longitudinal 3way moderation model to determine if the direct effect of teenparent relationships on substance use involvement is moderated by peer network characteristics which in turn is moderated by the risk and protective attributes within urban adolescents activity spaces among a sample of 248 adolescents results revealed that peer networks moderate the effects of relations with parents on substance use involvement for those adolescents with higher levels of risk attributes within their activity space but not for those who spend time in locations with less risk thus the teenparent relationship interacts with peer network characteristics for those urban adolescents whose activity space is constituted within highrisk environments we conclude that peer networks have important interactive effects with family relationships that influence substance use and that this is particularly salient for young adolescents who are exposed to risky environments this finding underscores the importance of continued study into the interrelations among microsystems of urban adolescents and provides further support that substance use is a social practice that is constituted within the unique geography of young adolescents lives

introduction nature occupies an essential space in american environmental discourses since the 19th century activists and professionals have extolled the virtues of nature and sought to protect and manage it contemporary environmental managers steward natural areas and encourage public participation in conservation activities despite the importance of public engagement in nature protection we know little about what people think about when they think of nature the paucity of knowledge is particularly glaring when it comes to what we know of young peoples thoughts about nature very few studies have explored what comes to mind when young adults reflect on nature there is general agreement that nature is vital to human wellbeing but what do people associate nature with when they think of it what are the differences and similarities in the way people think of nature this line of inquiry is significant as deeper insights into the ways people think about nature can foster more sustainable and meaningful humannature interactions these insights can also help us understand differing responses to nature hence this paper will examine how american college students think about nature given the wide variety of ideas that surface when cogitating nature the article will focus specifically on conceptions related to fear danger alienation and loathing it will also analyze how race gender class the participants educational attainment and parental educational background are related to such thoughts the connectednesstonature conceptual framework research on connectedness to nature is relevant to this study for decades scholars using biological and environmental psychology frameworks have theorized about humannature relationships for instance wilson posits a biophilia hypothesis that asserts that humans have an innate connection to nature adherents of this thesis contend that the humannature connection is mediated by values and those values are rooted in biology or our evolutionary past the biophilia thesis has led some researchers to attempt to measure peoples emotional connection or kinship to the natural world mayer and frantz and pereira and forster argue further that connectedness to nature is a strong predictor of ecological behavior dutcher et al also claim that environmental values stem from a sense of connectivity to nature the researchers argue further that connectivity with nature has a significant positive relationship with environmental concern and environmental behavior these arguments are significant since there is a considerable body of research that portrays blacks as being disconnected from nature this line of research also suggests that because of their race and evolutionary past blacks have unique outdoor recreational preferences for instance kellert and schroeder argue that blacks and urban dwellers are less likely to be attracted to nature and are less knowledgeable about environmental issues than white suburbanites or white rural residents similarly johnson claims that blacks have an aversion to wildlands she argues that the alienation is a result of the collective memory of slavery lynching and other acts of violence visited on african americans in the woods johnson who studied 147 whites and 116 african americans in gadsen county florida found that race was a strong predictor of attachment to wildlands the study revealed that blacks were less likely than whites to have strong attachments to wildlands lewis and hendricks also report that blacks are isolated from the forests some researchers studying outdoor leisure pursuits and affinity toward natural landscapes argue that blacks are disconnected from nature because they have a deeprooted dread about undisturbed natural and wild spaces scholars contend that fear leads to discomfort and avoidance of wildlands for instance talbot and kaplan argue that black detroiters prefer manicured urban settings over undisturbed or minimally disturbed wooded settings the researchers surmise that blacks favor the open manicured settings over densely wooded landscapes because they are frightened of the woods and believe it is dangerous although some scholars challenge the assumptions that leisure behavior or landscape preferences are a function of genetics evolution adaptation and are hardwired the biophobia thesis persists in the literature other researchers have also examined the issue of fear in park usage and interactions with nature in this vein gobster conducted a study of visitors in chicagos lincoln park and found that blacks were less likely than whites to say they preferred the parks natural attributes over developed facilities but latinx and asians recreators put a premiumto an equal or greater extent than whiteson the parks naturalistic features although research already discussed above hypothesizes or finds that blacks fear being in natural settings in the lincoln park study it was whites who were most concerned about safety white park users were more than twice as likely as ethnic minority park users to fear for their safety brownlow studied the fairmount park system in philadelphia and found what he describes as a legacy of fear towards the citys natural environment that has significant and lingering impacts on african american women hyun suggests that the fear of nature is transmitted intergenerationally however several researchers challenge the assumption that race is the preeminent determinant of connections to nature and landscape preferences shinew et al argue that class influences peoples perceptions of nature whereas virden and walker contend that gender is also influential in landscape preferences focus on students a limited number of studies have examined connectedness to nature and landscape preferences among american students peterson conducted a study of preference for scenery and reported that black high school students preferred urban landscapes while white students were more attracted to pastoral settings similarly medina claims that black youths preferred urban scenes while the environmental educators to whom they were being compared preferred natural areas with minimal or no disturbance bixler et al explored urban students fear and discomfort in wildland areas in their research by asking 48 naturalists to assess how students responded to nature while on field trips the naturalists reported that students feared the animals trees and people while exploring the wilds in 1997 bixler and floyd studied 450 suburban and rural 8 graders in texas and concluded that many of the students were fearful of and disgusted by wildlands the researchers found that strong fear and disgust was associated with an aversion to wild landscapes floyd et al studied 1200 black and white middle and high school students and reported that white students tended to rate wildland activities more highly than blacks the scholars found that fear was a factor in the students ratings that is fear of nature and preference for urban environments were positively related to a desire to participate in social activities that did not occur in wildlands despite being a large and relatively influential segment of the adult population few studies have focused on college or university students virden and walker studied 323 students attending a public university in the western united states and found that white and latinx students were more likely to prefer remote less developed settings than blacks in the end virden and walker concluded that the white participants in their study considered a forest to be safer than black and latinx respondents who perceived it as more threatening manning studied how students at southern utah university were connected to nature and found that male students scored higher on the connectednesstonature scale than females he also stated that urban students had higher scores on the scale than suburban and rural students lakenau studied university students too and found that an introductory ecology course enhanced students connectedness to nature however nisbet et al who studied college students enrolled in semesterlong environmental courses did not witness any changes in the level of students connectedness to nature that were attributable to taking the courses thoughts about nature despite the plethora of studies that examine peoples connections to nature and landscapes researchers usually do not ask study participants what they think of when they think about nature moreover studies do not examine how frequently respondents think about different aspects of nature while reflecting on the topic because there are unexplored connections between peoples thoughts and attitudes about nature johansson and henningsson suggest that attitudes are related to structures of thought hence we should pay more attention to what people think about nature bang et al and fischer and young argue further that attitudes are vital components of mental constructs about the natural environment consequently researchers have used wordassociation techniques to find out what thoughts study participants associate with nature a few researchers have explored how students think about nature scholars have also analyzed racial differences in students thoughts about nature for instance aron and witt studied urban minority youths and found that when it came to nature they were fearful of wild animals the unknown and were also anxious about lack of comfort and convenience taylor studied 157 college students and asked them to say what came to mind when they thought about nature respondents identified 47 discrete ideas and concepts the study which examined racial differences in thoughts about nature and landscape preferences found that black white and other minority students identified specific objects and situations in natural settings that they feared but did not express a generalized fear of nature in essence black and other minority students in the study did not express the widespread alienation aversion and disgust for nature that other studies have reported other research involving students have also found that maturitymeasured in years of educationimpacts students perception of nature besides gotch and hall found that family members influenced how teens perceived nature hyun corroborates this finding methods study objectives and survey description the objective of the study is to find out how college and university students think about nature the study also seeks to identify which factors are most significant in influencing students thoughts about nature this study builds on the work of buijs and elands and taylor in exploring what people think about when they contemplate nature to conduct their study of how environmental professionals and lay people thought about nature buijs and elands used a wordassociation technique to identify the implicit meanings study participants attach to or associate with the stimulus term nature the word association technique has also been used by environmental researchers such as aaron and witt to study urban youths definitions and perceptions of nature taylor asked respondents in her study what came to their mind when they thought about nature they provided openended responses to the question the answers varied in length from short phrases to lengthy paragraphs hence some responses generated multiple concepts each unique idea and concept identified was coded and analyzed the study analyzed in this paper uses a survey to produce both the qualitative and quantitative analyses presented below the survey designed and administered on a qualtrics platform asked respondents the following question when you hear the word nature which of the following comes to mind respondents in the current study got a list of words or short phrases that participants in past studies associated with nature these concepts were generated from taylors study as well as from the scholarly literature related to connectedness to nature in the research presented here each naturerelated concept has a fivepoint likert scale on which study participants indicated how often they thought about each aspect of nature the scale points are 1 never 2 seldom 3 about half the time 4 most of the time 5 always hence respondents were instructed to choose one answer on the scale for each concept to indicate how frequently each thought comes to mind likert scales are commonly used in analyses of this type to assess the presence or absence of a phenomenon and frequency of occurrence in this case it accomplishes both goals it is used to identify whether respondents think about a concept related to nature and if they do so how often do those thoughts occur similar likert scales have been used in environmental research by scholars such as bunyan et al in a study of citizens responses to environmental public goods and coastal flooding in the uk dutcher et al also used likert scales in their study of pennsylvania landowners connectivity with nature and environmental values the survey also contained questions that collected information on the race gender age educational attainment academic interest and social class of each respondent sample and response college and university students participating in science technology engineering math as well as arts humanities and social sciences courses and programming were asked to participate in the study the study used a purposive sampling technique purposive sampling is appropriate for a study of this nature it is a nonprobability data collection technique used to study population subgroups and identify and select informants who are knowledgeable about or have experience with the subject area of interest the method is also suitable for making comparisons between cases it is appropriate for qualitative and quantitative analyses the purposive sampling techniques widely used in social science mental health ethnobotany and environmental research the students mentioned above were contacted to ensure that the sample contained participants with varying levels of familiarity with nature and the environment this approach ensures that comparisons are feasible it also limits selection biases and allows the researcher to apply the findings beyond the sample seven hundred students attending public and private colleges and universities in the northeast midatlantic midwest south southeast southwest mountain and pacific regions of the country were asked to participate in the study i administered the survey from april 28 2017 through june 13 2017 in all 287 students submitted usable responses the response rate for the study is 41 the response rate is robust as response rates for electronic surveys are usually below 30 the sample contains 102 whites 63 asians 62 blacks 47 latinx and 13 others for this analysis latinx and other students are combined to create a category robust enough to withstand multivariate analysis there were 221 females and 66 males in the sample respondents ranged in age from 18 to 46 years old however 246 of the students were less than 25 years of age fiftyfour of the study participants were graduate students while 233 were undergraduates just over half of the students were majoring in the natural and physical sciences eightysix were social science humanities and arts majors while 50 were in engineering math computer science or their majors were unknown or undecided respondents were asked to say what the educational attainment of their parents or guardians were since parental guardian educational attainment provides an indicator of social class one hundred and eighteen of the study participants indicated that their parentsguardians had not attended college therefore 169 or 589 of the students in the study were from households with collegeeducated parentsguardians i obtained data on two other indicators of social classpell grant eligibility and first generation in college pell grants are meanstested financial assistance awarded to lowincome students one hundred and twentyseven of the samples were eligible for pell grants roughly a third of the sample were firstgeneration college students data analysis respondents assessed 58 descriptors or concepts relating to nature for analytical purposes i organized the descriptors into eight typologies or thematic areas though there are 58 categories of nature thoughts this paper will analyze the responses of one topical areaie thoughts related to fear danger and loathing loathing describes ideas related to hating or despising nature in taylor respondents who indicated that they loathed nature expressed hatred and a strong dislike for nature it is beyond the scope of a singlejournal article to analyze all 58 descriptors hence the focus on one typology the thematic area that deals with fear danger and loathing contains eight concepts these are the dependent variables analyzed in this paper examining this nexus of ideas is appropriate because scholars and environmental managers have expressed keen interest in the racial and gender differences reported in earlier studies this topical area is fascinating because of the racialization of the discourse related to peoples connection to nature that is blacks and other ethnic minorities have been linked to negative perceptions of nature environmental managers are curious about this they want to know how to manage natural areas so that they can engage the public introduce more people to new experiences get more significant input from lay people and foster an ethic of stewardship for nature this research will help to shine a spotlight on how one segment of the population thinks about nature it is a first step toward assisting managers in understanding how to garner greater public interest and engagement in naturerelated issues all the data are coded and analyzed in spss 24 as mentioned before respondents were asked to use a fivepoint scale to indicate how frequently they thought about each concept or idea the first level of analysis examined the distribution of responses on this scale mean scores calculated on the uncollapsed values of the descriptors are reported they range a low of 1 to a high of 5 because the sample size is relatively small it is not feasible to conduct multivariate analyses on variables that have five response categories consequently the five groups were collapsed to two thereby converting these variables into binarydependent variables the two response categories analyzed for each dependent variable is neverseldom and about half the timemost of the timealways for ease of reading neverseldom will be referred to as infrequently and about half the timemost of the timealways will be referred to as frequently researchers such as bunyan et al use the technique of converting dependent variables to binary forms in their study of attitudes toward the climate risk the article examines eight independent variables the definitions and the categorical distributions appear in table 3 several researchers discussed above have reported that race is an essential factor in nature preference they argue that blacks have an aversion to and fear of natural settings and a preference for urban landscapes however taylor provides evidence to the contrary prior research has also shown that age gender educational attainment income or social class was well below 5a suggested thresholdfor all tests performed the paper will discuss both descriptive and multivariate analyses crosstabulations were conducted to facilitate a descriptive analysis of how each independent variable was related to the dependent variables binary logistic regressions were performed to provide more detailed multivariate analyses a multiple regression analysis is conducted for each dependent variable all the independent variables are placed in the model in a forward stepwise fashion only the ones that had significant effects on the dependent variable are retained in the final model these modeling techniques are similar to the ones used in bunyan et al tables 5 and6 present the final models for each explanatory variable shown in the tables the value of the coefficient standard error wald chisquare statistic the significance level or ρvalue and the odds ratio are included the results of the cox and snell as well as nagelkerke pseudorsquare analysis are presented these are used to evaluate the goodness of fit of the models the classification ratewhich indicates the percentage of cases that the models predict correctlyis included for each model the tables also list the excluded category for each explanatory variable in the models limitations of the study the study has some limitations the sample size is small however it is well within the range of samples used in this type of research the study also focuses on a specific population rather than the general population because of time and funding constraints it was not feasible for the researcher to obtain a national randomized sample the study uses a purposive sampling technique such a method is subjective because the researcher relies on his or her knowledge of the subject area experience and judgment in the sampleselection process despite the limitations of the purposive sampling technique guarte and barrios conclude that this approach can yield the reliable results the limitations mentioned above can limit the replicability of the study and the generalizability of the results results contemplating nature when respondents think about nature they are most likely to think about the outdoors trees and forests as well as bodies of water as table 1 shows more than 90 of the sample think of the outdoors trees forests plants green space and animals frequently when they think of nature while 811 think of remote and far away landscapes and 662 think of rural landscapes only 291 think of urban landscapes frequently moreover twothirds or more of the students thought about the utility of nature frequently when contemplating nature study participants also thought about the sensations and feelings nature evokes as well as their experiences in nature that is to say more than 60 of the sample say they have these thoughts regularly study participants were far more likely to think about the above themes rather than feardangerloathing overall respondents gave the lowest scores to these ideas all eight concepts had mean scores of less than 275 in other words between 51 and 79 of the study participants said they think of these factors infrequently when they contemplate nature natural hazards table 4 shows that between 47 and 52 of whites asians blacks and latinxothers say they think about natural hazards frequently when they think of nature males were more likely than females to think about natural hazards frequently 569 of males and 466 of females said they did older students were more likely to think of natural hazards frequently than those who were under 25 years of age while 611 of graduate students thought about natural hazards frequently only 461 of undergraduates did roughly 57 of naturalphysical science majors thought of natural hazards often this far exceeds the 4041 of other students who think of this factor frequently infrequently frequently infrequently frequently infrequently frequently infrequently frequently infrequently frequently infrequently frequently infrequently frequently infrequently frequently respondents whose parentsguardians did not attend college were much more likely to think of natural hazards frequently than participants whose parentsguardians are college educated hence 423 of those with collegeeducated parentsguardians and 585 of those whose parentsguardians did not attend college thought about natural hazards frequently regarding natural hazards the difference between respondents who were eligible for pell grants and those who were ineligible was inconsequential however students who were firstgeneration college students were more likely to report that they thought about natural hazards frequently than those who were not firstgeneration college students race three of the explanatory variables were significant in the multivariate model the r 2 values are between 0077 and 0103 and the case classification rate is 608 the regression shows that age is significant and is the first variable retained in the model the odds ratio indicates that respondents who are 25 years or older are 2562 times more likely to think about natural hazards frequently than younger participants parentalguardian education is another independent variable that is significant students with collegeeducated parentsguardians are 0495 times less likely to think of natural hazards frequently than those without collegeeducated parentsguardians the other independent variable that had a significant effect on the final model was academic major the model shows that students majoring in social sciencehumanitiesarts were 0519 times less likely and those majoring in engineeringmathcomputer science unknown were 0428 times less likely to think about natural hazards frequently than naturalphysical science majors disconnected white students are less likely than ethnicracial minority students to say they think about being disconnected from nature frequently while 356 of white respondents thought about being disconnected frequently 51655 of the remaining students did likewise males were significantly more likely than females to think about disconnection from nature hence 601 of males and 427 of females frequently thought about being disconnected from nature older respondents are slightly more likely than younger participants to report thinking about disconnectedness from nature often graduate students have a greater tendency to think of disconnection from nature than undergraduates that is 574 of graduate students and 443 of undergraduates often think of being disconnected from nature while 537 of the naturalphysical science majors think about disconnection from nature frequently roughly 38 of other students do the same respondents whose parents did not attend college those who are pell grant eligible as well as firstgeneration college students are more likely to think of being disconnected from nature frequently than other students three independent variablesgender age and academic majorwere significant in the regression model the r 2 values are 0074 and 0098 the case classification rate is 665 gender had a significance level of χ 2 6261 and ρ 0012 the exp indicates that females were 0474 times less likely than males to think about disconnection frequently when they cogitate nature asians blacks and latinxothers were all more than twice as likely as whites to think regularly about disconnection from nature social science humanities and arts majors were 0511 times less likely than naturalphysical science students to think about disconnection from nature regularly in comparison engineeringmathcomputer scienceunknown majors were 0491 times less likely than naturalphysical science majors to think about disconnectedness frequently predators blacks stand out as having a much higher propensity to think about predators when reflecting on nature than other respondents consequently 639 of blacks regularly thought about predators when contemplating nature while 327 of whites did similarly in comparison 476 of asians and 508 of latinxother respondents considered predators frequently when they thought of nature there is a relationship between academic interests and the probabilities of thinking about predators when considering nature to wit naturalphysical science students are much more apt to think of predators than other students hence 541 of naturalphysical science respondents often think of predators when cogitating nature in contrast 395 of social sciencehumanitiesarts majors and 36 of engineeringmathcomputer scienceunknown majors focus on predators often while contemplating nature males and females think about predators similarly older respondents and graduate students are more liable to think of predators than those who are under 25 years of age or who are undergraduates as was the case with disconnectedness respondents whose parentsguardians did not attend college those who qualify for pell grants and firstgeneration college students are more inclined to ponder predators often when considering nature than students with collegeeducated parentsguardians who are not eligible for pell grants or who are not firstgeneration college attendees only two independent variablesrace and academic majorare significant in the multivariate regression the r 2 values are 0085 and 0114 while the case classification rate for the model is 637 race is very significant and contributes the most to the final model the odds ratio signifies that while asians and latinxothers are just over two times more likely than whites to think about predators frequently when imagining nature blacks are 4058 times more inclined to think about predators in this context than whites the significance level for academic major is χ 2 9053 and ρ 0011 the odds ratio indicates that social science humanitiesarts majors were 0486 times less likely and engineeringmathcomputer scienceunknown majors 0438 times less prone to think about predators frequently than naturalphysical science students when they reflect on nature getting lost a much lower percentage of white students reported that they regularly think about getting lost when they reflect on nature than racialethnic minority students while 287 of white respondents often think about getting lost more than half of the other study participants considered this factor regularly males were only slightly more inclined to think of getting lost than females similarly when respondents who were 25 years and older reflected on nature they were only slightly more disposed to think of getting lost frequently than younger respondents more than half of the undergraduates think of getting lost often conversely 481 of graduate students do likewise just over half of the natural physical science majors and social sciencehumanitiesarts majors think about getting lost frequently but 68 of engineeringmathcomputer scienceunknown majors often think about getting lost when they reflect on nature race was the only explanatory variable that had a significant effect on the multiple regression model the r 2 values were 0053 and 0071 the case classification rate for the model was 593 the model had a χ 2 of 8744 and a ρvalue of 0013 the odds ratio signifies that asians were 2731 times blacks 2740 times and latinxothers 2837 times more inclined to think about getting lost on a regular basis when they reflect on nature than whites were humanmade hazards asians were the least likely and latinxothers the most prone to think about humanmade hazards frequently when they consider nature on the other hand similar percentages of blacks and whites contemplated humanmade hazards regularly a higher percentage of males thought about humanmade hazards often than females older respondents also had a higher propensity to reflect on humanmade hazards regularly than participants who were under the age of 25 years of age while 463 of graduate students said they reflected on humanmade hazards often a third of the undergraduates thought about this factor regularly a higher percentage of students who were naturalphysical science majors tended to think about humanmade hazards regularly than their peers the pattern observed earlier with other factors held for this dependent variable too that is respondents whose parents are not college educated those who qualify for pell grants and firstgeneration college students are more apt to think about humanmade hazards frequently than other students however in this instance parentalguardian education is significant while 424 of the students whose parents guardians did not attend college thought about humanmade hazards frequently 315 of the respondents with collegeeducated parents thought about this factor frequently when they thought of nature the logistic regression for this factor appears in table 6 model 5 parentalguardian education and academic major make significant contributions to the final model the case classification rate is 647 and the r 2 values are 0045 and 0062 parentalguardian education has a χ 2 of 4167 and ρvalue of 0041 according to the odds ratio respondents with collegeeducated parentsguardians were 0593 times less likely than those with parentsguardians who did not go to college to think frequently about humanmade hazards the χ 2 for students academic major was 9483 and the ρvalue was 0009 the exp shows that social science humanitiesarts majors were 0427 times and engineering mathcomputer scienceunknown majors were 0509 times less probable than naturalphysical science majors to think of humanmade hazards frequently when reflecting on nature loathsome hateful places only 79 of white students think of loathsome hateful places frequently when they consider nature however significantly higher percentages of ethnicracial minority students make this association with nature hence 234 of asians about a third of blacks and 367 of latinxothers frequently think of hateful or loathsome places when they cogitate nature almost 31 of males think of loathsome hateful places regularly when they contemplate nature in contrast only 205 of females do likewise whereas 317 of respondents who were 25 years or older envisioned loathsome hateful places often when thinking of nature 213 of younger study participants think similarly graduate students were more prone to conjure up images of loathsome hateful places often when thinking of nature than undergraduates only 8 of engineeringmathcomputer scienceunknown majors often thought about loathsome hateful places when reflecting on nature in comparison 209 of the social sciencehumanitiesarts majors and 289 of the naturalphysical science majors had similar thoughts firstgeneration college students had a significantly higher tendency to think about loathsome hateful places frequently when considering nature than their peers who were not the first generation in their families to attend college hence 372 of firstgeneration and 157 of nonfirstgeneration college students thought about this factor frequently academic major race gender and firstgeneration college students were the explanatory variables that had significant effects on the final regression model the model had a case classification rate of 761 and r 2 of 0160 and 0243 regarding academic major the χ 2 was 11163 and the ρvalue was 0004 social science humanitiesarts majors were 0547 times less disposed than naturalphysical science majors to think of loathsome hateful places frequently when thinking of nature however engineeringmathcomputer scienceunknown majors were only 0160 times less likely than naturalphysical science majors to do likewise the odds ratio indicate that females were 0483 times less disposed than males to invoke images of loathsome hateful places regularly when contemplating nature this variable has the following significance leve χ 2 4216 and ρ 0040 race is very significant in the final model the exp signifies that asians were 3488 times blacks 4698 times and latinxothers 5909 times more likely than white respondents to think of loathsome hateful places frequently when they think of nature the intergenerational impact of college attendance is also significant in this model that is nonfirstgeneration college students are 0391 times less likely than firstgeneration college respondents to envision loathsome hateful places frequently when thinking about nature the significance level for this variable is χ 2 8632 and ρ 0003 fearful latinxother respondents were the most and white students the least apt to say that they thought about fear frequently when they contemplated nature while a third of latinxother students envisioned fear often when they thought about nature only 14 of white participants did however asians and blacks thought somewhat similarly about fearfulness and nature that is 222 of asians and 264 of blacks thought about fear regularly when reflecting on nature there is a greater tendency for males to think about fearfulness frequently when nature comes to mind than females as was the case with other factors examined above graduate students were slightly more prone to conjure up fear often when thinking of nature than undergraduates eighteen percent of engineeringmathcomputer science unknown majors think about fear in connection to nature regularly only a slightly higher percentage of social sciencehumanitiesarts majors and naturalphysical science majors responded similarly the differences in categorical responses for the variables parental guardian education pell grant eligibility and firstgeneration college adhered to the pattern identified earlier race was the only explanatory variable that was significant in the multivariate model the r 2 values were 0029 and 0045 the case classification rate of the model was 778 it had a χ 2 of 8083 and a ρvalue of 0044 the odds ratio indicates that asians were 1755 times blacks 2003 times and latinxothers 3071 times more likely than whites to think of fear frequently when reflecting on nature dangerous respondents tended to think similarly about danger when they think of nature race was the only independent variable that manifested significant variations in the categories of danger analyzed a low percentage of white students said that they thought about danger frequently when they think of nature 99 of them did this ethnicracial minorities were very consistent in their responsesroughly 27 of them envisaged danger often when they thought about nature while 277 of males imagined danger regularly when they considered nature only 191 of females did likewise younger respondents were more inclined to think of danger frequently when they cogitated nature than those 25 years and older similarly undergraduates were more apt to envision danger often when they contemplate nature than graduate students students in different academic majors were virtually identical in the way they thought about danger and nature respondents whose parentsguardians did not attend college those who qualify for pell grants and firstgeneration college students were slightly more likely than their counterparts to think about danger frequently in association with nature only one variableracehad significance in the regression model the case classification rate was 789 and the r 2 values were 0044 and 0069 the χ 2 was 10820 and the ρvalue was 0013 the odds ratio shows that asian black and latinxother respondents were 335 times more likely than white students to envision danger frequently when they think about nature recap discussion and conclusions the findings of this research demonstrate the need for scholars who study connections to and disconnections from nature to expand the repertoire of explanatory variables used to examine these phenomena it is clear from this study that educational generational age and class variables influence thoughts about nature culture rurality urbanization region and nationality are additional variables that could influence such thoughts although scholars have dedicated much effort to studying the relationship between race and nature this paper suggests that the intense focus on blacks and whites misses essential nuances that can help us understand peoples perceptions of and relationship to nature more fully so what matters in the way people think about nature six of the independent variables studied had significant impacts on the dependent variables in the multivariate models box 4 summarizes these impacts the study found that race had significant effects on thinking about disconnectedness predators getting lost loathsome and hateful places fearfulness and danger in the context of reflecting on nature however researchers should not stop there scholars should not think of racial groups as monolithic entities or think that race is the be all and end all to understanding human perceptions of nature this study indicates that not all members of a particular racial or ethnic group think about nature in the same manner consequently managers should refrain from making too many generalizations about any given racial group when it comes to their thoughts about understanding of and interactions with nature as the results of this study have shown a variablestudents academic interestsoften overlooked in this type of research also had significant influences on five dependent variables academic majors had significant impacts on thinking about natural hazards disconnectedness predators humanmade hazards and loathsome or hateful places gender was important in thinking about disconnectedness as well as loathsomehateful places whereas parentguardians educational attainment had significant influences on thinking about both natural and humanmade hazards age was influential in thinking about natural hazards while being a firstgeneration college student had significant effects on thinking about loathsome and hateful places though parentalguardian educational attainment is significant in two multivariate models the students educational attainment was not significant in any of the models another explanatory variablepell grant eligibilitywas not retained in any of the multiple regression models either though these two independent variables were not influential in this study they might be of significance when researchers explore other dimensions of thinking about nature this study suggests some important things about social class that is not described in earlier studies in this genre that is being low income did not have significant effects on thoughts about nature however the educational attainment of ones parentsguardians did hence having parentsguardians who were not college educated was associated with more frequent thoughts about natural hazards and humanmade hazards in addition another income indicator first generation in college was significant in respondents regularly thinking of nature as loathsome and hateful places these findings lend credence to the intergenerational transmission thesis posited by hyun and gotch and hall although race is salient in understanding peoples thoughts about nature the effects do not necessarily manifest themselves in the way previous scholarship has researchers have reported that blacks exhibit an aversion to the wilds are fearful of natural settings and are disconnected from nature the findings of this study show that thoughts about fearing nature danger in nature and disconnection from nature are not exclusive or unique to blacksall racial groups expressed these sentiments besides 475 of blacks think of being disconnected from nature infrequently furthermore most blacks do not think of nature as loathsome that is twothirds of blacks associate nature with hateful or loathsome places occasionally and 721 think of danger infrequently when they reflect on nature similarly high percentages of asians and latinxother respondents think of danger and hateful or loathsome places infrequently when they think of nature it is true that there are significant differences in the way whites think about these aspects of nature and the way racialethnic minorities do but we should not lose sight of the fact most minority college students are not always fearful of or disconnected from nature when they think of it unlike earlier studies that find that females consider the environment to be riskier than males this study does not fully support those findings findings from this study show that male students had a higher propensity than females to think of natural and humanmade hazards getting lost fear and danger regularly when they reflected on nature though manning argues that males are more connected to nature than females the findings of this study would not necessarily lead one to reach this conclusion this study suggests that environmental managers should think harder about the following question what is the relationship between what people think about nature and the way they act in concert with nature in other words what is the relationship between thoughts perceptions and action this study implies that managers should connect these factors more deliberately in their planning and programming this study reveals significant findings related to a specific segment of the adult populationcollege students college students are highly educated and tend to be efficacious and action oriented the data presented above show that regardless of race college students generally think about the favorable aspects of nature frequently college students generally positive view of nature is a useful insight for managers to consider as such students are influencers who can act as supporters of nature and as liaisons between managers and the general public college students can help to activate and spread support for nature among the general public they can also be a bridge to reaching underserved populations buijs and elands believe that understanding the way people think about nature may improve communication and collaboration between professionals and stakeholders working with influencers who can communicate on multimedia platforms could be quite helpful to environmental managers as there is an urgent need to reach broader audiences and incorporate more historically underrepresented people in the planning for and management of natural areas managers could benefit from the insights that people who are not typically involved in environmental management might have environmental managers should also embrace the flowering of peopleofcolorled naturefocused groups that have materialized over the last decade these groups organized and operated mostly by collegeeducated millennials include organizations such as latino outdoors outdoor afro asian outdoors natives outdoors people of the global majority in the outdoors nature and environment trail posse and brown girls climb environmental managers should collaborate with groups like these to develop culturally sensitive curricular materials and outdoor education activities environmental managers should also include leaders of these organizations in policy and planning employ members of these organizations and fund opportunities that increase access to natural areas to program participants though the study provides critical new insights into college students thoughts about nature there are limits to the extent to which one can generalize from the results not only does this study focus only on a specific subset of the young adult population but students themselves are also very diverse and this study does not capture the full range of that diversity there is a need for more research on this topic this study suggests that we should try to find out how people think about different types of nature that is how do they think about woodlands forests savannahs alpine meadows swamps and pastoral landscapes to name a few we need to examine concepts such as objectspecific and situational fear more thoroughly in future research it would help environmental managers if they knew whether fear of a particular object or situation that arises in nature grows into generalized anxiety that compromises a persons perception of and feelings towards nature open access this article is distributed under the terms of the creative commons attribution 40 international license which permits use duplication 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 license and indicate if changes were made conflict of interest the authors declare that they have no conflict of interest publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

despite the existence of a robust body of research that investigates humannature connections few scholars have examined what people tend to ponder when they think of nature the objective of the study is to find out how college and university students think about nature the study also seeks to identify which factors are most significant in influencing students thoughts about nature this paper analyzes racial gender class and academic differences in the way college students think about nature the study of 287 american students found that respondents thought about a wide range of concepts and ideas when they contemplate nature this article focuses on the demographic differences in thoughts about fear danger and loathing this set of ideas has been the subject of scholarly research and the findings presented herein contribute to this body of scholarship the paper discusses both descriptive and multivariate techniques that are used to explore the topic the study found that white students are less likely than racialethnic minorities to think about disconnection predators getting lost loathsome or hateful places fear and danger when they think of nature however the results also show that it would be inaccurate to describe racial ethnic minorities as universally fearful of and disconnected from nature moreover the paper demonstrates that race is not the only explanatory variable that has significant impacts in multivariate modelsthe students academic interest has significant impacts on thoughts about natural hazards disconnection predators humanmade hazards and loathsome or hateful places gender age parental education and firstgeneration college attendance also has significant impacts on the dependent variables

the process of cultural orientation entails both enculturation and acculturation domains enculturation refers to the degree to which individuals maintain and adopt characteristics of their culture of origin whereas acculturation refers to the extent to which individuals adhere to and adopt characteristics of the mainstream or host culture among ethnic minority families with adolescents this process has been linked to parentadolescent relationship domains and youth psychological adjustment examining the role of cultural orientation within a family system is critical given that this phenomenon may increase exponentially within a family system as different family members may respond and adapt to this process in different ways as a result an increasing interest has emerged in trying to understand the ways in which parents and adolescents own experiences with the process of cultural orientation contribute to family functioning and adolescent adjustment specifically scholars have examined how parents and adolescents individual levels of cultural orientation differ from each other and whether the dissonance between parents and adolescents cultural orientation is linked to family functioning and youths adjustment it is worth noting that in the acculturationenculturation literature terms such as gap discrepancy and dissonance have been used to describe the extent to which parents and adolescents differ from each other with respect to their individual degrees of acculturation and enculturation furthermore in the broader literature on adolescent development the term discrepancy or incongruence is used to indicate divergence in family members perceptions of parenting and family processes as well as divergence in adolescent developmental issues thus in the broader adolescent literature similar terms to those in the cultural literature are used but the terms center around the divergent views that parents and adolescents have on family and developmental issues alternatively the focus of the cultural literature is to have a deeper understanding about the degree to which parents and adolescents differ from each other on their individual levels of acculturation and enculturation and how this difference may contribute to family functioning and youth adjustment in the current study we used the term cultural dissonance to encompass both acculturation and enculturation domains by cultural dissonance we refer to the differing behaviors beliefs and values between parents and adolescents with respect to their native and host cultures overall studies linking parentadolescent cultural dissonance to adolescent adjustment have yielded equivocal results some results indicate that parentadolescent cultural orientation dissonance is directly and indirectly associated with youth adjustment whereas results from other studies yield little support for cultural dissonance being salient in predicting adolescent adjustment two issues may explain the inconclusive findings first scholars have used different operationalizations and methods to examine cultural dissonance for instance in some studies scholars have used variablecentered methodological approaches such as difference scores whereas in other studies scholars have used personcentered methodological approaches such as cluster analysis second the inconclusive findings may ensue from how cultural dissonance family functioning and adolescent adjustment have been linked for instance most scholars have examined the direct effects of cultural dissonance on family functioning and adolescent adjustment rather than examining how the interplay between parentadolescent cultural dissonance and family functioning together predict adolescent adjustment in the current study we address these two issues by employing four analytic procedures previously used in the cultural dissonance literature in order to identify the procedure that best explicates the interplay among cultural orientation dissonance family functioning and adolescent adjustment in a sample of mexicanorigin girls and their mothers the interplay among cultural orientation family functioning and adolescent adjustment a majority of previous research on cultural orientation has examined the direct influence of parentadolescent cultural dissonance on either family functioning andor adolescent adjustment with only a small number of studies investigating the interplay among cultural dissonance family functioning and adolescent adjustment yet scholars have indicated that it is not acculturation per se that is directly associated with adolescents functioning but that acculturation processes transform and disrupt more proximal aspects of adolescents lives suggesting that an interactive process between cultural orientation and family functioning contributes to adolescents psychological functioning for example conflict between mothers and daughters may only be detrimental to adolescents when there is great cultural orientation dissonance within the dyad the most common argument in existing work is that transformations in the parentadolescent relationship as well as adolescent adjustment are a direct result of the culturally mismatched environments in which adolescents are embedded however theoretical work suggests that cultural orientation dissonance between parents and youth adds to the stress of normative intergenerational conflict that occurs in families with adolescents based on the acculturation gapdistress hypothesis the role of acculturation and enculturation processes on psychological wellbeing is seen as a function of its interactive influence with family factors this postulation suggests that a cultural orientation mismatch between parents and youth can either exacerbate the normative levels of conflict experienced between parents and adolescents or disrupt other family relationship domains and this in turn affects adolescents adjustment for latino youth and their families culturallyrelated pressures may interact with family relationship factors and place adolescents at greater risk for poor psychological wellbeing based on this idea in the current study we explored the relation between acculturationenculturation and psychological adjustment by examining the interplay among motherdaughter cultural orientation dissonance family factors and adjustment cultural dissonance methodological issues across studies different methodological approaches have been used to examine parentadolescent cultural dissonance whereas variablecentered approaches focus on examining relations among variables personcentered approaches identify subgroups of people based on their similarities on a set of variables thus by assuming subgroups of individuals within a heterogeneous population a personcentered approach can help to detect groups where the associations among cultural and family factors and adolescent adjustment are most salient the majority of scholars examining cultural dissonance have used a variablecentered approach via two analytic procedures difference score and interaction of parents and childrens acculturation levels the disadvantages of this approach have been noted in the literature for instance variablecentered analytic procedures typically examine only one dimension of cultural orientation and there is difficulty when trying to implement nonlinear models recently scholars have begun to use personcentered approaches to study family cultural orientation several researchers have emphasized the utility of a more holistic or personcentered approach to study development and family dynamics specifically with a personcentered approach researchers recognize that the processes functions and development of behaviors are in part specific to individuals that is the individual or dyad is seen as an organized whole contrary to a variablecentered approach the focus of the personcentered approach is on patterns of operating factors among persons rather than among variables this approach better captures the multidimensional nature that can be found in family aspects and cultural orientation in the context of understanding cultural dissonance between parents and adolescents the emphasis should be on the dyadic unit as a functioning whole this emphasis thus entails examining cultural dissonance by including orientation characteristics from both the parent and the adolescent within a personcentered approach two analytic procedures have been used to examine patterns of parents and adolescents cultural orientation using berrys typology one procedure arbitrarily classifies individuals and their parents based upon subjective classification schemes such as being assimilated when endorsing over 50 of the acculturation values and less than 50 of the enculturation values and then creating matchmismatch cultural dissonance groups based on adolescents and parents level of acculturation a more rigorous personcentered procedure is latent profileclass analysis a modelbased technique in which individuals or dyads are classified into groups based on empiricallyderived classes the use of this approach in studying cultural orientation dissonance among parents and adolescents has been limited weaver and kim used a combination of latent profile analysis and arbitrary grouping to classify groups of parentchild cultural orientation dissonance in the first step profiles of cultural orientation were derived separately for parents and adolescents in the second step the authors created groups where parents and adolescents were similar and dissimilar in classifications of cultural orientation although innovative this twostep procedure is limited given that parent and youth profiles were estimated separately and the less rigorous arbitrary grouping was used as the final step possibly resulting in groups of parentchild cultural dissonance either being overrepresented or not accounted for because some families were arbitrarily forced into one group or another although both the variablecentered approach and the personcentered approach have limitations an important next step is to determine which approach and corresponding analytic procedure would best capture the associations among cultural orientation family functioning and adolescent adjustment birman recently noted the limitations of previous research in using differing conceptualizations of parentadolescent cultural dissonance and addressed the issue by using two variablecentered procedures to examine the association between cultural dissonance and parentadolescent conflict in the present study we addressed the issues noted by birman by employing four analytic procedures to examine how cultural processes in concert with family functioning were related to adolescent adjustment examining associations in early and middle adolescence there is substantial evidence indicating that the transition to adolescence is characterized by shifting power dynamics and emerging competing goals between parents and their children as adolescents become more independent their time spent with parents friends and others shifts as well as their emotional connections with them although parents continue to be an important interpersonal context in the lives of adolescents the interpersonal changes taking place during adolescence may play a role in the degree to which parents contribute to adolescent adjustment that is parents contribution to adolescent adjustment may vary as a function of adolescents developmental stage for instance research indicates that adolescents experience more frequent conflict with parents during the transition to adolescence conflict that declines as adolescents get older thus it is possible that parentadolescent relationship factors may be stronger predictors of psychological adjustment in early adolescence than middle adolescence given that more frequent conflict is experienced during this time for instance greenberger and chen found that in a sample of early and late adolescents from europeanand asianamerican ethnic backgrounds the magnitude of association between family process variables and depressed mood declined substantially among late adolescents thus we examined whether the relations among the variables varied across early and middle adolescence overview of study goals in the current study our overall aim was to identify which methodological approach and corresponding analytical procedure best elucidated the interplay among mexicanorigin motherdaughter cultural orientation dissonance family functioning and adolescent girls adjustment we used four different analytical procedures to examine how adolescent adjustment varied as a function of motherdaughter cultural orientation dissonance and family functioning in addition we examined whether those associations were moderated by adolescents grade in school currently criteria for choosing the best procedure do not exist thus in the current study we identified the most promising procedure based on observation interpretation and comparison of the findings from each of the four analytic procedures in sum based on the limitations from previous literature we used the following criteria for choosing the best method first given that previous studies have been less sensitive in capturing nonconventional families we paid particular attention to the procedure that best captured these families and linked their functioning to adolescent adjustment second because previous research has also been equivocal in depicting the associations among cultural and family processes we chose the procedure with the most meaningful and informative associations among family functioning and cultural orientation the two methodological approaches used in the current study were variablecentered and personcentered within each approach we used two analytic procedures that differ in the way that cultural dissonance was statistically computed and defined and how the associations among the variables were analyzed the first two analytic procedures were variablecentered difference scorea procedure using raw difference scores between mothers and daughters for cultural dissonance and interactionmoderationa procedure using the interaction between mothers and daughters for cultural dissonance the last two analytic procedures were personcentered arbitrary groupinga procedure where mothers and daughters are arbitrarily grouped together based on their reported values of cultural orientation and latent profilesa procedure that uses latent variable modeling to estimate group membership based on an assumption of underlying heterogeneity within a given population given the exploratory nature of this study and the use of multiple procedures we did not draw any specific hypotheses about which methodological approach or analytic procedure would be best suited for the studied associations however given theoretical work on cultural dissonance we expected that greater dissonance and poorer family functioning would be associated with greater depressive symptoms and anxiety in daughters no hypotheses were drawn with respect to the role of cultural orientation dissonance on adjustment for early versus middle adolescents given that previous work on cultural orientation has not examined differences across developmental periods finally based on previous work that has found a decline in parentadolescent conflict over the adolescent years we hypothesized that the associations between motherdaughter conflict and adjustment would be stronger during early than middle adolescence method participants adolescent girls in the 7 th or 10 th grade and their mothers were recruited from 10 public schools in a large southwestern metropolitan area in the us the percentage of latino students in each of the participating schools ranged from 67 to 88 of all eligible participants participation rates by school ranged from 171 to 259 for the 7th grade sample and from 61 to 179 for the 10 th grade sample the final sample included 338 adolescents and 319 mothers analyses for the current study were conducted on the 319 dyads from which data for mothers and adolescents were available most girls completed the survey in english whereas a majority of mothers completed the phone interview in spanish for the current study the 7 th grade sample consisted of 159 adolescents ranging in age from 11 to 14 years of these a majority reported being born in the us the 10 th grade sample consisted of 160 adolescents whose ages ranged from 14 to 17 years more than half of the 10 th grade participants reported being born in the us a majority of adolescents lived in households with their biological mother and father but other family constellations were reported as well a majority of mothers reported to be the biological mother of the target adolescent other relationships reported were stepmother grandmother sisterinlaw sister and aunt mothersmother figures ranged in age from 20 to 56 years and from 30 to 57 years for the 7 th and 10 th grade sample respectively most mothers identified themselves as mexican but other ethnic identifications were also reported ethnic selfidentification was reflective of mothers nativity a total of 273 of the mothers indicated being born in mexico a majority of mothers reported being married and completed less than high school education design and procedures school district and principal approval was obtained for all participating schools adolescents had to be enrolled in either 7 th or 10 th grade and both of their parents had to be of mexican descent teachers in homeroom and social science classrooms introduced the study to their students and distributed recruitment letters all documents that were not originally available in spanish were translated by the first author and backtranslated by a researcher of mexicanorigin to ensure that the translation was consistent with the spanish dialect of mexicanorigin families disagreements between the translation and backtranslation were resolved between the first author and the backtranslator in cases where more than one possible translation was correct the most common translation was selected all measures that were available in spanish with the exception of the anxiety measure were previously used with a latino sample where the majority of the participants selfidentified as mexicanorigin recruitment letters explained the purpose of the study indicated that participants would receive 10 and 15 incentives for daughter and mother participation respectively and stated that the study required both daughter and mothermother figure participation mothers also completed a form that indicated whether or not they were interested in participating in the study with their daughter provided their contact information and provided their signature to grant permission to obtain their contact information from school records if needed mothers also indicated the ethnic background and place of birth for both themselves and the target adolescents father all returned forms were entered into a drawing to win 1 of 3 50 gift certificates to walmart daughters whose mothers indicated interest in participation attended an informational meeting at school during this meeting the first author explained the purpose of the study provided a date for data collection and distributed a packet that included consent forms and youth assent form adolescents returned signed consent and assent forms on the day of data collection which was conducted in a group setting only girls who provided signed consent and assent forms completed the selfadministered questionnaire which took approximately one hour to complete research staff was available to answer potential questions from adolescent participants mothers completed a survey over the phone which took approximately 40 minutes to conduct the first author who has several years of experience conducting research with latino families conducted all phone interviews and trained ras scheduled the interviews mothers received a packet that contained the response choice sheet to be used at the time of the phone interview all participants received compensation for their participation in the study measures cultural orientation acculturation and enculturation language fluencythe 24item bidimensional acculturation scale for hispanics was used to assess mothers and daughters languagerelated cultural orientation this scale assessed frequency of participants use of english and spanish when speaking and thinking participants proficiency with regard to reading writing and understanding english and spanish and frequency of participants use of englishspanishelectronic media the scale has shown good reliability scores with adolescents with the current sample alpha coefficients for the 7 th grade sample were 88 and 93 for daughters and 97 and 92 for mothers for english and spanish subscales respectively for the 10 th grade sample alpha coefficients were 96 and 91 for mothers and 94 and 94 for daughters for english and spanish subscales respectively for the english subscale alpha coefficients greater than 80 and 90 were obtained for participants who completed the survey in english and spanish respectively for the spanish subscales alpha coefficients greater than 90 were obtained for participants who completed the survey in english whereas alpha coefficients greater than 66 were obtained for those who completed the survey in spanish cultural orientation familistic valuesthe cultural values scale was used to assess mothers and daughters cultural orientation regarding values this scale measures individuals adherence to traditional familyoriented values participants indicated their agreement to 19 statements concerning its important decisions rated on a 4point likert scale with the current sample alpha coefficients of 85 for daughters and 90 for mothers were obtained in both the 7 th and 10 th grade samples alpha coefficients greater than 83 and 81 were obtained for participants who completed the survey in english and spanish respectively parentadolescent conflictfrequency of conflict was assessed with an adapted version of the parentadolescent conflict scale originally developed by smetana this measure was adapted to include items believed to be specific to mexicanamerican families including issues such as putting family first and talking back to parents adolescents and mothers responded to 15 items on conflicts within the parentadolescent relationship across several domains the scale was rated using a 5point likert scale items were averaged with higher values indicating more frequent conflict in the current sample alpha coefficients for the 7 th grade sample were 87 and 85 for daughters and mothers respectively for the 10 th grade sample alpha coefficients were 85 and 82 for mothers and daughters respectively alpha coefficients greater than 80 were also obtained for participants who completed the survey in english and spanish maternal supportive parentingadolescents completed a 9item version of the inventory of parent and peer attachment to assess daughters perceptions of their mothers supportive parenting items were rated on a 4point likert scale the 9item scale obtained an alpha coefficient of 92 with a mexicanorigin sample of adolescents alpha coefficients of 93 were obtained with the current sample of 7 th and 10 th graders and for participants who completed the survey in english and spanish depressive symptomsadolescents depressive symptoms were assessed with the 20item center for epidemiologic studies depression scale this measure asked adolescents how often in the past week they have felt a certain way items were rated on a 4point likert scale high internal consistency has been demonstrated in studies with latino adolescents with the current sample alpha coefficients of 89 and 91 were obtained for the 7 th and 10 th graders respectively alpha coefficients of 90 were obtained for participants who completed the survey in english and spanish anxietygirls reported on their general frequency of various anxiety states by completing the 20item statetrait anxiety inventory for childrentrait version items were averaged with higher values indicating more frequency of anxiety states with a sample of latino and europeanamerican youth this scale obtained an alpha coefficient of 87 with the current sample alpha coefficients of 87 were obtained for the 7 th and 10 th graders alpha coefficients greater than 84 were obtained for participants who completed the survey in english and spanish results analytical strategy in the current study relations among cultural orientation dissonance family factors and adolescent adjustment were examined via four analytic procedures three procedures have been widely used in the culturalorientation literature the fourth procedure latent profile analysis has only recently been applied to the study of cultural processes analyses for the first three analytic procedures were done using spss and for the fourth procedure we used a combination of mplus version 31 l muthén muthén 1998 muthén 2004 and spss all analyses included cultural orientation family factors and adolescent grade as independent variables cultural orientation variables included both daughters and mothers report of acculturation enculturation and familism family variables included mothers and daughters reports of frequency of conflict and daughters perceptions of maternal supportive parenting adolescent nativity and mothers highest level of education were included as control variables dependent variables included adolescent depressive symptoms and anxiety in the first analytic procedure difference scores were created from three pairs of cultural orientation variables theoretical and empirical work shows that adolescents are usually more acculturated than their parents whereas parents are likely to be more enculturated and retain cultural values from their place of origin more so than adolescents thus we computed acculturation dissonance by subtracting mothers acculturation scores from daughters whereas we computed familism dissonance and enculturation dissonance by subtracting daughters scores from mothers scores this creation ensured that higher positive values on acculturation represented daughters being more acculturated than their mothers whereas higher positive values on enculturation and familism represented mothers being more enculturated than daughters we chose to compute the scores this way to aid in interpretation of the findings and to be consistent with previous literature on cultural orientation additionally we used the raw difference score instead of the absolute difference score because previous literature suggests that consideration of computing raw versus absolute difference scores should depend on whether interest is in the magnitude of the difference or the direction of the difference we used the raw difference score because we wanted to maintain information on the direction of the dissimilarities between mother and daughter cultural orientation the raw value provided information on whether mothers or daughter scored lower or higher than one another on cultural orientation furthermore by using the raw values for the difference score we were able to be consistent with the other analytic procedures which also accounted for the direction of the difference following procedures outlined by aiken west and colleagues for examining interaction terms between continuous variables all variables were centered at the mean prior to creating interaction terms among cultural orientation dissonance family factors and grade hierarchical regression analyses were used to examine the associations among the study variables in the second analytic procedure interactions were created for the three cultural orientation pairs including mother x daughter acculturation mother x daughter enculturation and mother x daughter familism interactions are a plausible procedure for assessing cultural orientation processes between parents and adolescents although this approach does not provide information on the actual mismatch between parents and youth per se as birman notes it does illustrate how cultural orientation for mothers moderates the association between daughters cultural orientation and adjustment birman argues that this information is less explicit in the difference score procedure in order to create the interactions all cultural orientation and family variables were centered at the mean interaction terms were created for mother by daughter cultural orientation mother by daughter orientation by family factor and mother by daughter orientation by grade hierarchical regression analyses were also employed for this approach in the third analytic procedure groups of cultural orientation were created where mothers and daughters were either matched or mismatched on levels of acculturation enculturation and familism we identified whether mothers and daughters were in the bottom 33 or the top 66 of their distribution for acculturation enculturation and familism although researchers have used bivariate grouping procedures such as mean or median split these procedures can be problematic and result in a loss of information when using continuous variables some researchers suggest using percentile cutpoints to dichotomize the sample as a more useful procedure for extricating high and low groups although one approach is to take the top 50 and the bottom 50 and create high and low groups it is also viable to take the top 25 and bottom 75 or the bottom 33 and top 66 to create groups these cutpoints can be used so that individuals in the middle or at the mean are not pushed into one extreme or the other however no standard percentile cutpoint to use has been established thus in this study we used the top 66 and bottom 33 of the sample to make sure that individuals who scored lowest were grouped together and individuals in the middle were grouped with the top next mothers and daughters values were crosstabulated separately for each cultural orientation variable finally three categorical grouping variables were created corresponding to acculturation enculturation and familism each containing three levels low matched mismatched and the high matched univariate analyses of covariances were utilized to examine mean differences in adolescent adjustment across cultural orientation groups grade and family factors in the fourth analytic procedure empirically derived family profiles were estimated using mothers and daughters cultural orientation levels and their responses on family conflict and maternal supportive parenting lpa identifies categorical latent variables among a set of continuous indicator variables it is a personcentered approach that attempts to identify subpopulations containing groups of similar individuals in an unobservable heterogeneous population lpa captures the heterogeneity within a population and classifies individuals into groups in order to provide better parameter estimates standard errors and tests of model fit the categorical latent structure of nine continuous indicators of cultural orientation and family factors were submitted to latent profile analysis all variables were standardized prior to inclusion in lpa starting with a one profile solution a series of models were sequentially tested with each subsequent model estimating one more profile than the previous the optimal number of profiles was determined using three strategies first four indices of fit were examined akaike information criteria bayesian information criteria samplesize adjusted bayesian information criteria and the vuonglomendellrueben value for the h o test of significance lower values for the aic bic and abic indicate a better fitting model and a value less than 05 on the vlmr indicates that the fit of a profile solution is significantly better compared to a solution with one less profile fit indices were compared were compared across each model to establish the best fitting profile solution second solutions were examined for the percentage of individuals assigned to each profile researchers have noted that a solution with at least 5 of the sample in each profile is necessary to have sufficient power to detect differences among profiles confidently finally profile solutions were examined for interpretability in order to examine interpretability of the best fitting solution we observed the class probabilities for all of the indicator variables in each profile after a meaningful profile solution was obtained we exported the class memberships and probabilities to an spss data file class probabilities were observed to determine whether the mixtures solution accurately classified individuals into their appropriate profiles preliminary analyses examined whether profiles differed on demographic characteristics and on the indicator variables mean levels in depressive symptoms and anxiety were examined via a 5 x 2 univariate ancova corresponding with previous analyses mothers level of education and adolescent nativity were entered as control variables variablecentered methodological approach the variablecentered methodological approach included the difference score and the interactive analytic procedures parameter estimates and results from the final models for the difference score and interactive procedures are presented in tables 3 and4 respectively difference score analytic procedurefor depressive symptoms the final model explained 25 of the variance results revealed that higher levels of parentchild conflict were related to higher levels of depressive symptoms in addition higher levels of maternal supportive parenting were related to lower levels of depressive symptoms for anxiety the final model explained 13 of the variance results indicated that higher levels of conflict were related to higher levels of anxiety no other significant effects were found interactive analytic procedurefor depressive symptoms the final model explained 27 of the variance similar to the difference score procedure results revealed that higher levels of conflict were related to higher levels of depressive symptoms higher levels of maternal supportive parenting were related to lower levels of depressive symptoms results also yielded a grade x familism interaction followup tests using tukeys least significant difference showed that motherdaughter familism was related to depression only for 7 th graders further followup tests of the interaction between mother familism and daughter familism for 7 th graders indicated that for individuals with average levels of familism a one unit increase in mothers level of familism was associated with a larger effect of daughter familism on depressive symptoms more specifically when mothers had higher levels of familism the effect of daughter familism on depressive symptoms was greatest no other significant effects were found for depressive symptoms including the cultural dissonance variables for anxiety the final model explained 17 of the variance results indicated that higher levels of conflict and enculturation were related to higher levels of anxiety no other significant effects were found for anxiety personcentered methodological approach the personcentered methodological approach included the arbitrary matchedmismatched grouping and the latent profile analytic procedures group means of depressive symptoms and anxiety for the lpa groups are presented in table 4 matchedmismatched analytic procedureonly the factors with significant fstatistics are reported here for this procedure nine groups were created corresponding to low matched mismatched and high matched for acculturation familism and enculturation respectively for acculturation 179 of the sample was in the low matched group 31 was in the mismatched group and 511 was in the high matched group in the mismatched group for acculturation on average daughters were higher than mothers for enculturation 16 of the sample was in the low matched group 379 were in the mismatched group and 461 was in the high matched group in the mismatched group for enculturation on average daughters were higher than mothers for familism 166 of the sample was in the low matched group 404 was in the mismatched group and 429 was in the high matched group in the mismatched group for familism on average daughters were lower than mothers for depressive symptoms the full model accounted for 34 of the variance similar to the variablecentered procedures results yielded significant effects for maternal supportive parenting f 1094 p 01 and mothers report of conflict f 641 p 05 there was a significant enculturation group by conflict interaction f 353 p 05 a followup test showed that the association between conflict and depressive symptoms was most pronounced for the mismatched enculturated group moderate in the matched high enculturated group and nonevident in the matched low enculturated group no other significant differences were detected for anxiety the full model accounted for 16 of the variance results yielded a significant enculturation group by conflict interaction f 322 p 05 a followup test showed that the association between conflict and anxiety was only evident in the high matched enculturated group no other significant differences were detected latent profile analytic procedure of cultural orientation and family factors results from the lpa showed that a fiveprofile solution provided the best fitting model for these data based on conventional fit indices although the vlmr test indicated no significant difference between the fiveand fourprofile solution the former criteria as well as the interpretation of the class solutions suggested that the fiveprofile solution provided the best fit for these data mean differences were evident across the five profiles on adolescent acculturation f 15239 p 001 adolescent enculturation f 6874 p 001 adolescent familism f 1792 p 001 mother acculturation f 20867 p 001 mother enculturation f 17090 p 001 maternal supportive parenting f 6121 p 001 mothers report of conflict f 720 p 001 and daughters report of conflict f 1031 p 001 but not for mother familism f 104 p 05 to examine the demographic characteristics and composition of the profiles a series of pearsons chisquare tests and oneway anovas were conducted results indicated that profiles differed significantly on language spoken at home χ2 2026 p 001 adolescent nativity χ2 4734 p 001 and maternal level of education f 1503 p 001 but not maternal age f 35 p 05 description of the profile solution the first profile was labeled cultural orientation dissonance dyads this group comprised 129 of the sample this group was characterized by dissonance between mothers and daughters on levels of familism and acculturation although daughters reported average levels on enculturation and mothers reported slightly above average these values were comparable this group was also characterized by below average reports of maternal supportive parenting and above average levels of conflict from both mothers and daughters reports fiftyone percent reported that they spoke spanish and english at home 46 spoke only spanish and less than 1 spoke only english most adolescents were us born and mothers on average had less than a high school diploma at the time of the study the second profile was labeled low acculturated daughters dyads this group comprised 163 of the sample this group was characterized by mothers and daughters having different reports on acculturation and similar on enculturation and familism this group also had average levels of maternal supportive parenting and conflict of this group 824 reported speaking only spanish at home with the remaining speaking spanish and english most adolescents were born in mexico and on average mothers had less than a high school diploma at the time of the study the third profile was labeled familism matched dyads this group comprised 473 of the sample this group was characterized by daughters and mothers reporting similar levels of familism and slight dissonance on acculturation and enculturation this group was also slightly above average on maternal supportive parenting and average on conflict of this group 463 spoke spanish and english at home 523 spoke only spanish and less than 1 spoke only english two participants in this group did not respond to the question what language was spoken at home most adolescents in this group were us born and mothers had on average less than a high school diploma at the time of the study the fourth profile was labeled low enculturated dyads this group comprised 75 of the sample this group was characterized by daughters and mothers having different reports on enculturation acculturation and familism the group was also characterized by above average levels of maternal supportive parenting and mothers report of conflict and average levels of daughters report of conflict additionally 833 of the group spoke only english at home and 167 spoke spanish and english all adolescents in this group were born in the us and on average mothers had attained a high school diploma or equivalent at the time of the study the fifth profile was labeled cultural orientation matched dyads this group comprised 16 of the sample this group was characterized by mothers and daughters having similar reports on acculturation enculturation and slight dissonance on familism this group was also characterized by slightly above average reports on maternal supportive parenting and average levels of conflict from both mothers and daughters reports additionally 667 of this group spoke spanish and english at home 255 spoke only english and less than1 spoke only spanish most adolescents in this group were born in the us and on average mothers had a high school diploma or equivalent at the time of the study means of the nine indicator variables across the five profiles are presented in figure 1 latent profiles and adjustmentfor depressive symptoms the full model accounted for 12 of the variance results yielded a significant effect of cultural orientation f 710 p 01 a followup test indicated that cultural orientation dissonance dyads had a significantly higher mean level of depressive symptoms than did all other groups in addition the low acculturated daughters dyads had a significantly higher mean level of depressive symptoms than did the familism matched dyads there was a significant cultural orientation by grade interaction f 251 p 05 followup tests indicated that for those in 7 th grade cultural orientation dissonance dyads had a higher mean level of depressive symptoms than those in all other groups daughters in the low acculturated daughters dyads also had higher mean depressive symptoms than did those in the familism matched dyads and cultural orientation matched dyads for those in 10 th grade daughters in the cultural orientation dissonance dyads had higher mean depressive symptoms than did those in the familism matched dyads no other differences were detected for anxiety the full model explained 7 of the variance a significant effect was found for cultural orientation f 318 p 05 followup tests showed that cultural orientation dissonance dyads and low acculturated daughters dyads had significantly higher mean levels of anxiety than did familism matched dyads and cultural orientation matched dyads additionally low enculturated dyads had a higher mean level of anxiety than did cultural orientation matched dyads no other significant differences were detected discussion in the current study our overall aim was to identify a methodological approach and corresponding analytic procedure that best elucidated the associations among cultural dissonance between mexicanorigin mothers and daughters family functioning and adolescent adjustment we utilized variableand personcentered approaches via four analytic procedures to examine these associations following our analyses we compared the four analytic procedures based on how meaningful and interpretable the findings were in order to surmise which procedure best captured the interactive process by which motherdaughter cultural orientation and family factors explained variations in girls adjustment to our knowledge this is the first paper that applies both variablecentered and a personcentered approaches using four different analytic procedures to assess culturalorientation dissonance in the same dataset and using the same variables and sample for all analyses notably our results differed depending on whether a variablecentered or personcentered analytic procedure was employed across procedures the latent profile procedure was the most informative regarding how multiple aspects of individuals cultural orientation were associated with adolescent adjustment furthermore family factors were found to be important predictors of adolescent adjustment in all models but to some extent results varied in the models using personcentered analytic procedures additionally the associations were present across early and middle adolescents with a few findings being only present for one group methodological approaches and analytic procedures with respect to the variablecentered approach cultural dissonance was not related to girls depressive symptoms or anxiety when using the difference score analytic procedure this is consistent with previous work by lau et al in which the difference score procedure did not predict conduct problems among mexicanorigin families on the other hand the interactive analytic procedure illustrated that daughters with higher levels of familism were more likely to report less depressive symptoms this association became more evident as mothers familism levels increased and it was only present for early adolescents consistent with birmans postulation the interactive approach provides more detailed information about the underlying processes of cultural orientation associated with family factors and adjustment outcomes when compared to difference scores when using the personcentered approach results showed that these models better captured the interplay among cultural orientation family factors and adolescent adjustment especially in the latent profile procedure results also indicated that family factors were important predictors of adolescent adjustment across both models however the contribution of family factors to adjustment differed as a function of cultural orientation domains for instance the grouping procedure indicated that enculturation moderated the association between motherdaughter conflict and depressive symptoms and motherdaughter conflict and anxiety such that the predictive value of conflict differed as a function of enculturation dissonance the finding that enculturation and not acculturation predicted adjustment is consistent with the work of costigan and dokis who found that chinese dimensions of cultural orientation rather than canadian dimensions showed the most consistent associations with adjustment in their sample of chinese families in canada our findings with lpa indicated that cultural dissonance coupled with high conflict and low maternal supportive parenting appears to be the most detrimental for girls adjustment although the grouping and lpa procedures are both personcentered lpa is statistically more rigorous because it determines profiles based on empiricallyderived classes rather than based on arbitrary cutpoints furthermore the statistical advances in lpa allowed us to combine cultural orientation variables and family process variables to create classes by doing this we were better able to capture the multidimensional nature of family functioning with respect to familyrelational and cultural domains taking this approach provided more insights as to what aspects of cultural orientation and family process variables together predicted higher levels of depressive symptoms and anxiety in girls although the grouping analytic procedure can be used to create a matrix that takes into account both cultural orientation and family process variables to create groups birman argues that constructing a matrix of matched and mismatched possibilities across different variables is overly complex and statistically prohibitive given that some cells would have a very small sample size or none at all finally one of the most notable findings is that lpa identified a group of girls who reported lower levels of acculturation relative to that of their mothers this suggests that parents are not always less acculturated than their children unfortunately the other procedures were limited in allowing us to unveil such patterns although the difference score procedure revealed nonconventional families by assigning negative values we were not able to infer from our results how families with different directional patterns faired in terms of adolescent adjustment furthermore this procedure did not allow us to examine all domains of cultural orientation together the arbitrary grouping procedure portrayed a somewhat different picture than the difference score procedure in the matchedmismatched procedure 5 mismatched acculturation families had mothers with higher acculturation scores than daughters 44 mismatched enculturation families had daughters with higher enculturation scores than mothers and 69 mismatched familism families had daughters with higher scores on familism than mothers as in the difference score procedure the arbitrary grouping procedure did not provide sufficient information about these families and how the counterdirection in cultural dissonance was related to adolescent adjustment discovering this family pattern in lpa and being able to include this group in our final analysis was important because our findings indicated that adolescents in this group reported higher levels of depressive symptoms than those in the familism matched dyads and the cultural orientation matched dyads despite all groups reporting average levels of conflict and maternal supportive parenting this suggests that when mothers are more acculturated than daughters this is more detrimental for girls adjustment interplay among cultural orientation dissonance family functioning and adjustment our findings provided support for the importance of family factors but their contribution differed as a function of the outcome variable under investigation and the analytic procedure utilized specifically parentadolescent conflict predicted depressive symptoms and anxiety whereas maternal supportive parenting only contributed significantly to depressive symptoms by using the arbitrary matchmismatch grouping procedure results indicated that greater frequency of conflict was significantly associated with depressive symptoms for the mismatched enculturation dyads however surprisingly this was also true for the matched high enculturation dyads in addition motherdaughter conflict predicted anxiety but only in the matched high enculturation dyads these findings suggest that both high cultural dissonance and high cultural concordance coupled with high levels of conflict may be risk factors for poor psychological adjustment the personenvironment fit perspective suggests that the closer the match between individuals and their environment the more successful an individuals adaptation however unlike lpa the matchedmismatched procedure did not allow us to infer how individuals in the matched high enculturation group fared with respect to the other domains of cultural orientation assessed in the study thus it is possible that for this group high enculturation is linked to berrys acculturation mode of separation that is adolescents in these dyads may be characterized by low levels of acculturation and feel isolated with respect to the mainstream culture which compounded with parentadolescent conflict contribute to poor psychological adjustment furthermore it is possible that girls in the high enculturated dyads also have high levels of acculturation thus the high level of language enculturation compounded with high levels of acculturation may provide more opportunity for more verbal disagreements between mothers and daughters disagreements in these dyads may be exacerbated by the more traditional views that highlyenculturated parents may have leading to more detrimental implications with respect to girls adjustment early and middle adolescence with respect to grade in school findings varied for the interactive and latent profile analytic procedures but only for depressive symptoms in the interactive procedure early adolescents who reported higher levels of familism also reported less depressive symptoms this association was intensified for families where mothers also had high familistic values suggesting that when both mothers and daughters have high levels of familism this concordance may be protective against depressive symptoms in addition results using the derived profiles indicated that for early adolescents girls in the cultural orientation dissonance dyads reported significantly higher depressive symptoms than did girls in all other groups similarly middle adolescents in the cultural orientation dissonance dyads reported significantly higher levels of depressive symptoms than did those in the familism matched dyads it is important to note that the cultural dissonant group was also characterized by high levels of conflict and low levels of supportive parenting compared to all other groups thus the combination of culturalorientation dissonance high levels of conflict and low maternal supportive parenting appeared to be the most detrimental for girls limitations and future directions few caveats are worth mentioning first findings from the current study may differ when examining positive adjustment or behavioral outcomes we ran preliminary analyses examining the association among family factors cultural orientation and selfesteem and found that these models did not explain much of the variation in selfesteem which is consistent with other studies examining the relation between cultural orientation and selfesteem furthermore it is also possible that for behavioral outcome variables the association among family cultural and adjustment differs for example the association between cultural orientation dissonance and substance use has been shown to be mediated by family factors such that cultural orientation predicts family factors which in turn predicts drug use second across all analytic procedures the models explained more of the variance in depression than did anxiety suggesting that among this sample the conglomeration of family factors and cultural orientation were more salient for depressive symptoms previous work has not examined differences in associations among cultural orientation family factors depressive symptoms and anxiety given the high comorbidity rate between anxiety and depression among children and adolescents it may be important to study these associations taking into consideration the cooccurrence of depressive symptoms and anxiety third we were not able to incorporate all facets of cultural orientation discussed in the literature we did include language acculturation and enculturation but in terms of values we only had data available for enculturation not for acculturation from our findings it is not clear whether values or language have the most important implications given that we did not include values that tapped into acculturation it is possible that different profiles would have emerged if we had information on acculturative values fourth our study examined cultural orientation from mothers and daughters but it excluded other family constellations recent scholarship emphasizes the importance of examining multiple family constellations especially those that move beyond dyadic family relationships although this is a limitation of the current study it is important to note that most studies on latino families rely on adolescents reports for their own views values and behaviors as well as those of their parents furthermore the use of latent profiles to examine the cultural orientation of latino adolescents and their parents is limited fifth caution is warranted given the crosssectional nature of our study it is possible that profiles of parents and adolescents change over time as adolescents may be more likely to embrace the cultural aspects of their parents native culture as they grow older and as a result the cultural dissonance between adolescents and their parents may narrow we were not able to determine the developmental pathways that adolescents and parents experience regarding the process of acculturation and enculturation in their lives and the changes that may occur with respect to cultural dissonance scholars have noted that acculturation and enculturation are processes that unfold over time thus one may argue that the cultural dissonance that exists between parents and adolescents may in part be due to parents and adolescents own developmental pathways integrating aspects of the mainstream and native culture gaps may narrow or widen as a function of the integration process of cultural orientation that adolescents and parents experience across time furthermore it is also possible that the contribution of cultural orientation to adolescent adjustment changes over time for instance adolescents may be affected to a greater extent by the mismatch that exists between themselves and their parents when they are young but as they grow older they may begin to see these mismatches as part of the reality of latino families rather than unique only to their lives that is they may normalize this experience and therefore be less affected by it the crosssectional nature of our study also did not allow us to make inferences regarding the link between parentadolescent conflict and adjustment over time a recent metaanalysis concluded that the rate or frequency of conflict declines through the adolescent years but the affective intensity of conflict increases from early to middle adolescence thus it is possible the strengths of associations examined in this study would decrease over time given our focus on frequency of conflict future work should look at the strength of associations between frequency and intensity of conflict over time finally our findings are only generalizable to latino families of mexican origin not to families from other latino groups the families that participated in this study were embedded in communities where other families shared a similar ethnic background resulting in a unique experience of cultural dissonance that may be different for families who may not have neighbors who share their ethnic background in addition the adolescent participants attended schools where more than half of the student body was latino with most of them being of mexican origin it is possible that the cultural orientation dissonance that exists in families may be more detrimental when these mismatches are not experienced by many in an adolescents immediate peer context future work that examines the contribution of cultural factors in regions of the us that do not have a high latino presence is warranted in spite of these caveats this study has implications for prevention programs targeting mexicanorigin youth and families first previous literature points to the importance of cultural orientation dissonance for latino youths adjustment yet there are several measurement and conceptual issues to assessing cultural orientation dissonance this study helped to identify an approach that best elucidates the dissonance between latino mothers and daughters as well as illustrates how that dissonance is linked to youth adjustment the latent profile approach placed families in groups based on mothers and daughters cultural and family variables being able to improve our assessments of motherdaughter cultural dissonance would help in the design of interventions specifically aiming to alleviate the stress associated with gaps in parentchild cultural processes in addition we examined how cultural orientation dissonance and family functioning were linked to depressive symptoms and anxiety the findings from this study showed that family and cultural variables were differentially associated with anxiety and depressive symptoms for latino adolescent girls this suggests the importance for interventions targeting adolescent psychological adjustment to have multiple mental health components as well as cultural and family processes for mexicanorigin families and youth finally this study has implications for the evaluation of interventions because it offers an approach that can help in classifying individualfamilies into groups in order to detect families for whom the intervention is most beneficial conclusion notwithstanding the aforementioned limitations the current study provides important information about using variableversus personcentered approaches for studying how cultural and family factors contribute to adolescent psychological adjustment whereas the variablecentered analytic procedures provided information that demonstrated links among adjustment and family functioning in unidimensional space the personcentered analytic procedures illustrated how the multidimensional nature of family and culture together contribute to understanding variation in adolescent psychological adjustment the latent profile analysis provided the most information and best clarified how adolescent adjustment varied as a function of motherdaughter cultural orientation dissonance and family functioning from this procedure we were able to obtain information about families where mothers had higher acculturation than daughters the low enculturated dyads as well as how parentadolescent conflict and maternal supportive parenting factored into profiles of cultural orientation dissonance for mothers and daughters moreover drawing from a personcentered approach demonstrated that family may not always mediate the association between cultural orientation and adolescent adjustment but that in some instances it is the combination of these factors together that best explains youths functioning

the overall aim of the current study was to identify the methodological approach and corresponding analytic procedure that best elucidated the associations among mexicanorigin motherdaughter cultural orientation dissonance family functioning and adolescent adjustment to do so we employed and compared two methodological approaches ie variablecentered and personcentered via four analytic procedures ie difference score interactive matched mismatched grouping and latent profiles the sample consisted of 319 girls in the 7 th or 10 th grade and their mother or mother figure from a large southwestern metropolitan area in the us family factors were found to be important predictors of adolescent adjustment in all models although some findings were similar across all models overall findings suggested that the latent profile procedure best elucidated the associations among the variables examined in this study in addition associations were present across early and middle adolescents with a few findings being only present for one group implications for using these analytic procedures in studying cultural and family processes are discussed

d espite increasing gender and sexual minority research relatively little research has been conducted on individuals with intersectional sexual and gender minority identities intersectionality theory deals with understanding people of intersecting marginalized identities and identifying their unique vulnerability to converging systems of domination those who are asexual and transgender and gender nonconforming hold an intersectional identity as a gender minority and a sexual minority asexual people experience divergent amounts of sexual attraction relative to allosexual individuals or have an absence of sexual attraction they often face a negative social context systemic oppression and devaluation similarly transgender gender nonconforming people struggle with a profoundly negative social context through stigma and discrimination connected to their gender identity these experiences are consistent with minority stress frameworks that show higher stigmatizing experiences among sexual and gender minority individuals meyers minority stress theory suggested that added psychological stress could lead to psychological dysfunction minority stress can be distal and can occur through various external events such as societal stigma prejudice and violence minority stress can also be proximal and occur through various internal events such as identity concealment and hypervigilance when external stressors are experienced proximal stress via processes such as internalization via rumination or isolation can lead to mental health issues although empirical findings supporting minority stress were initially derived from studies on gay men the model was expanded to include lesbians and gay men bisexual men and women and lgb people of color hendricks and testa hypothesized that the minority stress model could also be applied to clinical work with tgnc clients testa et al s research expanded meyer s minority stress model to account for gender minority stress and resilience people with intersecting sexual and gender minority identities may have a cumulative and significantly higher rate of minority stress than cisgender sexual minority people minority stress and psychological distress asexual tgnc people may be especially susceptible to stigma compared to the overall lgbtqia com munity in addition to the stigma experienced by the lgbtqia community from people outside of that community stigmatizing experiences within the lgbtqia community are not uncommon often asexual tgnc people feel reticent to disclose their combined gender and sexual minority experience to the broader lgbtqia commu nity because of the discrimination they may experience within that community essentially minority stressors related to tgnc minority stress may be compounded when coupled with asexual minority stressors although minority stress is known to be linked to poor mental health there is a shortage of literature investigating the intersection of asexual tgnc adults relationships between minority stress and mental health only one study could be located which was explicitly focused on young adults and adolescents in that study asexual tgnc participants had higher rates of proximal stressors than their allosexual peers other studies have also shown that internal ized lgbphobia lgbtphobia and lgbtqiaphobia are linked to mental health difficulties the asexual young adult and adolescent participants in the study by mcinroy et al also had poorer mental health than their allosexual peers individuals with multiple stigmatized identities may experience various forms of stigma and discrimination the effects of which cannot be understood by studying each identity in isolation because the only existing quantitative research on asexual tgnc individuals showed that proximal stressors might be higher than distal stressors relative to allosexual individuals and because of the importance of using an intersectional approach it was important to assess proximal and distal stressors in this study that could be especially salient in the asexual tgnc community based on the literature isolation vigilance harassment discrimination gender expression minority stress and violence seem to be the most salient minority stressors based on the literature for asexual tgnc and asexual tgnc individuals the current study informed by the concepts of intersectionality and minority stress theory and based on previous sexual and gender minority research each minority stressor was hypothesized to be positively associated with psychological distress in asexual tgnc individuals methods study design and procedures the michigan school of psychology institutional review board reviewed and approved the study materials and procedures a convenience sample of participants was collected during the height of the omicron surge of the covid19 pandemic due to the sensitive nature of sexual and gender minority research previous research has highlighted the importance of confidentiality associated with recording internetbased survey responses at one point in time therefore online surveys were conducted participants were recruited from email listservs of lgbtqia community centers and online platforms such as facebook reddit and asexual visibility and education network web forums upon accessing the online survey participants were provided with informed consent information and asked if they identified as asexual tgnc lived in the united states were fluent in english and were 18 years of age or older participants who affirmed that they met the study criteria and consented to participate were directed to a survey introduction and were then prompted to respond to the survey items across the entire dataset only 1 had missing data on the psychological distress and minority stress question naires of that 1 the percentage of missing data was 5312 beyond the threshold value of 10 of missing data identified by bennet et al therefore these participants were excluded from the study boothaury psychological distress of asexual tgnc people participants a total of 300 participants met the inclusion criteria and completed the survey between october 3 2021 and october 24 2021 of those who participated 48 were transgender men 51 were transgender women and 198 were gender nonconforming individuals participants ranged from 18 to 70 years old two hundred thirty participants identified as white or european american 15 identified as hispanic latino or spanish origin 14 identified as black or african american 10 identified as asian four identified as american indian or alaska native two identified as middle eastern or north african and 22 identified as another race or ethnicity one hundred fiftythree participants had incomes of less than 25000 40 had incomes of 25000 34999 37 had incomes of 35000 49999 33 had incomes of 50000 74999 11 had incomes of 75000 99999 seven had incomes of 100000 149999 and five had incomes of 150000 or more six participants indicated an education level of some high school 57 indicated an education level of high school 18 indicated an education level of associates degree trade school 103 indicated an education level of some college 74 indicated an education level of bachelors degree 34 indicated an education level of masters degree and four indicated an education level of a doctoral degree fiftythree par ticipants had a feminine gender expression 61 had a masculine gender expression 92 had an androgynous gender expression 36 had a genderqueergender nonconforming gender expres sion 29 had a gender fluid gender expression and 25 reported another gender expression not listed twentyfive participants reported a homoromantic orientation six reported a heteroromantic orientation 121 reported an aromantic orientation 36 reported a biromantic orientation 54 reported a panromantic orienta tion and 50 reported a romantic orientation not listed most participants met yule et al s cutoff score for the asexual identification scale yule et al developed the ais to assess asexual identity the ais consists of 12 items that reflect one dimension an example item is i lack interest in sexual activity each item is rated on a 5point likert scale higher scores suggest experiences more characteristic of people who identify themselves as asexual a total score is used with a cutoff score of 40 with scores above 40 capturing 93 of selfidentified asexual participants and scores below the cutoff captur ing 95 of selfidentified allosexual participants the ais included in the present study had good reliability with the study sample measures asexual identification scale support for the validity of the ais is evidenced by an independentsamples t test showing scores on the ais12 which differed significantly between the groups convergent validity was demonstrated with respective moderate and weak correlations with spector et al s sexual desire inventory which has two subscales dyadic and solitary discriminant validity was evidenced by a nonsignificant correlation with bernstein et als childhood trauma questionnaire which was used because nega tive sexual experiences may be construed as indicative of asexuality the ais was administered as a posthoc validation of asexual identity because heterogeneity within the asexual community exists and competing definitions for asexuality complicate research on this community current researchers recommend against allowing self identification and operationalizing the identity prause and graham similarly cautioned against bogaerts research model that included a single selfidentification question about asexuality which has questionable validity they criticized the lack of measures of desire attraction and arousability and cautioned that the lack of operation alization might hinder the collection of representative samples therefore yule et als asexuality identification scale is recommended for researching this population and has been used in numerous studies a cutoff score greater than or equal to 40 for participants delineates who is considered asexual although this scale operationalizes asexuality and may improve research the lack of allowing participants to selfidentify moves in a direction opposite to that of the american psychological association and the field of psychology therefore this scale was used after the survey to validate selfidentification rather than as a strict inclusion measure each item was rated on a 5point scale ranging from 1 to 5 higher scores indicate experiences of people with more psychological distress and diagnosable mental illnesses cronbachs alpha for the fullscale k10 was excellent and ranged from α 92 to 93 in initial studies researchers assessing psychological distress in american and australian transgender individuals reported values of α 93 and 94 respectively the k10 included in the present study had acceptable reliability with the study sample support for the validity of the k10 has been found with adequate prediction of affective disorders from the fourth edition of the diagnostic and statistical manual using sheehan et al s miniinternational neuropsychiatric interview balsam et al developed the daily heterosexist experiences questionnaire to assess minority stress among lesbian gay bisexual and transgender adults the dheq includes 50 items reflecting nine dimensions vigilance harassment discrimination gender expression parenting victimization family of origin vicarious trauma isolation and hivaids an example item begins with the question how much has this problem distressed or bothered you during the past 12 months and includes difficulty finding lgbt friends each item is rated on a 6point scale ranging from 0 to 5 higher scores indicate higher levels of minority stress the scores on the nine subscales had internal reliabilities of α 86 85 86 83 87 79 82 76 and 79 support for the validity of the dheq is evidenced by moderate correlations with assessments of psycho logical distress these were measured using andresen et al s mohr and fassingers outness inventory one of these items assessed the interference of homophobia in living a rewarding and productive life the other item was related to how different people think their lives would be if they did not have to deal with the challenges associated with lgbt identity daily heterosexist experiences questionnaire results raw survey data was uploaded into ibm spss for mac the primary analyses used in the present study were multiple regression analyses all assump tions for linear regression were met and in addition to planned analyses demographic variables were analyzed as potential covariates summary statistics are presented in tables 1 and2 minority stressors and psychological distress the present study assessed whether proximal distal and gender expression minority stress predict psychological distress multiple regression analysis was conducted to test whether minority stressors predicted psycho logical distress specifically vigilance was a significant positive predictor of psychological distress gender expression minority stress was also a significant positive predictor of psychological distress as illustrated in table 3 none of the other minority stressors significantly predicted psychological distress discussion the author of the present study predicted that all types of minority stressors assessed would positively predict psychological distress this was partially supported the results showed that participants experienced more psychological distress when they faced more vigilance and gender expression minority stress the results of this study support previous research on vigilance and gender expression minority stresss relationship to psychological distress in tgnc and asexual individuals a possible explanation for this is that vigilance and gender expression minority stress could be the most salient minority stressors related to psychological distress in the asexual tgnc community this possibility is congruent with minority stress and gender minority stress theory which suggests that internalized or proximal stressors more directly predict psychological distress than distal stressors because proximal stressors are internalized due to chronic external minority stress the salience of vigilance and gender expression minority stress in the current study could be related to previous research on vicarious discriminationtrauma research has indicated that vicarious trauma in gender and sexual minority communities affects vigilance even when victimization and harassment are not personally experienced because individuals exhibit heightened awareness and a sense of vulnerability associated with having identities aligned with individuals who are victims of hate crimes similarly gonzalez et al found an increase in vigilance among gender and sexual minority people after the 2016 presidential election and subsequent targeting of gender and sexual minority communities particularly among tgnc individuals thus asexual tgnc individuals may face particularly challenging struggles with vigilance in the post2016 sociopolitical climate research has indicated that vigilance may include concerns related to an increase in politicians attempting to restrict healthcare access and public accommodations based on gender identity and eliminate existing civil protections related to sexual and gender identity relatedly the media has become increasingly antago nistic and has propagated transphobic messaging about tgnc individuals as illustrated by research on anxiety related to ballot referenda on genderbased civil rights protections the current sociopolitical climate could have caused significant gender expression minority stress in the present study when experiencing greater antagonism in the sociopolitical sphere tgnc individuals may respond with more vigilance as a protective response to potential discrimination or harm this is consistent with research that has shown that in some individuals vigilance is used as a coping strategy a predictive relationship between isolation and psychological distress was not supported prior research has indicated that isolation is heightened among asexual and tgnc individuals individuals in the current study were recruited from affirming online spaces for asexual or tgncidentified individuals and could have felt a sense of community with other asexual or tgnc individuals which has been shown to alleviate feelings of isolation research has supported the idea that lgbtqia individuals have primarily socialized online during the covid19 pandemic because of physical distancing previous research has indicated that finding community in affirming lgbtqia spaces among gender and sexual minorities contributes to a lack of isolation even if the identified community is solely online predictive relationships between harassment and discrimination victimization and psychological distress were also not supported harassment and discrimination and victimization might not have been significant because the sample was recruited in affirming online social media spaces because the dheq only asks about experiences over the past 12 months participants who have been social distancing during the pandemic might not have had elevated distal or external minority stressors despite not currently experiencing significant distal stressors participants might still have had heightened proximal stress from previous distal stressor experiences from before the pandemic and still struggle with isolation internalized selfstigma and anticipation of future negative distal stressor experiences outside of their affirming environments research has indicated that the covid19 pandemic and social distancing may contribute to increased online socialization and for some lgbtqia individuals safety from harassment and discrimination and victimization this is similar to earlier research indicating that online communication may be a source of resilience because resources information positive space for finding role models navigating identity and selfexpression are more available to tgnc individuals in online communities although general online socialization poses risks for harassment and discrimination and victimization minority stress the benefits of online socialization in affirming spaces offering safety and support might have resulted in comparably fewer opportunities for recent harassment discrimination and victimization the results of the present study suggest that future research may need to assess how much socialization occurs online and what the quality of that socialization is like especially as the covid19 pandemic subsides limitations this study has several limitations that could inform future research on intersectional asexual tgnc com munities first there were unequal groups based on gender identity with gender nonconforming individuals accounting for over half of the sample transgender men and transgender women each accounted for less than 25 of the sample limiting the generalizability of the present study another limitation related to generalizability was the racial and ethnic homogeneity of the sample although efforts were made to recruit diverse participants the sample was overwhelmingly white accounting for approximately 75 of the sample mirroring previous research as indicated by guz et als represent the overall asexual tgnc population another limitation of this study was the lack of measures validated for use with asexual tgnc individuals in addition to the lack of scale validation with members of the asexual community selfreport measures are susceptible to construct validity problems and response bias which could have affected the results of this study also there is the possibility that covid19 could act as a confounding variable affecting the study results because of history effects although collecting data during this unique time could add to the literature base it is a limitation of this study because no questionnaire was used to assess and control the impact of covid19related distress when the data for this study were collected many places were still shut down and people were physically distancing from one another and socializing more online than in person the pandemic and significant social discord affecting lgbtqia individuals could also have impacted recruit ment and affected the characteristics of participants who opted to participate in the study external variables such as covid19 and antagonistic political and media messaging are why researchers like bleckmann et al have called for longitudinal research on sexual and gender minorities to account for potential history effects regardless of the pandemic future research on this intersectional community should assess whether socialization occurs predominantly online or in person and the frequency of each type of socialization directions for future research the present study elucidates more understanding of the effects of minority stress on psychological distress among asexual tgnc individuals however the use of other research methods to study this community may provide a more nuanced understanding the sample for the current study was a crosssectional convenience sample collected online which provides limited informa tion regarding the causality of the observed relationships a repeatedmeasures longitudinal approach could help mitigate limitations associated with crosssectional research such as the history effects associated with the covid19 pandemic future research may also benefit from better measurement of asexuality better measurement of asexuality could include collecting larger sample sizes and breaking down the analysis by subgroups within the asexual spectrum because of differential experiences within the asexual community for instance demisexual individuals may be more likely to be perceived as allosexual in addition for the purpose of this study those who selfidentified as asexual were included regardless of their ais score the ais has historically been used as a measure with a cutoff score to identify those who are asexual however only 68 of the sample in this study met the cutoff score used by yule et al to identify asexual individuals previous research has indicated that more than 90 of selfidentified asexual individuals meet the ais cutoff score this indicates that the scale may not be as useful as a measure of the asexual tgnc population as it is for the general asexual community posthoc kruskalwallis tests indicated that issues with the ais scale might not have affected the results of the present study psychological distress χ 2 040 p 53 η 2 009 harassment discrimination χ 2 211 p 15 η 2 003 victimization χ 2 066 p 42 η 2 008 isolation χ 2 030 p 58 η 2 009 vigilance χ 2 029 p 59 η 2 009 and gender expression minority stress χ 2 056 p 45 η 2 008 did not significantly differ based on whether participants met the ais cutoff score however refine ment of this scale for the asexual tgnc community remains a possible direction for future research additionally future research on asexual tgnc minority stress and psychological distress may benefit from incorporating qualitative data collected through interviews prior qualitative research on the asexual community has yielded information about the com munitys unique experiences which has informed subsequent quantitative research narrative exploration of how an asexual tgnc persons minority stress fluctuates over time and how that influences psychological distress may provide additional information and themes that explain the experiences of psychological distress and how to mitigate that distress this could also reveal other factors that have the potential to moderate the relationship between minority stress and psychological distress despite the limitations of the present study and the factors that future researchers may need to consider the findings of this study suggest that experiences of vigi lance and gender expression minority stress negatively impact the mental health of asexual tgnc individuals the elevated psychological distress consistent with a moderate mental disorder identified among participants in the present study using the k10 cutoff scores by andrews and slade underscores the importance of mitigating minority stress among asexual tgnc individuals conclusion the present study also helps researchers and clinicians better understand how the intersectional asexual tgnc populations selfreport gender expression minority stress earned for conducting research focusing on aspects of diversity open data and open materials badges earned for transparent research practices data and materials are available at

the presence of minority stress has been welldocumented among members of the transgender and gender nonconforming community as has the effect of minority stress on their psychological distress little attention has been given to transgender and gender nonconforming people who identify as asexual this study examined the relationships among minority stressors and psychological distress among individuals holding the intersecting identities of transgender and gender nonconforming and asexual data were collected from 300 adults using various listservs and social media platforms it was hypothesized that all minority stressors assessed would predict psychological distress however multiple regression results revealed that only vigilance β 22 p 001 and gender expression minority stress β 24 p 001 were significant positive predictors of psychological distress f 11 258 1021 p 001 f 2 43 the overall model accounted for approximately 30 r 2 30 of the total variance in psychological distress implications for practice and research are discussed

introduction new zealand is a small geographically isolated country located in the pacific ocean with a population of approximately 5 million people 1 the first covid19 case was reported in nz on 28 february 2020 2 less than four weeks later the country moved into selfisolation entering alert level 3 on 23 march and then level 4 on 25 march in effect both level 3 and level 4 were states of national lockdown with people instructed to stay home in a household bubble and not to integrate with other household bubbles level 3 restrictions allowed businesses to operate but only in a contactless manner with social distancing and hygiene guidelines in level 4 people could only leave home to access essential services or for exercise in the local area maintaining social distancing from others only essential services could operate with all other clientfacing services closed online services could operate under strict social distancing and hygiene rules 3 this state of lockdown continued until 13 may when the alert was reduced to level 2 and services could again be accessed with social distancing then finally a move to level 1 level 1 continued into 2021 the largest region in the country the greater auckland area experienced three more level 3 lockdowns in august 2020 february 2021 and late februaryearly march 2021 2 during these periods the rest of the country was at level 2 the rapidity of the nz initial response to the covid19 pandemic was internationally unprecedented and resulted in the elimination of community level covid19 and few covid19 related deaths 34 the nz gambling environment although highly regulated is relatively liberal allowing many landbased opportunities for gambling such as table games and electronic gaming machines in casinos egms in community pubs and clubs track and sports betting via the totalisator agency board lotterybased products bingo and more informal activities such as charitable raffles 5 provision of online gambling also known as remote interactive gambling is prohibited in nz with the exception of government approved activities provided by the lotteries commission and the tab however the nz public is not prohibited from accessing overseas online gambling sites 6 although this means that a large selection of online gambling activities are accessible by the nz public online gambling by nz adults occurs at relatively low rates in 2015 9 of adults gambled on online activities provided by the lotteries commission and the tab and 07 gambled on overseas sites 7 by 2018 the proportion of adults who gambled on nzbased online activities had increased slightly to 13 with 2 gambling on overseas sites 8 most of the online gambling was additional to gambling on the same activity via landbased means with fewer than 10 gambling exclusively online apart from keno gamblers where 185 solely gambled online 9 this is similar to findings from other countries that have indicated that online gamblers generally also gamble on landbased activities 10 during alert levels 3 and 4 in nz access to landbased gambling was denied with the only available gambling opportunities being online these included nz lotterybased products gambling via the tab and overseas online gambling sites preliminary gambling expenditure data collated by the nz department of internal affairs indicated that during the 201920 financial year all gambling expenditure decreased because of the pandemic apart from lotterybased gambling which increased by 13 due to increased online gambling 11 despite online gambling also being available through the tab because sports and racing events were cancelled the opportunity for this type of betting was much reduced leading to a 10 decrease in expenditure 11 these data however only related to gambling expenditure on nz regulated sites and did not capture overseas online gambling expenditure several research articles investigating gambling behavior changes during covid19 restrictions worldwide have recently been published these have mainly been crosssectional online survey studies a recent review of published studies relating to gambling participation during the covid19 pandemic identified that as was to be expected with restricted landbased gambling opportunities gambling engagement was reduced overall however risk factors for increased online gambling although varying between studies generally included a higher gambling risk categorization related to being a young adult and being male 12 whilst informative there were several methodological shortcomings with the studies discussed in that review with major limitations being that the studies were conducted via online surveys and relied on retrospective reports of gambling behaviors prior to covid19 lockdown restrictions the present study aimed to extend current knowledge of gambling behaviors during covid19 restrictions by examining nz data this was achieved via a new partial wave of data collection in 202021 from an existing population representative cohort for which annual gamblingrelated data had been collected over a fouryear period from 2012 to 2015 the nz national gambling study there were two aims to the present study to describe changes in nz gamblers online gambling participation during a year in which there were covid19 lockdowns and to use existing longitudinal data to identify risk factors associated with increased online gambling because of covid19 lockdowns and the associated unavailability of landbased gambling opportunities materials and methods study design this study utilized data collected from the first and last years of the population representative nz national gambling study in 2012 ngs baseline data were collected from 6251 participants including gamblers and nongamblers the design and methods of the original ngs are published separately 14 the final data collection was in 2015 from 2770 of the original participants an additional data collection was conducted in 202021 with selected ngs gambler participants the 202021 data collection was designed for another study but due to the pandemic the opportunity was taken to include questions relating to gambling behaviors during covid19 lockdown periods procedure the original ngs data were collected via facetoface structured interviews however the 202021 data collection was via telephone structured interviews due to the various social isolation and restriction procedures in place at periods during the year the 202021 questionnaire was modelled on the baseline ngs questionnaire to enable comparison and analyses of changes over time however the questionnaire was updated to take into consideration the changed gambling environment since 2012 including more detailed questions on online gambling and new questions relating to online gambling behavior change during periods of covid19 lockdown the short gambling harm screen was also added interviews were conducted from 2 october 2020 to 9 march 2021 participants received a nz 50 gift voucher after completion of the interview as an appreciation of the time they gave to the interview measures the 202021 questionnaire included the following measures gambling participation participants were asked about their involvement in gambling activities in the past 12 months for each reported activity participants were asked about frequency and if the activity was available online these questions were repeated specifically for the online behavior participants were then asked if their online behavior increased decreased or stayed the same during covid19 lockdown participants were also asked about their involvement in freetoplay online gambling type activities gambling risk level the nineitem problem gambling severity index 15 was used to measure current gambling risk level the pgsi has been assessed for robustness and reliability in the nz population 18 and been found to have high internal reliability participants are categorized as nongambler nonproblem gambler low risk gambler moderate risk gambler or problem gambler gambling harm the 10item short gambling harm screen 19 was used to measure experiences of gambling harm in the prior 12 months the screen adapted from a larger 72item scale 20 measures financial emotionalpsychological and relationship harms each item scores 1 if the harm is present the higher the score the more harm experienced by a participant major life events participants were asked about 15 major life events and whether they had experienced these in the prior five years an other category was also included mental health general psychological distress in the prior four weeks was measured with the 10item scores ranged from 0 to 40 and were categorized as low distress moderate distress high distress or severe distress quality of life the eightitem eurohisqol 8 measured quality of life in the prior two weeks this short form is psychometrically robust and overall performance is strongly correlated with scores from the original whoqol instrument 22 scores are presented as quartiles and categorized as very poor quality of life poor good and very good substance use hazardous alcohol consumption was measured using the threeitem auditc which was developed from the 10item alcohol use disorders identification test 23 the auditc is timeefficient and accurate when compared with the full audit 24 individual questions asked about tobacco and illicit drug use general health individual questions were asked about overall general health and disability in the prior 12 months deprivation to measure current individual level of deprivation the eightitem nz index of socioeconomic deprivation for individuals was used 25 it has good statistical validity the more items that are scored positive the greater the level of deprivation experienced by an individual sociodemographic data sociodemographic data that could vary since the baseline survey were collected in the 202021 questionnaire sociodemographic data collected at baseline and used in the present study included gender age ethnicity and country of birth data analysis descriptive statistics were produced for the variables of interest presenting counts and percentages inferential statistics utilizing pearsons chisquare and fishers exact tests where relevant were undertaken to examine changes over time mixed effects logistic regression was undertaken to investigate associations with increased online gambling during lockdown potential explanatory covariates were considered for possible inclusion in the model for age gender and ethnicity baseline measures were used for other covariates that varied over time both 2015 and 202021 measures were utilized model selection generally proceeded through several steps the first step identified candidate variables in bivariate analyses with the outcome variables that had a pvalue ≤ 02 models were then developed for each of the major data domains using the candidate variables in order to identify the best subset of variables from that data domain all of the results from the separate domains were then considered for an overall model each of the model building procedures followed a stepwise selection method tempered by consideration of the information criteria parsimonious models were favored and competing models with a similar fit but markedly different compositions have all been reported the base odds and odds ratio of potential explanatory covariates are reported as point estimates and 95 confidence intervals accompanied by a pvalue for the covariate results participant demographic characteristics the study sample comprised 301 participants there were slightly more females than males and about twothirds were born in nz half of the sample were of nz europeanother ethnicity onequarter were of māori ethnicity 143 were of pacific ethnicity and 11 were of asian ethnicity at baseline twothirds of participants were aged between 25 years and 54 years table 1 details the participant demographic characteristics at baseline table 2 details sociodemographic participant characteristics by data collection year there were several characteristics that changed over time with most of the differences noted in 202021 compared with 2012 and 2015 overall there was a tendency for higher annual personal income in 202021 probably due to most salaried participants receiving annual pay increases however a majority of participants earned below or about the nz national median income in 202021 and this remained similar to the percentage in 2012 26 there were increases in the percentages of people experiencing five or more major life events in 202021 and disability whilst an increase in hazardous alcohol consumption was also noted in 202021 a lower proportion of participants reported using cannabis although statistical significance was attained for change in the highest educational level visual inspection indicated that the significance was likely due to the increase in participants who gained a university or other qualification there were small statistically nonsignificant changes in employment status deprivation and quality of life with small increases in the percentages of participants who were studentshomemakersretired or unemployed but actively seeking employment there were corresponding decreases in percentages who were employed parttime or were unemployed and on a state benefit additionally there were small decreases in the percentages of participants with a midlevel of deprivation and an increase in the percentage with goodvery good quality of life there were no obvious major changes between 202021 and previous years for household composition mental health or general health gambling risk level over time participants moved between the different risk levels over time at baseline in 2012 more than onethird had gambled in a risky manner this increased to more than twofifths in 2015 however in 202021 there was a decrease in the proportion of risky gamblers with only onequarter remaining classified as such this difference between the years was statistically significant using pearsons chisquared test online gambling behavior during lockdown table 4 details pastyear online gambling participation and gambling behavior during periods of lockdown the most popular activity with 85 of the sample reporting participation was lotto activities that were popular online with half or more of the respondents who participated in the activity reporting online participation were keno lotto and sports betting all provided by nz operators online track betting and scratch card gambling were less popular at 35 and 19 respectively for online lotto and scratch card gambling similar proportions either increased or decreased participation during lockdown with a larger proportion gambling at the same level as prior to lockdown however substantially higher proportions of participants reported decreased nzoperated online sports and track betting during lockdown compared with the percentages who gambled more on these activities similarly a higher proportion of online keno participants decreased their gambling during lockdown compared with those who increased their participation only 5 of participants reported engaging in overseas online gambling of these onethird increased their gambling during lockdown and onefifth reduced their gambling overall for all online gambling activities about onequarter of participants increased or decreased their online gambling during lockdown risk factors for increased online gambling during periods of covid19 lockdown inferential analyses adjusting for confounding factors identified four covariates that were statistically associated with increased online gambling during covid19 lockdown periods in nz table 5 details results of the bivariate and multiple logistic regression analyses there were two sociodemographic factors associated with increased online gambling one was educational level with participants with the highest educational level in 202021 having 807 times odds of increased online gambling compared with participants without any formal qualifications almost onequarter of participants with a university degree or higher increased their online gambling during lockdown the other sociodemographic factor was hazardous alcohol consumption in 2015 but not 202021 participants who drank alcohol in a hazardous manner in 2015 had 280 times odds of increased online gambling in lockdown compared with participants who did not drink alcohol hazardously almost onefifth of participants of participants who drank alcohol in a hazardous manner in 2015 increased their online gambling behavior during lockdown being a risky gambler in 202021 was associated with 409 times odds of increased online gambling compared with nongamblersnonproblem gamblers this association was not found with being a risky gambler in 2015 participants who engaged in freetoplay gamblingtype activities in 2015 had 338 times odds of increased online gambling compared with participants who did not participate in freetoplay gamblingtype activities this association was not found with engaging in freetoplay gamblingtype activities in 202021 almost onequarter of participants of participants who engaged in freetoplay gamblingtype activities in 2015 increased their online gambling behavior during lockdown no other covariates were associated with increased online gambling during lockdown when confounding variables were taken into consideration although some associations were noted in bivariate logistic regression analyses for age employment status cannabis use experiencing two or more indicators of gambling harm and taking up gambling for money from a freetoplay site discussion the nz population was relatively fortunate in that they were able to live much more of 202021 normally compared with people in other countries who experienced longer lockdown restrictions due to covid19 nonetheless nz experienced its fair share of strict lockdown periods during 202021 and this provided an opportunity to study gambling behavior changes during those times a strength of the present study is that data from an existing populationrepresentative gambling study were available and could be used in analyses of covid19 related behavior change with the opportunity taken to collect new data from the cohort in 202021 we were specifically interested in understanding changes in online gambling behavior during lockdown periods as landbased gambling was not possible at those times and to understand current and past risk factors for increased online gambling during lockdown in 202021 online gambling participation was relatively high ranging from 19 of scratch card gamblers to 70 of keno gamblers in general lotto gamblers were the most common with half buying tickets online relatively few participants gambled on overseas online gambling sites with only 5 reporting doing so overall 56 of participants reported gambling online during periods of lockdown twothirds of the online gamblers reported that their online gambling stayed the same and just over onequarter reported a decrease in online gambling this finding was similar to that reported in a scoping review conducted in the first part of 2021 27 whereby it was reported that gambling behavior either stayed the same or decreased for most gamblers during the pandemic the largest proportions of participants who reduced their online gambling during lockdown in the present study were those who gambled on track or sports events this was unsurprising given that most horse and dog race meetings and sports events in nz and worldwide were cancelled during covid19 lockdown restrictions however almost onequarter of online gamblers increased their gambling during lockdown with the largest proportions being for lotto scratch card gambling and overseas online gambling initially this profile appeared to be different from other studies for example in australia and sweden the largest increase in online gambling during lockdown was noted for track betting 2829 and as speculated by the australian authors was likely to be due to this gambling activity being the least affected by lockdown in other words the availability of online gambling drove the behavior thus our results support that finding as in nz lottery products and overseas online gambling sites were the least affected by lockdown whilst nzbased track events did not proceed as keno is also provided by the lotteries commission we expected a similar proportion of online keno gamblers to have increased their gambling activity during lockdown in comparison to those who decreased their online gambling however only 13 of online keno gamblers increased their gambling whilst 29 reduced their gambling this requires further research but one reason could be that keno appears to be substantially less popular in nz as a lottery game compared with lotto and scratch card gambling other studies of online gambling behaviors during covid19 lockdowns have generally found that being male a young adult and having a higher gambling risk level categorization were risk factors 12 our analyses also found that having a current risky gambling categorization was significantly associated with increased online gambling during lockdown although being a risky gambler in the past was not significantly associated this supports prior research that has identified an association between current problem gambling behaviors and online gambling 3031 in our study in bivariate analyses although age was a risk factor for increased online gambling during lockdown male gender was not and the statistical significance for age disappeared when confounding factors were accounted for this finding was contrary to that reported in many other studies the reason for this difference bears further investigation as in nz online gamblers are more likely to be male and aged between 18 and 54 years 8 however gambling on nz lottery products is the most popular online gambling activity 8 nz lottery gambling is an activity participated in by relatively equal proportions of males and females 32 and this could be one explanation for male gender not being a risk factor for increased online gambling during lockdown in nz compared with other countries where online track betting was the most increased during lockdown track betting is traditionally participated in by males more than females however our study found that highly educated participants had greater odds for increased online gambling in lockdown than uneducated participants this could simply be due to financial stability more highly educated people tend to earn higher incomes and to be able to work from home during periods of lockdown compared with less educated people who may be in lower paid manual labor jobs and unable to work during lockdown thus reducing disposable income for activities such as gambling they may also more easily access individual devices making it easier to gambling online however this is speculation and requires further investigation as noted by 27 who reviewed 24 articles on gambling and covid19 knowledge on this subject is limited and unclear as previously mentioned a strength of this study was the ability to draw upon previously collected data for the participants thus reducing the likelihood of recall bias which can occur when participants are asked to retrospectively reflect on behaviors our study found that participants who drank alcohol in a hazardous manner in 2015 or who engaged in freetoplay gambling type games in 2015 had higher odds for increasing their online gambling during lockdown in 202021 that current hazardous alcohol consumption was not associated with increased online gambling during lockdown is a similar finding to that noted by 33 this is despite that fact that there was an increase in hazardous alcohol consumption amongst participants in the current study in 202021 compared with 2015 nonetheless it is interesting that in our study prior hazardous alcohol consumption was associated with increased online gambling there are several potential explanations including that during lockdown alcohol was less easily available in nz with only beer and wine available for purchase from supermarkets although stronger liquor could be bought online and delivered furthermore people were not able to socialize in alcoholserving institutions such as pubs overall a majority of the nz population either reduced their alcohol consumption during lockdown or consumed alcohol as usual with about onefifth increasing alcohol consumption 34 whilst little studied there is preliminary evidence that about onequarter of freetoplay online gamers migrate to online gambling six months later with microtransactions being the only unique predictor of the migration 35 in our study such a migration could explain the risk factor of past participation in freetoplay gamblingtype games being associated with increased online gambling in periods of lockdown particularly if disposable income increased because of an inability to spend money on other activities bivariate analyses found that such a migration was associated with increased online gambling during lockdown however the statistical significance disappeared when confounding factors were accounted for indicating that the association is complicated this phenomenon requires further investigation particularly since other researchers have not identified such a migration 36 a limitation of our study is that due to budget and time constraints it was not possible to collect data from the full ngs cohort in 202021 with only participants who had previously scored as a risky gambler recruited this means that our study is not population representative however collecting data only from people who had at some point previously been gambling in a risky manner is justifiable as this study aimed to investigate online gambling behaviors prior research has indicated that online gambling is associated with problem gambling 3031 and earlier covid19 research indicated that higher gambling risk categorization was a risk factor for increased online gambling 12 thus the present study enabled a detailed study of the behaviors of this atrisk population which comprise a low percentage of a general population furthermore only about onequarter of participants were classified as a current risky gambler in 202021 which was a statistically significant reduction from earlier data collection years when there had been no disruptions to gambling accessibility and availability a strength of the present study is that participants were not recruited via an online sample as is the case with the majority of previous studies investigating lockdown effects on online gambling online samples have their own limitations including careless responses and identity misrepresentation 37 and they are likely to underrepresent people who do not regularly use online technology even though such people may partake in online gambling however online samples have benefits such as the ability to obtain large samples of specific subgroups and the possibility of reduced bias for highly stigmatized topics 38 conclusions to date most studies of online gambling behaviors during periods of covid19 lockdown have been crosssectional in nature whilst these have identified risk factors for increased gambling behaviors during periods of restriction and social isolation colloquially known as lockdown potential past behavior risk factors remained unknown yet knowing what such factors are could help in public health efforts to encourage safer online gambling behaviors during future periods of lockdown or other similarly stressful situations especially as online gambling is known to be highly associated with risky and problematic gambling this study identified that past hazardous alcohol consumption and past participation in freetoplay gamblingtype games were both significantly associated with increased online gambling during lockdown being past behaviors they are likely to be known to others and are potential trigger points for health providers and family or friends to check on a persons gambling behaviors during lockdown and support safer gambling the gambling activities in which the highest proportions of participants increased their gambling during lockdown were overseas online gambling and online scratch card gambling both types of activity are continuous in nature and more likely to lead to harm than noncontinuous activities such as lotto gambling encouraging a person to stick to the recently released lower risk gambling guidelines 39 could help reduce potential harms from gambling during lockdowns or other extended periods when usual behaviors are not possible data availability statement microdata from the four years of the ngs are available on request at informed consent statement informed consent was obtained from all subjects involved in the study

recent research investigating changes in gambling behaviors during periods of covid19 social restrictions such as enforced lockdowns are somewhat limited by methodology being generally crosssectional in nature and with participant samples recruited via online panels the present study overcame these limitations via a secondary analysis of data collected in 2012 and 2015 from a new zealand nz longitudinal gambling study with questions related to gambling behaviors due to covid19 lockdown periods included in an additional data collection of participants who had previously scored as a risky gambler during 202021 almost onequarter of online gamblers increased their gambling during lockdown with this most likely to be on overseas gambling sites instant scratch card gambling and lotto the only sociodemographic risk factor for increased online gambling was higher education behavioral risk factors included being a current low riskmoderate riskproblem gambler a previously hazardous alcohol drinker or past participation in freetoplay gamblingtype games these past behaviors could act as trigger points for health services or family and friends to monitor a persons gambling behaviors during lockdown or future stressful periods when usual terrestrial gambling opportunities are curtailed or unavailable and to support safer gambling practices

physical activity promotion is widely used to promote healthy aging and wellbeing among older adults physical activity has positive effects on physical and mental health including improvements in life satisfaction selfefficacy and control over ones health selfesteem and sense of purpose equitable and efficacious physical activity promotion requires a deep understanding of physical activity behavior as well as tailored efforts targeting subgroups of the population that universal interventions tend to leave behind such as older and less fortunate people older public housing tenants present both these characteristics yet there is a dearth of information on their physical activity older public housing tenants are at greater risk of being inactive than older adults living on the private market because they present many characteristics associated with inactivity lower income lower education levels older age and higher likelihood of living alone prevalence studies consistently show a social gradient of physical activity by which participation levels are proportionately associated with socioeconomic disadvantage including older age as well as lower education and income moreover compared with similarly socioeconomically disadvantaged older adults living on the private market and especially to older adults in general older public housing tenants have higher risk of chronic disease and therefore have much to gain from greater physical activity levels yet older public housing tenants are scarcely represented in the scientific literature potentially limiting the benefits they receive from physical activity practice and promotion there is a pressing need to better understand older public housing tenants physical activity and to learn about the different needs of different segments of the population available data suggest that public housing residents of all ages physical activity levels are low in comparison with public health recommendations in seattle the proportion of inactive older adults was significantly higher in older subsidized housing tenants compared with a control group of older adults among canadian ruraldwelling older public housing tenants 56 reported participating in physical activity every day socioecological models of physical activity postulate that factors ranging from societal norms laws and regulations to personal beliefs influence actual physical activity as well as perceptions of it research suggests that personal attitude toward physical activity may have a greater influence on participation than social norms results of a crosssectional quantitative study conducted in canada among 170 older adults with low socioeconomic statuses show that more positive aging attitudes related to greater selfreported physical activity levels together these data suggest the importance of focusing on individual perceptions to better understand older public housing tenants physical activity qualitative data could provide a deeper and more nuanced understanding three qualitative studies among older public housing tenants show ambivalent perceptions of physical activity in the first study using focus groups among public housing residents of all ages in boston united states participants described physical activity as an obligation a necessity rather than a choice study participants also noted many financial barriers to physical activity participation similarly another study using semidirected interviews showed that public housing tenants in houston united states acknowledged its benefits for health yet perceived having little access to physical activity they felt it is reserved to people of young age and in great physical condition participants also described physical activity as more of an indirect effect of a busy lifestyle rather than a goal in itself inversely a third study examining the life goals of 161 older public housing tenants in boston united states found that the two most common goals were improving health and physical activity the discrepancy in perceptions of physical activity among older public housing tenants may be attributable to differences in how researchers defined physical activity this remains unknown because physical activity was not conceptually defined in these publications more research is needed to elucidate these divergences not only are studies concerning older public housing tenants physical activity rare but existing studies are also mostly quantitative and fail to document their perceptions of physical activity in contrast qualitative research allows to gather rich detailed and contextualized descriptions of phenomena from the viewpoint of those who experience it however existing qualitative knowledge includes few perspectives from socioeconomically disadvantaged older adults the few studies reporting on the physical activity of older public housing tenants were conducted in the united states in specific contexts not representative of those in montreal canada finally researchers categorized physical activity into four domains active travel leisure everyday tasks and volunteerwork yet studies on older adults physical activity focus on active travel and leisure and tend to dismiss everyday tasks and volunteerwork which may be more relevant and meaningful to older public housing tenants although their low income may constrain older public housing tenants to resort to active travel it limits their access to active leisure activities thus more research is needed to understand what type of physical activity older public housing tenants conceive of and engage in as well as for what purposes if physical activity promotion is to be tailored to their reality study objectives as argued above older public housing tenants could greatly benefit from physical activity promotion that is tailored to their perceptions needs and everyday realities indeed tailored promotion efforts can contribute to reduce social inequalities in physical activity and health this is especially important to older public housing tenants in the current context of a rapid demographic aging process in the province of quebec canada where the older adult population is expected to triple by the year 2061 consequently older adults represent an increasingly large proportion of public housing tenants rising from 15 in 1981 to 21 in 2006 and predicted to represent 37 of public housing tenants in quebec by 2061 thus in the greater aim to improve health promotion for older public housing tenants this study explored their perceptions of physical activity using walkalong interviews in their residential environment materials and methods design we conducted semistructured individual walkalong interviews with older public housing tenants from three neighborhoods in montreal canada one pilot interview was conducted at each site these were informative and were thus included in the study without any major changes to the interview guideline the main author was the sole interviewer and had previous training and experience conducting sitdown interviews with older adults material and procedures partners at the public housing authority in montreal facilitated access to the study sites also lending researchers trust and legitimacy by proxy in quebec canada public housing developments are dispersed among the spectrum of neighborhood socioeconomic status and landmix type partners helped to select three diverse study sites in terms of landuse mix neighborhood socioeconomic status and racialethnic makeup within the building and neighborhood the sites include commercial residential and mixed areas because inclusion of public housing tenants is a methodological challenge we combined traditional strategies with recommended recruitment strategies including onsite facetoface recruitment and word of mouth ethical considerations participants psychological safety and physical safety were primary concerns we addressed the former by explicitly and repetitively stating that they could skip any questions or topics they did not wish to expand on moreover the questions were openly worded giving participants the agency to direct their answers to topics they found relevant and appropriate we also prepared a list of free and accessible psychosocial support services for each study site in case participants showed signs of unwellness two participants were offered and accepted this resource list concerning physical safety issues prior to data collection the interviewer updated her cardiopulmonary resuscitation training and canvassed the study sites to identify areas where participants could take breaks from walking as well as any potential hazards the interviewer was a certified physical conditioning instructor with experience leading older adults in aerobic exercise during data collection she carried a mobile phone in case of a medical emergency and consciously walked slower than the participants to reduce any pressure to walk at a fast pace finally sociodemographic data were purposively left for last so that the interviewer could observe the participants cooldown period in their own homes for at least 20 min before leaving no further intervention was necessary the committee of ethics and research including human subjects at the université du québec à montréal reviewed and approved this study the interviewer verified selection criteria during brief telephone screenings before starting each interview the interviewer explained the study scope and procedures to potential participants and then sought verbal and written consent to participate in the study participants received 20 at the end of the interview as compensation for their time walkalong interviews following a constructivist approach to highlight older public housing tenants perceptions of physical activity within their residential environment we chose to conduct walkalong interviews within a constructivist approach in this approach the researcher and participants coconstruct reality and knowledge through communication interaction and practice in a walkalong interview the researcher accompanies the participants on foot through their reallife context collecting information about the study subject and especially probing for the participants experience of the space or activity of study in the format of an informal conversation the walk builds familiarity between interviewer and interviewees and exposes both to the reallife context this allows the interviewer to gain a deeper understanding of how interviewees experience a space by watching how they interact with it combining observation methods that are both direct and indirect walkalong interviews promote coconstruction of knowledge interviews were audiorecorded and transcribed verbatim the interviewer took field notes during and after each interview to summarize key elements of the interview general impressions challenges successes questionings and preliminary interpretations field notes stimulate critical awareness and reflection providing analytic distance through a systematic and yet creatively conscious narrating and analyzing of ones observations actions and budding interpretations these were periodically shared with the research team and included in the data analysis process linking interview excerpts to field notes and coding the entire corpus as a whole the interview guide focused on physical activity within the residential environment which includes the apartment building and close neighborhood because older public housing tenants are typically financially and functionally restrained to this area figure 1 illustrates the data collection protocol table 1 presents the main questions that constituted the semidirected interview guide for this study sociodemographic and health characteristics to allow us to describe our sample participants orally completed three scales including a homemade sociodemographic and health questionnaire asking for information such as age sex country of birth education level and yearly household income as well as perceived social support physical and mental health they also reported presence or absence of the 18 health conditions composing the functional comorbidity index finally to evaluate participants physical activity levels we used a fouritem questionnaire validated among an older adult sample the questionnaire dactivite physique pour les personnes agees participants reported all the physical activities lasting at least 10 min that they performed over the last 7 days starting with vigorousintensity activities and ending with moderateintensity activities data analysis coders used a mixed approach combining deductive and inductive thematic analysis using nvivo software we used deductive content analysis to categorize examples of physical activity according to four domains of physical activity an inductive analysis strategy allows meaningful dimensions to emerge from patterns found in the cases under study without presupposing in advance what those important dimensions will be which was key to obtain the participants own perceptions of physical activity thus coders performed inductive analysis inspired by braun and clarkes description of thematic analysis coders cocoded six interviews and compared their coding strategies twice before coding independently and then met regularly to discus discrepancies until consensus was reached three mechanisms recommended by smith and mcgannon supported this studys qualitative analysis rigor member reflections critical friends and a tailored and flexible set of quality criteria member checking occurred during data collection as the interviewer shared interpretations or questionings emerging from previous interviews with new participants to gain their insight iteratively testing impressions the interviewercoder met with the research team regularly during data collection and analysis to challenge confirm or infirm codes and themes throughout the data analysis process the panel of critical friends was composed mostly of graduate students from various fields of expertise allowing to challenge interpretations from various perspectives the quality criterion chosen for this study were as follows to seek consistency between the scientific literature the research objectives and the data and interpretations to honor the participants words using an inductive approach and authentic quotes to illustrate themes to protect participants anonymity to offer a meaningful contribution to the scientific literature and especially to local practitioners and to produce a nuanced and general representation of perceptions by backchecking data searching for counterexamples of themes and perceptions within it results study sample this paper presents data from 26 participants aged between 60 and 93 years interviews were conducted in french english and spanish between september 11 2017 and october 25 2017 one participant could not walk four 10min bouts as per selection criteria thus we excluded this data from analysis because they did not meet the housing programs traditional eligibility criteria and had accessed the housing program because of an exceptional situation this person did not represent the majority of older public housing tenants thus we deemed that their exclusion from the study would not impact data interpretation a slightly larger proportion of participants are female and born in canada which is representative of the older public housing population in montreal canada table 2 further describes the samples characteristics interviews lasted between 1 and 25 hr definitions of physical activity participants shared wideranging examples of physical activity varying not only by domain but also in intensity duration and intention the same physical activities could be categorized in different domains for example walking related to all four domains active travel leisure everyday tasks or volunteerwork participants most frequently reported partaking in active travel and everyday tasks to describe their own physical activity participants general examples of physical activity on the other hand frequently pertained to leisure sports and activities inductive thematic analysis of older public housing tenants perceptions produced six themes describing physical activity physiological emotional interpersonal occupational intellectual and existential each themes relative importance depended on participants personal beliefs values and preferences thus they should be interpreted as interconnected parts of the same whole theme 1 physiological movingor just usingthe body most participants described physical activity in relation to the human body it was said to be a natural human endeavor allowing to give their body what it needs and to respect ones body including its limits this included either moving or solely soliciting the muscles of their body with physiotherapy exercises in mind one participant defined physical activity saying i guess using the muscles of your body a040 participants presented differing perceptions of how much energy expenditure constituted physical activity for some the required intensity was as low as breaking up periods of sedentariness by getting up periodically well it means not sitting around all day b010 for others the effortbe it housework or a leisure walkhad to be intense enough to cause sweating feeling hot and needing to shower or to rest for others still it required much greater physical effort you have to struggle you have to challenge yourself a060 the latter view was especially true for younger participants those who were active in their younger years and those with higher levels of functional capacity supplementary illustrative quotes for this theme are presented in table 4 theme 11 maintaining and treating the body most participants stated that general physical activity served to maintain bodily health and strength as well as hunger sleep mobility and independence physical activity was commonly said to have important outcomes for health a lot it brings us youth and health i have my sister she is 70 years old yes 70 years old she moves a lot shes sick breast cancer but thanks to god she is cured and thats good but she moves moves moves moves c010 theme 12 wearing the body out despite being aware of physical activitys benefits some participants feared wearing their body out as well as the pain it may cause for some working through the pain was worthwhile because it would lead to more pleasant sensations for others pain and wear was revolting and frustrating ive been exercising all my life and ended up getting both my knees operated on because ive been exercising all my life a70 theme 2 emotional doing what makes you feel good some participants described physical activity in terms of pleasure and fun this theme mostly encapsulates but is not limited to leisure activities such as walking biking and going on outdoor organized group excursions exercise and other active hobbies these things were said to constitute physical activities because they are enjoyable for example a few participants felt that housework or household tasks do not constitute physical activity because these things are obligations while physical activity is supposed to be a fun break from routine for me that housework thats a job and working outlike when i used to go work out on saturday mornings with my niecefor me thats a pleasure b020 supplementary illustrative quotes for this theme are presented in table 5 theme 21 enjoying oneself participants spoke of the joy they experienced walking for leisure dancing playing bocce or basketcornhole and so on they also mentioned feeling pride and contentment from accomplishing everyday tasks through active travel doing housework and performing physiotherapy exercises as well as volunteerwork many participants stated that physical activity helps to feel good c080 they mentioned emotional effects such as helping to reduce anxious and depressive symptoms placing ones thoughts during leisurely walks as well as preventing depressive symptoms by being active and getting out of the house and its very good i liked dancing i used to dance i was crazy about it first of all it allows you to get dressed and take your mind off things lets say a person is depressed do you know how to get depression its easy its when you do nothing and you juggle all your issues in your head b060 theme 22 feeling badly about inactivity the subject of physical inactivity can also provoke negative emotional experiences we observed fear of injury or harm as well as the shame of not being able to be as active as ones peers and i feel kind of like embarrassed in some ways cause i have a friend my age shes still riding her bicycle and shes driving her car you know shes doing everything i used to do a040 we also observed evidence of resentment and envy especially from participants who physically could not be as active as they once were one participant with a serious health condition explained that not being able to be as active as they wanted makes me angry many participants stated that physical activity it is a form of being social c070 including social activities the active travel of walking to meet with friends or standing while speaking to them thus physical activities of the interpersonal nature also include walking standing chatting sitting singing laughing and simply having a good time 12 wearing the body out like i dont wanna over do it because i was going for a class they had a class at place and i joined it and then my knee started bother me when i was riding the what do they call it the bike thing i was doing it and my knee started and it continues to hurt c070 because even here in the evening in the summer they go dancing in the park there well yes it costs nothing but dancing on the asphalt forget it i cant you have to be in shape now b060 well sometimes its hard because you see all the others doing it and you want to try to do it because not long ago i had capsulitis that called so there are times that ahhhhh it it hurt b070 a few participants attributed their perceptions of physical activity to cultural heritage as well as the family and socioeconomic conditions growing up this could be from family traditions growing up in a busy household in quebec or growing up abroad with activityminded habits and customs explaining that doing benevolent acts for the communityespecially cookingis being physically active one participant explained it through their growing up in the bush providing food required hunting as a family from a young age they would run to catch wild boar run to a neighbors hut to borrow a cooking utensil or run to exchange food with neighbors for them preparing food was then and still is a physical activity supplementary illustrative quotes for this theme are presented in table 6 theme 31 belonging to the neighborhood and the community describing the relation between moving about and feelings about the neighborhood a few participants mentioned that physical activity allows them to feel a sense of belonging to the neighborhood some participants stated that being active in the building or neighborhood favored feeling like a family b060 and being in the community a020 activities said to favor sense of community included socializing with neighbors in the building active travel in the neighborhood and everyday tasks completed in the neighborhood we have such an example from the participant who denounced how vigorous physical activity caused double knee replacements yet they felt satisfied through everyday tasks that make them feel normal lots of activities not mandatory normal everyday life so i feel like my neighborhood i move like my neighborhood a070 physical activity was said to allow to observe and adapt to incoming culture one participant shared that walking his friends dog provided exposure to the recently culturally and ethnically diverse individuals moving to the neighborhood walking for leisure or for active travel in the neighborhood also allows to observe its specific local culture and thus to better integrate the community for example one participant who had moved from a more disadvantaged neighborhood to the current one stated that walks are opportune times to learn how to blend in the culture you look around how theyre dressed how its different were immigrants here in this neighborhood in this building among the rich and its a push to be like the others c060 theme 32 conforming to social pressure some participants described physical activity in opposition to those around them including their friends and family who would get on their case to be more or even less active one participant mentioned they felt pressure from their children to maintain the same physical condition they have always had and to leave their walker aside when their adult children visit another participant stated a common view that older adults should have the right to their choices their limitations as well as to not feel badly about not meeting public health recommendations people should not be made to feel uncomfortable with the way they are if theyre happy the way they are then people go up and say well youre not doing enough well if i was sitting on my couch and not doing anything then i got something to worry about but i dont sit on my couch youve seen i can walk i dont like the way walking makes me feel a030 others physical activity requires having something to do like visiting the health care clinic occupational perceptions encompassed leisure activities such as walking physical conditioning classes or group excursions as well as everyday tasks such as ones physiotherapy supplementary illustrative quotes for this theme are presented in table 7 theme 41 accomplishing something many participants spoke of the sense of accomplishment they get from physical activity for a few participants engaging in ones community through acts of formal or informal service constitutes physical activity this included the active travel to formal volunteering in community organizations or as a part of their involvement in the tenants committee as well as informal volunteering like baking and cooking goods for their neighbors it also included walking about to gather firstor secondhand goods to donate thats right thats an activity i call that yes you do you move along you go around you help people and things like that at least youre busy youre not sitting one place all the time c080 theme 42 fulfilling an obligation some participants expressed displeasure of any activity resembling an obligation be it active leisure rehabilitative walks physiotherapy exercises or housework for example in response to the question if we think about your general views of physical activity what comes to mind one participant remarked obligations i dont like being obligated b050 for others physical activity is neither enjoyable nor unenjoyable it is simply a necessary means to a necessary end i cant say well i dont hate it and i dont love it i do it out of need to maintain my joints im going to do it to heal something but its not a hobby b070 theme 5 intellectual moving the brains participants also described physical activity as using the brains or moving intellectually this theme describes physical activity as soliciting intellectual effort including playing board games preparing food social dancing and even chatting with people it encompasses mostly leisure activities involving other people at the community center they move a little bit well not physically but they move intellectually if you will they play a board game and talk about it and play games and meet people and all that c010 participants also spoke of getting the brains going during solitary activities in which cognitive processes are involved such as preparing a recipe supplementary illustrative quotes for this theme are presented in table 8 theme 51 broadening the mind concerning the benefits of various forms of physical activity a few participants noted positive impacts on intellectual ability or broadening the mind the cognitive effect that was most frequently mentioned was that it is stimulating for the mind which was especially linked to walking in the neighborhood you see a lot of architecture a lot of houses some beautiful some not so beautiful but you look and you enrich your brain because the brain has to work has to collect informa tion c060 participants rarely mentioned physical activitys benefits to cognitive function spontaneously when asked directly about the relation between the two some participants said they were confident physical activity could benefit cognitive function well for sure its good it makes our brain work because our brain it makes our feet work our hands our head our body it works everything b090 well yes selfrealization yes yes because we are in good health we feel in good health so we feel available we feel we are listening to others we want to listen to others because we are in good health we are available and we have more we have endurance if someone is in pain for example if we are sick we cant we dont have the strength but if we are not we do sports generally we are healthy we can listen to others despite that perception few participants mentioned engaging in physical activities specifically to benefit their cognition yet losing cognitive ability was a frequently cited and seemingly deeprooted fear physical activity gives me hope thats the fear that we dont lose our memory that we dont lose our feet because if we lose our heads and feet were screwed the mind it can go what is what life is that without thinking without being able to express without being able to just stay looking at others you dont recognize them i dont want that i said god give me feet and head until i die c060 theme 52 needing discipline participants mentioned the challenge of needing cognitive selfregulatory abilities to be physically active this was true of many participants who mentioned needing to force themselves to be more active but also those who needed to learn to pace themselves to see how my body will react because maybe i burn myself out i like to go to the max of everything but its exhausting you know i would have to talk to myself and say wow take it easy b060 theme 6 existential feeling alive for some participants more specific activities such as walking to accomplish everyday tasks and observing others doing the same testify to their active existence in the world being physically active implies being autonomous and thus alive all domains of physical activity could lend to this description depending on the meaning or purpose each participant attributed to the given activity examples include dancing walking talking with others and engaging in sexual intercourse one participant noted that leisure activities such as physical conditioning classes like yoga and playing adapted sports constitute play they remarked that physical activity is capital in helping adults to stay young at heart supplementary illustrative quotes for this theme are presented in table 9 theme 61 cultivating gratitude and hope in the previous theme a quote illustrated how physical activity cultivates hope of maintaining cognitive and physical abilities in the future participants also stated that accomplishing everyday tasks through active travel constitutes an opportunity to acknowledge and appreciate mobility leisure walks seeing others be active and noticing improvements in ones health through physical activity were a source of hope that autonomy and life meaning can be developed and maintained in older age it shows me how i see sometimes i can meet people who have difficulties to walk who are handicapped who cant carry things i meet many people today thank you lord you have given me strength a020 theme 62 anticipating death a male participant from each site mentioned they gave up on physical activity saying they are ready to die these men varied in age physical activity level and physical capacity but were all caucasian they stated that in their remaining years they would rather do things they enjoy as opposed to physical activity one of these participants preferred not to draw out life with healthful habits but rather wanted to live to the fullest for a shorter time avoiding incapacity and dependence it wont change anything in my life to do that physical activity as they say you have to die of something and if they could make me a cocktail of pills so that i wouldnt wake up that i would fall asleep and take my cocktail of pills and end it i would be the first buyer not because im not in good spirits because i dont want to get to that phase to get to the diaper phase to get to the walker phase to get to the phase of justifying myself for this justifying myself for that because im in good spirits and i live well and i dont deprive myself of anything a070 discussion this studys objective was to describe older public housing tenants perceptions of physical activity namely their own descriptions and examples of it their appreciation for it and its perceived effects using thematic analysis of 26 walkalong interviews gathered perceptions cover the range of physical activity domains and intensities however participants reported that their actual physical activities were mostly active travel and everyday tasks physical activity was described not only as a catalyst to wellbeing but also to illbeing depending on preference access and functional capacity or in other words according to life course these results are in line with previous work showing an important relation between perceptions of physical activity and aging attitudes our results signal that it could be counterproductive as well as insensitive to promote physical activity to a population who has already accumulated socially determined ill health without also providing the necessary support and assurance using their experiential knowledge to develop recommendations and promotion materials in partnership with older public housing tenants could foster greater informational relevance and lesser emotional distress despite using an inductive approach our themes resemble an eightdimensional model describing the wellbeing of older adults developed using a review of 273 scientific studies this model not only describes older adults wellbeing as physical emotional relational vocational cognitive and spiritual but also contextual and developmental the two latter dimensions could make interesting additions to the study of older public housing tenants physical activity the contextual dimension encompasses the availability of resources in the environment and its influence on wellbeing similarly the financial cost of physical activity was a common thread throughout our study future research should further investigate the influence of such contextual factors on older public housing tenants perceptions of physical activity the developmental dimension encompasses individual perspectives of aging and their influence on wellbeing in later life this is in line with our results showing that physical activity relates to individual life course and functional capacity however our study highlights that aging attitudes and life course can lead to perceiving physical activity as a threat to wellbeing similar to eugeni et als findings among public housing tenants faith or interest in physical activitys health benefits varied in our sample in fact in line with scammell et als study among public housing tenants traditionally defined physical activity could be seen as an obligation though some participants conceptualized their own physical activity in accordance with the traditional definition of physical activity many did not instead our results support a more recent and broader definition proposed by piggin physical activity involves people moving acting and performing within culturally specific spaces and contexts and influenced by a unique array of interests emotions ideas instructions and relationships indeed our results were described in terms of different people doing different actions that relate to various spaces and contexts and intersect with numerous individual characteristics for example participants defined physical activity in relation to their age gender capacity cultureethnicity financial means and community these aspects are important to consider given that older public housing tenants are most often women living with incapacities from diverse cultural and ethnic backgrounds having experienced a life trajectory of adversity thus the lifecourse perspective on physical activity promotion appears particularly relevant among older public housing tenants understanding physical activity as contextually anchored informed by all the life transitions one has and is living while also considering personenvironment fit or human agency it recognizes the individuals ability to make their own choices in relation to the resources and the demands they have experienced over time and place furthermore our results support a broader approach to populationlevel physical activity promotion emphasizing the need for a multidimensional holistic understanding of physical activity and its promotion in line with previous research among older adults living on the private market our existential theme echoes other findings showing that older adults perceive physical activity as the product of a full life and a means to achieve meaningful life goals this supports recent research suggesting adopting an approach that is also holistic in focusing on everyday physical activity and using a wider set of goals to physical activity promotion that goes beyond its health benefits indeed some but not all of our participants were uninterested by physical activitys potential to better their health our results are in line with research showing some older public housing tenants being very interested in improving their health through physical activity and others not an allencompassing or holistic approach to physical activity promotion is warranted to cover such variance in personal goal preference for example researchers summarized european older adults hopes for healthy aging as activeness which refers to generally maintaining an attitude and lifestyle that favor physical and cognitive health as well as selfrealization in older age as opposed to engaging in distinctive behaviors like physical activity intervention studies are required to test whether such promotion would be better suited to older public housing tenants the present study adds to existing literature by showing that older public housing tenants nonorganized physical activity positively influences their perceptions of the neighborhood and their sense of community physical activity in the building and neighborhood provides contact with like others and exposure to nonlike others potentially encouraging cultural integration social capital is conducive to physical activity among communitydwelling older adults in general and older adults living in low socioeconomic conditions much literature shows that older adults physical activity favors developing social capital and depends on characteristics of the social environment such as social cohesion this highlights the importance of considering community aspects to reach older public housing tenants through physical activity promotion similar to findings among lowincome older adults in southern thailand few participants in our sample associated physical activity to improved cognitive function though all emphasized the importance of maintaining cognitive function yet scientific literature is unequivocal healthy older adults show cognitive functioning improvements even immediately following acute aerobic physical activity this information must be disseminated to older public housing tenants study strengths and limitations to our knowledge this is the first study to focus on older public housing tenants perceptions of physical activity the walkalong method may have allowed for greater recall and ecological validity we succeeded in reaching less active and less mobile older public housing tenants with varying degrees of health status and mobility still further research should concentrate on older public housing tenants with minimal mobility of course because of our samples small size and its limited generalizability these results will need to be replicated in other cities and among other samples to bolster its conclusions conclusion in this study older public housing tenants described physical activity as a multifaceted construct described in six interrelated dimensions that contribute not only to wellbeing but also to illbeing physical activity promotion targeting this subgroup of the population should adopt a lifecourse perspective to avoid adverse effects physical activity promotion typically focuses on disseminating its benefits for physical health but our study suggests that cognitive health should be given greater attention these are essential data that may serve to tailor physical activity promotion to older public housing tenants practical tools like the physical activity messaging framework could aid practitioners in translating this studys knowledge into action the physical activity messaging framework guides decision making for the elaboration of tailored promotional messaging promoting a coconstructive equity diversity and inclusivitybased approach its three sections respectively hone in on what contextual factors influence physical activity promotion what message content to prioritize and how to deliver that message concerning older public housing tenants the present study suggests that contextual factors to consider include age all forms of capacity gender as well as cultural and community belonging however future studies are needed to analyze in depth how these individual characteristics influence older public housing tenants perceptions about physical activity for certain older public housing tenants promotional message content centered on improving and retaining cognitive ability could be more successful than focusing on avoiding muscle loss this too needs to be corroborated in future studies in sum this study provides further support to a broader physical activity promotion approach geared toward encouraging personal goal attainment and life purpose not solely health benefits future work is needed to investigate the specific contextual factors message content and delivery to better promote physical activity for older public housing tenants

few studies have focused on older public housing tenants perceptions of physical activity greater understanding of how they define appreciate and engage in physical activity could lead to better targeted promotion and reduced health inequalities for this subgroup of the population we conducted 26 walkalong interviews with older public housing tenants in montreal canada tenants were aged 6093 years and lived in either one of three study sites including a commercial a residential and a mixed landuse area physical activity was described as a multidimensional construct through six interdependent dimensions physiological emotional interpersonal occupational intellectual and existential participants perceived physical activity as having potential for both wellbeing and illbeing perceptions of physical activity were a function of age physical capacity gender culture revenue and relation to community these results support using a lifecourse perspective and a broader definition in promoting physical activity to older public housing tenants

introduction research studies in kenya the united states south africa and tanzania have suggested a link between hiv infection and womens experience of intimate partner violence gender inequality has been cited as an underlying factor for both womens risk of ipv and hiv and the associations between them in addition poverty and lack of access to education increase vulnerability to hiv infection among women the antecedents of ipv among hivinfected women are in need of further study in lowresource settings like south africa that carry a higher risk of interpersonal violence studies conducted in africa among hivinfected women have reported ipv as a result of hiv disclosure a review of 17 studies indicated that between 35 and 146 of women reported experiencing a violent reaction from a partner following disclosure in south africa hivinfected women in serodiscordant couples were the most likely to experience violence while ipv can lead to hivinfection risk in women it is also reported to be a cause of violence among women and the prevalence of ipv has been noted to be higher in hivinfected women than among hivnegative women hivinfected women are at increased risk of all forms of violence but predominantly physical sexual and emotional violence ipv among pregnant women is even more dangerous and has been associated with adverse maternal and infanthealth effects similarly the combination of ipv and hiv infection may result in even greater adverse consequences among pregnant women among hivinfected pregnant women in nigeria 325 reported ipv in 2012 with psychological violence being the most common and physical violence the least often form reported a similar study in 2009 found 658 of pregnant hivinfected nigerian women reported abuse verbal abuse threats of violence and sexual deprivation studies on ipv have typically focused on pregnant women or hivinfected women fewer studies have focused on the combination of ipv during pregnancy among hivinfected women particularly those in rural areas in south africas rural mpumalanga province in nkangala district 116 of hivinfected pregnant women reported physical abuse by their partner in the previous six months in comparison to hivnegative women in a similar study in mpumalanga many hivinfected pregnant women reported verbal aggression minor violence and severe violence in the past month during facetoface interviews these studies point to the potentially high rates of physical violence during pregnancy in this population factors associated with ipv among hivinfected pregnant women have been identified as multiparous having an hivpositive child the experience of violence before they were diagnosed with hiv having partners without postsecondary education having an hivnegative partner and lower likelihood of disclosure the dangers inherent in ipv during pregnancy especially among highrisk pregnancies in hivinfected women make identification of factors that may predict and prevent ipv an urgent priority this study aimed to determine the prevalence and determinants of intimate partner violence among pregnant hivinfected women in primary health care facilities in rural mpumalanga south africa we hypothesised that women newly diagnosed with hiv who had not disclosed their serostatus would be more likely to report ipv and to report greater perceived hivrelated stigma we further speculated that women reporting ipv would be less likely to have male partners involved in their pregnancy method participants and setting participants were 673 hivpositive pregnant women in south africa recruited during the baseline phase of protect your family a clinicrandomised controlled trial designed to test the effectiveness of a behavioural intervention aimed at increasing preventionofmothertochildtransmission uptake family planning and male partner participation in the antenatal and postnatal process in 12 community health centres in gert sibande and nkangala districts in mpumalanga province south africa both newly diagnosed and previously diagnosed women were recruited newly diagnosed women had received preand posthiv counselling and testing per the south african pmtct protocol and referral for immediate cd4 assessment and antiretroviral therapy as such eligible women candidates were referred to the study assessor by pmtcthct staff posthiv testing and referral for treatment consistent with the design of the main study only seropositive women with partners were invited to participate in the study although their partners were not enrolled additional inclusion criteria included participants from 18 years or older and candidates who did not meet these criteria were not eligible to participate interested participants were offered an appointment and enrolled after providing informed consent sample characteristics participants were adult hivinfected women with male partners although male partners were not enrolled on average the women were 178 weeks pregnant with a range of 6 to 30 weeks of the 709 hivinfected pregnant women invited to participate in the study eight declined and 28 had unusable data due to technical difficulties or protocol deviation as such the final sample consisted of data from 673 participants yielding a response rate of 949 95 ci 932 965 participants were on average 284 ± 57 years old and most had completed at least 10 to 11 years of education the majority of the women were unemployed and had a monthly income of less than 949 zar although all participants had a partner the majority of the women were not married nearly twothirds of participants reported that their partner was hiv infected most of the women had at least one child and 905 reported that their children were hiv uninfected the majority of participants reported that they had disclosed their hiv status to someone although disclosure to their partner was much lower 584 on average the women had been diagnosed with hiv for 2315 ± 3680 months and had been on art for 1300 ± 2387 months further details on demographic characteristics and description of demographic comparisons of women who reported not having experienced ipv as opposed to those who reported experiencing ipv are reported in table 1a comparisons between women who reported experiencing psychological or physical ipv on the other hand are presented in table 1b procedure permission for the study was granted by the human sciences research council ethics review committee mpumalanga province department of health research and ethics committee and the university of miami human subjects research office participants consented to the study all the participants completed measures in their preferred language using the questionnaire development systems audio computerassisted selfinterview software in order to enhance disclosure and accommodate all levels of literacy to familiarise participants with the software assessors completed the demographic component of the questionnaire with participants prior to completion of all other assessments in addition an onsite assessor was available at all times to answer any questions a physician clinic officer counsellor or other trained health care provider at each clinic was available to immediately evaluate participants who disclosed experiencing serious depression or thoughts of selfharm after assessing the level of risk if so deemed by the provider the participant was referred for further assessment andor hospitalisation or if not in immediate danger of harming herself was referred for outpatient counsellingtreatment community health centres had access times to licensed psychiatric nurses and social workers as well as psychiatrists and clinical psychologists at the associated district hospital measures sociodemographics and hivrelated questionsparticipants responded to demographic questions including age education income employment status number of children planned pregnancy alcohol use condom use at last sex time since hiv diagnosis and time since art initiation depressionthe edinburgh postnatal depression scale 10 was used to assess depression the edps10 is a 10item instrument asking participants to rate how often they have experienced different symptoms associated with depression in the past seven days scores range from 0 to 30 the validated cutoff score for south african populations is 12 cronbachs alpha for the edps10 scale was 075 in this study sample showing adequate internal consistency as in prior research in south africa disclosurehiv serostatus disclosure was assessed using an adapted version of the disclosure scale assessing disclosure among sexual partners and family members during pregnancy as well as factors associated with disclosure for this study only responses regarding the participants disclosure to anyone and her partner were used intimate partner violence ipv was assessed using an adaptation of the conflict tactics scale 18 which assesses reasoning psychological aggression and mild and severe physical aggression through the use of different subscales respondents indicated the number of times in the past six months their partner had engaged in specific behaviours using a scale of 0 to 6 scores on the reasoning subscale range from 0 to 18 with higher scores indicating their partner more frequently used reasoning techniques during conflict resolution the psychological aggression subscale scores range from 0 to 42 such that higher scores indicated that their partner had engaged in more frequent acts of psychological aggression similarly the combined totals of mild and severe physical aggression subscales scores range from 0 to 48 such that higher scores indicated that their partner engaged in more frequent physical aggression in this study only the severe physical aggression totals were considered and were dichotomised into a score of 0 if reporting no physical aggression and 1 if reporting any form of physical aggression internal reliability was adequate for the reasoning and psychological aggression subscales and excellent for physical aggression male involvementmale involvement was assessed using a male involvement index comprised of 11 items related to the participants partners involvement in the antenatal period questions included does your male partner attend antenatal care visits with you and have you discussed antenatal hiv prevention for your baby with your male partner participants responded to each item as 1 or 0 and scores ranged from 0 to 11 cronbachs alpha was 084 in this sample stigmathe aidsrelated stigma scale was used to measure internalised stigma the arss is a nineitem scale and some items include people who have aids are dirty and people who have aids should be ashamed which are rated dichotomously using a score of 0 disagree or 1 agree scores range from 0 to 9 such that higher scores suggest a higher degree of stigma adequate internal reliability for this scale has been reported in previous research in south africa the reversed coded item was removed from the total score given the scales poor internal reliability with its inclusion excluding that item reliability was adequate data analysis descriptive statistics were used to analyse demographic and psychosocial characteristics and 95 confidence intervals with 1 000 bootstrap samples were used to determine the prevalence of ipv given the severe positive skew of the psychological and physical aggression variables scores were dichotomised into values of 0 if the participant had a total score of 0 and 1 if her score was 1 or greater a combined total of psychological and physical aggression scores was also computed and scores were dichotomised in a similar manner then to compare the groups of women that had experienced ipv versus those that had not ttestsor its nonparametric alternative the mann whitney testand chisquare tests were used similar comparisons were conducted to identify group differences between women that reported experiencing psychological ipv and physical ipv lastly three separate logistic regression models were developed using ipv as the dichotomous outcome variable using variables significant at p 010 as predictors a cutoff of p 005 level was used as the threshold for significance ibm statistical package for the social sciences v22 for windows was used to conduct the analyses results prevalence of intimate partner violence overall 563 95 ci 526 602 reported having experienced either psychological or physical ipv with regard to psychological ipv 551 95 ci 513 588 of participants reported having experienced psychological ipv physical ipv on the other hand was reported by 196 95 ci 166 226 of the women further details of specific behaviours reported by the women on the cts subscales is reported in table 2 bivariate and multivariable associations with intimate partner violence in bivariate analyses higher levels of depressive symptoms higher stigma and decreased male involvement were associated with combined psychological and physical ipv younger age unwanted pregnancy higher levels of depressive symptoms more frequent use of alcohol higher stigma and decreased male involvement were associated with psychological ipv in bivariate analyses lastly in bivariate analyses having children unwanted pregnancy higher levels of depressive symptoms more frequent use of alcohol higher stigma and decreased male involvement were associated with physical ipv in logistic multivariable regression analyses increased depression and higher stigma were associated with combined physical and psychological ipv after controlling for age planned pregnancy alcohol use and male involvement psychological ipv was also associated with higher endorsement of stigma and depression in the multivariable model after controlling for age planned pregnancy alcohol use and male involvement similarly for the physical ipv multivariable model higher levels of depression and stigma were associated with physical ipv after controlling for number of children unplanned pregnancy time since diagnosis alcohol use and male involvement further description of all three multivariable models is presented in table 3 discussion this study of hivinfected pregnant women in a rural setting designed to identify determinants of ipv was characterised by high levels of ipv as hypothesised women reporting ipv were less likely to have male partners involved in the pregnancy and to report greater perceived stigma both hivrelated stigma and depression were predictors of ipv such that an increase in stigma and depression were associated with an increase in any type of ipv as well as in all types of ipv combined surprisingly neither recency of hiv diagnosis nor hiv disclosure was associated with ipv the prevalence of ipv identified in this study is similar to rates found in nigeria this finding reflects previous studies suggesting that it is typical of women in rural settings to report more ipv experiences compared to those in urban areas rates of both psychological and physical ipv were higher than previously reported in a sample of pregnant hivinfected women in primary health care facilities in the same region of south africa but were similar to another study in community health centres in this region other studies in south africa using paper questionnaires have found lower ipv prevalence rates among hivpositive pregnant women this variability is not surprising as reporting may vary when using facetoface interviews the current study utilised computerised questionnaires to provide privacy to participants enabling disclosure of sensitive information such as ipv both physical and psychological ipv were associated with higher levels of depressive symptoms in this study this finding is consistent with other studies that identified an association between ipv and adverse mental health outcomes such as depression the combination of ipv hiv infection and poor living conditions may contribute an additional burden to the lives of pregnant women compromising their mental health status accounting for almost half of the women in this study reporting symptoms of depression bearing in mind that slightly more than half of the women in this study reported having experienced psychological ipv it is not surprising that most of these women also reported having experienced depressive symptoms similarly internalised stigma reported may be related to depression although there is limited literature regarding the association of internalised stigma to ipv reports indicate a strong relationship between both physical and psychological ipv and internalised stigma given that the study data is not longitudinal it is not possible to ascribe a predictive relationship between internalised stigma and ipv which may in part account for the lack of association between recency of hiv diagnosis and disclosure with ipv it can be conjectured that women participating in this study may harbour stigmatising beliefs about their hiv infection andor partners may have responded to their hiv diagnoses negatively as has been noted in previous studies clearly the stigma remains associated with hiv on a communitywide scale and efforts to reduce hivrelated stigma must continue although not predictive of ipv several factors were associated with increased ipv including a decrease in male partners involvement in pregnancy unwanted pregnancy and increased alcohol use these relationships highlight the importance of reducing ipv as current pmtct guidelines promote male involvement in pregnancy to enhance maternal adherence and retention in care similarly greater male involvement in pregnancy increases the potential for the uptake of safer conception strategies and longterm contraception methods finally the association between alcohol use and ipv accentuates the need for targeted mens programmes to reduce ipv including mens groups and legal consequences for ipv additionally provisions must be in place and implemented at the community level to inform women about how to avoid and respond to ipv when it occurs implications for the design of ipv prevention interventions with women living with hiv gender inequality has been cited as an underlying factor in both womens risk of ipv and hiv and the associations between them and the high ipv prevalence in this study may be partly explained by the low socioeconomic status of most women in the study the results of this study reflect the poor living conditions experienced by women in rural south africa it has been theorised that rural poverty is associated with ipv as it may cause women to feel stuck in harmful relationships due to limited options for gaining financial freedom promoting gender equality including equal access to education and employment of women is of great importance in improving their socioeconomic status the majority of the women in this study were not married although they had a partner and neither marital status nor socioeconomic status was associated with ipv in the current study in contrast with earlier research in previous studies both low socioeconomic status and single marital status were related to increased risk of ipv while marriage and high socioeconomic status have been associated with reduced risk of ipv this studys results may reflect the relatively low income of the majority of participants and the lack of variability of the overall sample conclusion in conclusion the extent of ipv among hivinfected pregnant women in rural and urban south africa underscores the need for communitybased prevention interventions although the factors associated with ipv can be utilised to inform appropriate intervention strategies ipv appears to be widespread and in need of immediate action implementation of multidimensional interventions that can empower and protect hivinfected pregnant women against partner violence in south africa is essential

the aim of the study was to determine the prevalence of intimate partner violence ipv and associated factors among pregnant hivinfected women in primary health care facilities in nkangala and gert sibande districts mpumalanga south africa participants were 673 women who were on average 2839 ± 573 years old data were collected through audio computer assisted self interview acasi and analysed using the ibm statistical package for social sciences spss overall 563 reported having experienced either psychological or physical ipv and 196 reported physical ipv in logistic multivariable regression analyses higher levels of depressive symptoms and greater perceived stigma were associated with combined physical and psychological ipv psychological ipv and physical ipv were also individually associated with greater perceived stigma and higher levels of depressive symptoms the design and implementation of evidenceinformed interventions that can empower and protect hivinfected pregnant women from ipv is essential to managing their healthrelated quality of life

introduction the use of injectable drugs is a known risk factor for the spread of human immunodeficiency virus and other blood borne diseases 1 in addition to socioeconomic and legal challenges people who inject drugs experience a range of health problems such as increased mortality compared with the general population 1 the united nations office on drugs and crime estimated in 2016 that there were 106 million pwid worldwide where one out of eight pwid are living with hiv 1 in subsaharan africa unodc estimated that the average prevalence of hiv infection among pwid was around 11 1 given that injection drug use is increasingly common among young adults in subsaharan africa and that drug use is also associated with increased sexual risk behaviors pwid are known to play an important role in generalized hiv epidemics in the region 2 harm reduction programs based on effective substance use education and drug treatment services are very limited while imprisonment due to the criminalization of drug use is common 2 studies have identified various structural barriers to access to health services in subsaharan africa such as criminalization of drug use punitive laws uncoordinated services lack of transportation high cost of services and fear of stigmatization 2 other barriers include systemic inequalities such as discrimination as well as intrapersonal factors such as the preference of pwid to use addictive substances rather than seeking medical help 3 other studies have pointed to barriers such as the restriction of treatment to inpatient services which limits acceptability of such services as well as the difficulty in meeting entry requirements 4 prior to 2013 there was no data about health seeking behaviors or service uptake specifically for pwid in mozambique government interventions for this population mainly focused on educational campaigns to prevent drug use and the provision of mental health services and psychiatric treatment for pwid at public health facilities 2 interventions also included hiv counseling testing and linkage to care at health facilities 5 however needle and syringe exchange programs and opioid substitution therapy key components of national harm reduction strategies were not available in mozambique 1 there is a critical need to describe the health seeking behaviors and barriers to care among this population in order to inform the design of effective interventions and evidencebased policies the first biological and behavioral survey among pwid in mozambique was conducted from 2013 to 2014 to address this gap in knowledge the purpose of the survey was to estimate the prevalence of hiv hepatitis b and hepatitis c among pwid in two urban areas in mozambique and to identify associated risk behaviors 6 in addition the survey assessed access to and use of health and social services for pwid in those urban areas before survey implementation a formative assessment was conducted to inform the design and implementation of the bbs survey using qualitative research methods and tools common to ethnographic research a formative assessment is an important element of any bbs survey because it provides the design and implementation of the survey and also establishes a relationship between the research team and key stakeholders according to the who the formative assessment is exploratory and multimethod with the following objectives understand the target population and context identify existing services and gaps inform survey methods and engage stakeholders 78 the formative assessment included two phases 1 ethnographic observation and mapping and 2 stakeholder engagement through semistructured interviews with key informant and focus group discussions we present the results of the key informant interviews and focus group discussions to assess access to and use of health and social services among pwid 8 the purpose of the formative assessment was to examine the logistics of carrying out this integrated biological and behavioral survey and assess the characteristics of pwid locations these populations often visit availability of social welfare and health services and other information particular to this key population we present the results of the formative assessment of the ibbs among pwid related to access to and use of health and social services methodology the formative assessment was conducted in maputo city and nampula citynacala city between june and july 2013 and included key informant interviews and focus group discussions with former and current pwid and people knowledgeable about the target population such as members of organizations providing services targeted to pwid kii and fgd were conducted until responses reached data saturationa point at which further data collection is unlikely to produce any new information 9 all kii and fgd followed a semistructured interview format and were conducted in portuguese key informant interviews the key informants served as community experts who could provide insight into the risk behaviors of pwid and their access to health and social services these key informants were a diverse group that included community leaders current and former pwid lay counselors community activists peer educators current drug dealers researchers working with pwid health professionals and other service providers 10 the information gathered through kii was used to formulate fgd questions to explore issues in greater depth focus group discussions the fgd were conducted by two trained research assistants who served as moderator and annotator 11 the fgd were designed to provide information on topics of interest such as risk behaviors in the community of interest and social networks of pwid recruitment of fgd participants was done through purposive sampling to provide a comprehensive description of pwid in each study location 12 data collection tools standardized interview guides were used during kii and fgd to facilitate discussion of issues related to sociodemographic characteristics of pwid risk behaviors access to and use of health services barriers to the provision of health care and social assistance offered to pwid the interview guide has been previously published 13 the acceptability of the bbs research procedures such as the proposed sampling method biological testing and treatment for sexually transmitted diseases and blood borne diseases were also discussed however these results are beyond the scope of the current manuscript data analysis all kiis and fgds were audio recorded and transcribed field notes were developed immediately after each kii and fgd and later transcribed data analysis was based on the principle of grounded theory and aligned with data analysis procedures by the who for formative assessments 7 whereby codes were grouped into categories and then categories grouped together to form themes 11 transcripts were coded and analyzed using the qualitative research software application nvivo version 10 two study investigators independently coded the transcripts and compared codes any ambiguities or discrepancies in coding were discussed and resolved categories and themes were also determined jointly for the purpose of this manuscript quotes were translated into english by two coauthors fluent in both english and portuguese and then verified by other bilingual coauthors results we conducted 22 key informant interviews and 4 fgd including a total of 40 fgd participants the majority of participants were male and represented different socioeconomic and educational levels those who participated in fgd or kii came from a variety of backgrounds including current and former pwid health and social services and peer educatorscommunity health workers kii participants were representative of several organizations such as drug abuse prevention services faithbased organizations social reintegration services psychological and psychotherapeutic assistance treatment organizations and government institutions sociodemographic characteristics of pwid participants reported that pwid were a diverse group between the ages of 15 and 60 years the large majority of whom were male from all income levels and spoke various national regional and global languages a participant described the diversity of socioeconomic status among pwid as follows i can see people who consume drugs that have limited financial resources so poor sometimes i do not know how they can afford the drugs they consume and also there are people of high social level who are consuming cocaine even injecting heroin participants reported that although some pwid have regular jobs and can in some way afford drugs others often have unstable economic conditions and are eventually involved in unlawful activities to support their drug use there are those who live from garbage bins there are those who are street vendors there are those who sell second hand clothes there are street burglars there are others who use knives to steal money there are others who steal clothes in buildings there are others who steal bottles there are others who have money because of work there are scammers there are taxi drivers there are the children whose papa and mama give them money sexual risk behaviors there was a high level of sexual risk behaviors reported by participants particularly low condom use among pwid often due to a preference for carne com carne it was reported that drug use impaired condom use you need to remember that after consuming drugs you see jesus so just imagine after seeing jesus you dont have time to use a condom participants also mentioned sex work as a common practice among pwid women who inject drugs were reported to trade sex for drugs or for money to buy drugs as one participant mentioned girls end up in prostitution to support their habit because they have no easy access to money however sex work was not perceived to be exclusively associated with women who inject drugs often gays in their fancy cars go to the places frequented by the pwid and call one and ask if they want cigarettes they then invite them to stroll and go to a discrete location here they propose to trade sex for money when the act takes place these men do not pay little they pay well access to injection materials and needle sharing participants mentioned that although pwid had knowledge of where to access clean needles needles were often bought through illicit means because of stigma and fear of criminalization and even dealers themselves purchase a certain amount of syringes and you purchase the syringe there done this buying syringes from dealers is more for people who do not want anyone to find out that wow … hes doing these things the syringes are rented for about 50 meticais in crack houses because it is safer instead of buying the syringe for 10 meticais in pharmacies and then hanging around and risk of police finding and arresting the person on charges of being under the influence of drugs in both study sites it was also reported that health professionals often trade new andor used syringes from health facilities there are syringes sold by employees of health facilities some employees collect used syringes that should be disposed off in the trash and sell them needle sharing and exchange was also commonly reported in the crack houses renting of syringes happens without a lease meaning that no one questions whether the syringe and needle is sterile or not one thing i can be sure of when there are no syringes a single syringe serves for many users they do not take care of themselves very well so the risk is still there despite knowledge of where to obtain clean needles sharing was reported to be a result of barriers to transportation as one participant explained if im in need at this time … im having withdrawal symptoms and i have to run up there to the pharmacy take public transport go to the pharmacy thats closed from 12 pm to 2 pm to be able to get another syringe and then go to inject myself … its easier to take another needle that someone else has used and use it because it has an immediate effect of getting me high barriers to access and use of health and social services the need for health and social services for pwid was mentioned during both kii and fgd especially given that this population often suffers from problems resulting not only from drug use but also from associated risk behaviors and poor living conditions as mentioned in a fgd many of us who are drug users right we have health problems yeah and hiv tb … participants also perceived there to be a shortage of pwidtargeted programs respondents often indicated that the lack of treatment options forced them to end their drug addiction abruptly without opioid replacement therapy to reduce withdrawal symptoms some respondents felt that hiv counseling and testing services have to be more accessible in terms of location and working hours for pwid who were aware of health services the poor quality of these services was a barrier to healthseeking behavior t here are centers that do not treat us well for example there is bad food and when one goes to be hospitalized but then sees the conditions they cant endure the time required to get better structural barriers the distance between where pwid live and socialize and health care and social services was another barrier to the access and use of services one respondent noted the problem is the characteristic of this group people are closed off so it automatically gets complicated for them to go to an institution providing services participants also mentioned other structural barriers some of which were specific to the mozambican context where services cannot be given anonymously and an identity document must be presented to receive services for example i dont go to the hospital because i have no document this structural barrier was linked to the fear of potential criminalization the first thought is that there is lack of trust for these people health workers … they want to collect information about us that can be referred to the police about where we are to later cause problems finally the participants mentioned that statesponsored treatment services located at psychiatric hospitals was a barrier to use of such services because of the stigma associated with mental illnesses i said yes i am a drug user … and they sent me to the psychiatric hospital and i thought the mental hospital is a hospital for crazy people and im not crazy t he only hospital that provides such services is the psychiatric hospital the psychiatric hospital deters young pwid because they have the fear of being labeled as mentally ill crazy and somehow end up crazy pwid also mentioned their experience with stigma from healthcare providers or centers as a barrier to care so these are the conditions we need in a health center we got there we are well received as anyone else but because there are those who go there and you know this is a junkie or because he is poorly dressed or because he appears to be half dizzy and treatment is done but not equally to other patients so these are things equal treatment we also need as drug addicts finally the lack of onestop services was mentioned as a barrier where pwid had to ask several times for support at a centralized location one key informant described the long referral process and the resulting gap in linkage to services the referral process for an injection drug user is very complicated because he can receive the referral document and throws it away never going to the hospital … to facilitate my work i prefer to go with him to the hospital because if you send them he wont go and will end up prioritizing something else facilitators of access and use of health and social services despite most participants being dissatisfied with the quality of services received some described a positive experience with the health system one of them reported in my case for example i had treatment for about six months or something when i contracted tuberculosis years ago and we were well attended one participant noted that a staff member from a treatment organization explained the purpose of treatment in order to address the stigma associated with the use of psychiatric services i t required a deep conversation for him to explain that no the hospital is not for crazy people but that is a type of mental illness so eventually i accepted and went there participants mentioned the existence of different institutions and organizations where they could obtain physical and mental health support which included disease and drug abuse prevention peer educators counseling and public informational meetings voluntary hiv counseling and testing at health facilities psychosocial support including psychological and psychotherapeutic assistance for detox social reintegration through the development of professional skills and competencies and social reintegration programs a key informant who worked as a service provider described a comprehensive list of services offered by a local institution this institution is a rehab center based on a spiritual care program and also some other extra activities such as occupational therapy and vocational training which are included in various activities such as car repair mechanic activities for example you know therapy for a process of transformation and also capacity building so people can be selfsustainable discussion the sociodemographic characteristics of pwid as described by our participants was similar to previous studies including diverse age range and economic backgrounds and mostly male 2 the exchange of sex for drugs or money to buy drugs was also described as a common practice especially among female injection drug users this same dynamic was observed in ghana 14 where female pwid reported exchanging sex for money andor drugs and male pwid reported paying table 2 organizations providing social and health services to the pwid by province identified by participants in the qualitative assessment on barriers to access to health and social services for people who inject drugs in the cities of maputo and nampula city nacala mozambique 2013 for sex from female pwid and having sex with them after using drugs similar to the results from our kii and fgd despite having knowledge about how to obtain injection materials pwid in south africa also reported difficulty in access 15 a systematic review also found that stigma distance and fear of criminalization due to drug use were reported to impact the access to safe injection materials thus contributing to needle sharing behaviors 16 a study conducted among pwid in south africa also reported that the immediacy of drug need contributed to needle sharing because of the perceived lack of time required to go the pharmacy or hospital 15 participants mentioned structural barriers to access to health and social services such as distance reluctance to appear in public services and fear of criminalization as well as the identification requirement for the use of these services these barriers were also reflected in research conducted in tanzania where programs fail to reach those who could benefit because of requirements that make it difficult to enter and remain in the services 4 while some participants reported the existence of key population friendly services and comprehensive services as facilitators to access and use of services there was a general low awareness about the services currently available for pwid low awareness of services was also reported in the literature 16 and not surprisingly one study found that health seeking behavior among pwid in tanzania was directly correlated to knowledge of services 17 thus highlighting the importance of awareness campaigns targeting pwid about the existence of services low quality of health services including interaction of health care professionals and noncoordinated services 4 was also mentioned as a barrier to access among participants in south africa 14 a study reported that there is usually a long wait for access to both treatment as well as hiv testing and generally pwid feel that negative attitudes and unprofessional behavior from healthcare providers exacerbate the problem where they feel that they are treated with disrespect respondents mentioned the need to improve professionalism among staff of both hiv aids services as well as for staff in support and rehabilitation services hiring more qualified personnel such as counselors and psychologists and that the existing personnel introduce themselves with a positive attitude and be careful and understanding towards clients 18 similar to our findings previous studies have outlined various structural and environmental barriers to access to services including uncoordinated services complicated requirements for treatment access lack of transportation high costs and fear of stigmatization and criminalization 2412131516 other important structural issues from the literature that were not mentioned in our study included homelessness and precarious housing 19 these barriers to access and use of services can be addressed through the integration of hivpwid treatment services peer education programs enhanced training of health personnel to provide key population friendly services community engagement and the revision of criminal code which frames injection drug use as a public health issue 141216 many of these strategies can be a costeffective particularly in resourcelimited settings such as mozambique 1 limitations our findings represent the first exploration about access to and use of health and social services by pwid in mozambique however there are important limitations to consider first the kii and fgd were limited to specific urban geographic areas given the nature of the bbs surveys and therefore the results may not be generalized to other urban areas in mozambique nor to the realities of pwid residing in rural areas second there are potential experiences and risk behaviors of some pwid subgroups including women and people with higher income that may not have been well represented in this assessment since the number of female participants and people of high income was virtually nonexistent next there was also potential selection bias because current or former pwid already engaged in services were more likely to have participated than pwid who are isolated from health and human services or support networks selfexclusion could have meant that more vulnerable subgroups may have declined to participate in fgd however we attempted to address this by ensuring that kii and fgd were continued until responses reached a level of saturation finally given that injection drug use is a highly stigmatized and criminalized behavior in mozambique responses are potentially subject to information bias and social desirability bias however despite these limitations the study provides important information about risk behaviors for hiv infection for pwid in mozambique as well as their access and use of services conclusions understanding service delivery gaps identified during the formative assessment was used to strengthen referral systems during survey implementation however in general the results helped to improve service delivery access and quality of services both of which are necessary efforts aimed toward epidemic control in mozambique interventions to support this key population must systematically address the barriers related to access to and use of health and social services 2 several policies and harm reduction programs must urgently be introduced such as detox and rehabilitation services methadone treatment services and prevention programs incorporating peer educators governmentsponsored syringe exchange programs have the potential to reduce injection drug use behaviors in mozambique to date there is only one needle and syringe exchange demonstration project finally a patientcentered model of care through the creation of mental health and psychiatric treatment services in public health facilities rather than inpatient psychiatric facilities is of the utmost importance this model could ensure highquality of services and also address the stigma and discrimination experienced by this population in order for harm reduction efforts for pwid to be successful a coordinated effort is necessary between health professionals civil society policy makers and donors recommendations further research is necessary to explore the specific genderedexperience of access and use of services by female pwid in mozambiqueeducation programs competing interests the author declares no competing interest author details 1 instituto nacional de saúde maputo mozambique 2 university of california san francisco usa 3 faculty of medicine and health sciences ghent university ghent belgium 4 national hivsti control program public health directorate ministry of health maputo mozambique 5 rede nacional contra drogas maputo mozambique 6 department of anthropology university of washington seattle usa 7 mental health department national public health directorate ministry of health maputo mozambique 8 school of public health rutgers university piscataway nj usa

background prior to 2014 data about health seeking behaviors or service uptake for people who inject drugs pwid in mozambique did not exist we present the results from the formative assessment component of the biological and behavioral survey bbs methods standardized interview guides were used during key informant interviews kii and focus group discussions fgd in maputo and nampulanacala to discuss issues related to risk behaviors and access to and utilization of health and social services by pwid the target sample size was not defined a priori but instead kii and fgd were conducted until responses reached saturation data analysis was based on the principles of grounded theory related to qualitative research results eightyeight respondents ages 15 to 60 participated in kiis and fgds participants were majority male from diverse income and education levels and included current and former pwid noninjection drug users health and social service providers peer educators and community health workers respondents reported that pwid engage in highrisk behaviors such as needle and syringe sharing exchange of sex for drugs or money and low condom use according to participants pwid would rather rent share or borrow injection equipment at shooting galleries than purchase them due to stigma fear of criminalization transportation and purchase costs restricted pharmacy hours personal preference for needle sharing and immediacy of drug need barriers to access and utilization of health and social services include distance the limited availability of programs for pwid lack of knowledge of the few programs that exist concerns about the quality of care provided by health providers lack of readiness as a result of addiction and perceived stigma related to the use of mental health services offering treatment to pwid

background the three components of population change have consequences on one another and the overall size andor structure in countries at the second stage of demographic transition mortality reduction is followed by fertility decline 1 however drop in fertility is not yet witnessed in the general population of subsaharan africa although it has been observed in some metropolitan areas and selected communities in the sub continent 2 3 4 ethiopia has never been unique in this regard as there were only half a child cut off between 2000 and 2005 from a total fertility rate of 59 to 54 children per woman 56 fertility is higher in rural compared to urban areas in the country nevertheless below replacement level fertility of 19 children per woman was observed in addis ababa the total fertility rate was however over 6 children per woman in rural ethiopia moreover there are regional disparities in fertility in the country southern nations nationalities and peoples region where this study was conducted has one of the highest total fertility rates of 56 children per woman in 2005 6 regardless no detailed study on fertility that had policy implication in the context of current decentralization for such high fertility regions was recently done in ethiopia various individual and household background characteristics of women influenced the level of fertility which required systematic assessment the study area is also located in one of the densely populated and resource constrained parts of the country frequent food shortages land degradation and population pressure lead residents to migrate and face high mortality of children under the age of five years 7 8 9 this also gives an additional impetus to assess the effects of migration and childhood mortality on fertility in the study area therefore the main purposes of this study are to assess determinants of fertility in rural ethiopia characterized by high child mortality and mobility resulting from population pressure frequent episodes of drought and pestilence methods this study was conducted in butajira demographic surveillance system started with 10 villages sampled according to probability proportional to size technique from 82 rural and 4 urban villages 10 butajira dss is located in guraghe zone of southern nations nationalities and people region of ethiopia residents of the study region varied in type of residential ecology social cultural environmental reproductive health and economic characteristics 11 active resident women in the reproductive age group recruited from the butajira dss database were interviewed during octoberdecember 2009 the number of women in the reproductive age group living in the butajira demographic surveillance area at the time of the survey was 11133 a structured demographic and health survey type maternity history questionnaire was developed in english and translated into the local language of the respondents and then back translated to english by an independent person the questionnaire has been pilot tested in a different area prior to this study twenty clinical nurses and 5 supervisors all with a bachelor degrees were recruited as data collectors and supervisors respectively clinical nurses were recruited because advice on family planning use was part of the ethical consideration various data quality assurance mechanisms including using a standard data collection tool recruitment of qualified female field staffs intensive supervision and mechanisms to minimize information contamination were put in place professional bias was over emphasized during the training prior to data collection to minimize it data were entered into a template prepared on epi info software with the check program to manage internal consistency data were cleaned by reconciling inconsistencies the cleaned data were exported to stata version 11 for analysis total fertility rate mean children ever born and parity progression ratio were computed moreover poisson regression 1213 incidence rate ratio with 95 percent confidence interval was used to assess the association of various maternal and household characteristics with fertility we checked that all assumptions of poisson regression were fulfilled total children ever born to women in the reproductive age group which is a count data is considered as the outcome variable for this study the overall significance of each covariate was first checked and those turned statistically significant were included in the bivariate and multivariate poisson regression model to compute crude and adjusted irr the reference category for each of the factors included in the model was selected based on a prior knowledge that women in this category had smaller fertility compared to the rest of the categories except for the case of household livelihood ethical clearance was obtained from the research and ethics committee of the school of public health and institutional review board of the college of health sciences of addis ababa university support letters were obtained from the districts in which the study was conducted through the butajira dss which hosted the study oral consent was also obtained from each study participant results though the overall size of women in reproductive age group in the butajira dsa was 11133 we interviewed 9996 which resulted in a response rate of about 90 the mean age of first marriage of study participants was estimated to be 169 years with more than 80 of them married when they were aged between 1519 years nearly half of the women had no formal education as shown in table 1 study participants were fairly distributed in different residential ecological zones having large household size appears to be an accepted norm as nearly 59 percent of study participants were living in households that had more than four family members the average household size was around 52 persons more than 65 percent of women in this study belonged to households whose main livelihood was farming sixty five percent of the study participants were born within surveillance villages about 28 percent of the study participants lived in foodinsecure households about 43 percent of the interviewed women had incidence of child death the majority of women knew when in the menstrual cycle pregnancy could occur if they had sex sixty two percent of women did not have sex preference for their children the mean children ever born to women in the reproductive age group was found to be 45 children whereas the average number of children born to those in the age group was 76 children on the other hand total fertility rate was estimated to be 53 children and the total marital fertility rate was higher with 78 children per married woman the age specific fertility rate revealed a typical developing country pattern the parity progression ratio the conditional probability of having the next parity given that the women had already a certain parity level revealed that women of parity four had 791 percent chance of having the 5 th children analysis of determinants of fertility using poisson regression incidence rate ratio with 95 percent confidence interval showed that age at first marriage as a significant predictor of fertility even after including other variables in the model fertility was 138 times higher among women married in their teens compared to those married after they celebrated their 20 th birthday educational status of women had also been consistently and significantly found to be negatively associated with fertility women who had never been into any formal education had 124 times more children compared to those who completed secondary and above level of education residential ecology composed of altitude and residence type in this study the dsa comprised of lowland midland and highland rural areas covered lowland and highland areas while butajira fall in midland area residential ecology was significantly associated with fertility although the direction of association was changed when other covariates were included women resided in lowland rural butajira had 13 times more children compared to those lived in the urban area however when other factors are included women who lived in lowland rural butajira had 12 percent lower fertility compared to urbanites no fertility difference was observed between urban and highland rural butajira when other factors were included on the other hand women who were members of a larger household had about 2 times higher fertility compared to those who belonged to smaller households after other factors were added into the model fertility among women whose households main source of income was trade or service had 14 percent lower fertility compared to their counterparts whose household livelihood was farming after other factors were put into the model on the other hand women belonged to families whose household income was from the civil service had lower fertility compared to those earning their household income from farming although the statistical significance vanished when we control for other important variables meanwhile the study was conducted in a drought prone area 7 women who were members of a foodinsecure household had 6 percent higher fertility as compared to their counterparts in food secure households the fertility of inmigrant women to the demographic surveillance area was lower than those who were born in the dsa although the association was statistically not significant when the effect of other vital variables were controlled women who had lost at least one of their children had about 17 times more fertility compared to their counterparts who never had an experience of child death fertility was about 9 percent higher in women who did not know the time at which women could be pregnant if they had sex similarly women who had no sex preference to their children had about 9 percent higher fertility compared to those with sex preference after including other significant covariates discussion total fertility and marital fertility rates of 53 and 78 children per woman respectively obtained in this study was similar to the finding in gondar north west ethiopia done in 2007 14 the fertility level is still one of the highest this could be attributed to the credence of the wider community to large family size norm as children assisted households in subsistence farming and petty trade though disparities were observed across major regions of the world children were considered as assets to their parents when they get older as shown in a study using the demographic and health survey in 43 countries 15 this posit was further supported by the statisticallysignificant finding of higher fertility among women who were members of larger households compared to those who belonged to smaller sized households in this study in this study household constituted individuals regardless of their blood relations that live in one or more houses with the same cooking arrangement most members of the household were nuclear family members the fact that women of parity 4 had more than 79 percent chance to have the 5 th parity augmented the deep rooted culture of larger family size that might have been supported in the study community in the foreseeable future thus the totalfertilityrate goal stipulated in the ethiopian population policy is far from reach 16 women that married in their teens had a significantly higher fertility compared to those married after they celebrated their 20 th birthday moreover this study revealed that current contraceptive prevalence among women in the reproductive age group and married women were 15 and 25 percent respectively besides women who marry early in life may have an increased risk of having many children in particular if they started childbirth before the age of 20 years on the contrary several studies 1617 have shown that postponement of first childbirth to later ages leads to fertility reductions since women would have fewer years of reproduction window which may introduce parity specific controls even after the initiation of child birth on the other hand women who had many years of education had significantly lower fertility as compared to those who had never been enrolled into any formal education system this corroborates with similar studies 13 17 18 19 and may be attributable to the postponement of childbirth due to longer schooling educated women might be more worried to have many children if their area of usual residence had been stricken by frequent food shortage 7 nonetheless a study among sidamas in southern ethiopia indicated that fertility was higher among women with primary level of education compared to those who never attended any formal education higher educational level of women gives an opportunity of social and economic empowerments thus able women might feel that they could take care of many children and opted for large family size this is consistent with the claim by some researchers that increased family income leads to increased fertility when family planning use is low 17 education might also have impacts to bring about change in the knowledge and attitude towards low fertility by the same token women who did not know the time at which they could be pregnant had higher fertility as compared to those who knew it disparities in level of fertility between urban and rural communities in this study population were similar to the finding in gondar 18 that could be attributed to differences in contraceptive prevalence and age at first marriages between urbanites and rural residents in ethiopia since women in urban areas had better access to media general knowledge and services it was however difficult to document reasons for the change in the direction of associations between residence ecology type and fertility when other factors were controlled meanwhile informed urbanites might have a positive attitude towards smaller family size besides having better access to family planning services for instance the urban fertility level of 33 children per woman found in this study was similar to the level found for awassa town which is the capital of the study region 18 in a similar context fertility was significantly lower among women whose major livelihoods are based on trade or services compared to those households who got their main incomes from subsistence farming most of the households who relied on trade or services as main source of household income could be influenced by urban culture and practice which showed a low fertility norm although food security was widely misunderstood researchers considered it as shortages in the quality and quantity of food at any time while others defined it as shortage or absence of edible food 20 in this study encounter to household food scarcity in the past calendar year was collected this variable might not precisely measure the household food security which could be cited as a limitation however it indirectly showed the household economic status and risk to vulnerability fertility was significantly higher among women whose households suffered from food shortages there could be an eggchicken dilemma in this claim since the food shortage might be caused by the large family size which in turn could mainly be triggered by higher fertility in a resource constrained environment such as the study area people had to share the scarce food and could probably be exposed to shortages particularly in rainy seasons the time at which grain foods of farming households would be depleted 21 fertility was also found to be lower among malnourished mothers compared to nourished ones in a similar study done for sidamas in southern ethiopia 22 an inmigrant to the dsa is a person who went there to live or stayed in it for 6 or more months if did not have such intention no significant association has been shown between migration status of women and fertility in this study this could be due to the fact that the duration of residence of inmigrants may not be long enough to influence fertility and reproductive health behavior in the study area as migration was categorized broadly it may also that inmigrant women could have come from rural villages in the same or nearby districts of the country which had similar sociocultural and behavioral characteristics nevertheless a study in china had indicated that ruralurban return migrants from middle and large cities had adapted positive fertility behavior towards small family size norm compared to their ruralrural return migrant counterparts 23 the same study had also revealed that areas with higher prevalence of ruralurban return migrants particularly from middle and mega cities would have a positive effect to adapt small family size studies done on fertility responses to childhood mortality have focused on insurance and replacement effects 24 couples in highmortality settings anticipate the death of some of their children that might dictate them to change their reproductive preferences and behavior childhood mortality could also have the combined biological and volitional replacement effects to reduce the time to subsequent conception if the death occurs within a given interval the time to conception could also be reduced if a childhood death occurs during a prior birth interval accordingly this study had revealed child mortality as a strong and significant predictor of fertility as documented for the same study population a decade ago and elsewhere 17 18 19 epidemic and frequent episodes of drought in the study community which might have claimed the lives of their children provoked mothers to replace the lost ones 7 contrary to the findings of many studies fertility was significantly higher among women who had no preference to the sex of their children conversely studies done in ethiopia and asia had revealed more preference towards sons compared to daughters because males inherit properties from their ancestors in a patrilineal society a similar study in usa indicated a stable marital union or request for the custody of their child by fathers if the marriage was dissolved when couples had sons instead of daughters 222526 religiosity among women in the study community had probably dimmed their decision the use of butajira dss database to recruit study participants and administration of standard maternity history questionnaire by clinical nurses could be mentioned as strengths for the current study the demographic surveillance staffs knew study participants for a long time and this built trust on the participants side to provide reliable information the study was also conducted in a peak harvesting season which reduced the participation of certain community groups that could be away from their home by virtue of their work conclusions local government authorities should play pivotal role to make women stay more years at school thereby increase the age at first marriage to reduce fertility in the area special attention should also be given to increase the enrollment of women in secondary education to significantly reduce fertility in rural communities moreover the community should be made aware on the negative impact of large family size on the household economy environmental degradation and the countrys socioeconomic development at large efforts to enhance child survival have to be scaled up to curve the level of fertility in resourceconstrained rural ethiopia authors contributions wm participated from conception to the final approval of the final version of the article aw supervised the whole exercise and made critical comments at each step in the research he also approved the final version of the article competing interests the authors declare that they have no competing interests

background fertility is high in rural ethiopia women in the reproductive age group differed in various characteristics including access to food and encounter to drought which requisite the assessment of determinants of fertility methods reproductive age women were recruited from a dss the butajira dss database a dhs maternity history questionnaire was administered on 9996 participants data quality was assured besides ethical clearance poisson regression crude and adjusted incidence rate ratio with 95 confidence interval were used to identify determinants of fertility results delayed marriage higher education smaller family absence of child death experience and living in foodsecured households were associated with small number of children fertility was significantly higher among women with no child sex preference however migration status of women was not statistically significant conclusions policy makers should focus on hoisting women secondary school enrollment and age at first marriage the community should also be made aware on the negative impact of fertility on household economy environmental degradation and the countrys socioeconomic development at large

introduction social quarantine measures such as movement control order shelter in place and lockdowns are considered effective methods to curb the spread of covid19 1 countries all over the globe affected by this pandemic have at least considered implementing this modus as a national strategy to bring covid19 cases down and reduce the burden on their health care system until a vaccine can be effectively administered to the public the only effort that can be done to reduce virus transmission sustainably is by exercising prevention measures and embracing it as the new living norm this includes restricting movement that reduces social contact and improves physical distancing 2 physical distancing is performed to decrease the risk of virus transmission from one who is likely to be infected to other healthy individuals 3 a study measuring the effectiveness of physical distancing in england found that this method can significantly decrease the contactlevel frequency up to 74 and was the key factor in decreasing the total confirmed cases in the country 4 effective physical distancing correlates with a gradual decline in the number of cases infected 5 in most countries affected by covid19 nationallevel physical distancing order such as lockdowns movement control and shelter in place are implemented as strategies to bring down the number of coronavirus cases this regulation has been proven as the most effective strategy to eradicate the spread of the virus in several countries such as brunei 6 new zealand and vietnam 7 as a result those 3 countries have succeeded in flattening the curve since the first wave of infection up until now a valuable lesson can also be learned from indonesias closest neighboring countrymalaysia through a study on covid19 control measures ng et al 8 summarized that the movement control order had managed to suppress the transmission within only 3 weeks after its implementation thus despite difficulties in implementing physical distancing measures in the long run this method is a critical and effective measure in curbing the spread of infection 9 after the first case was reported on march 2 2020 the covid19 curve of indonesia started to show a significant increase at the end of the month with no signs of decline as the number of infected cases continued to hit a new peak every day in that month with 136 deaths out of 1528 total positive cases indonesia surpassed china in its case fatality rate chinas death rate was at 4 at the time 10 the implementation of the largescale social restriction on march 31 2020 was overdue as the number of cases was significantly high 11 at the time the number of positive cases in indonesia was still 2 times lower compared with malaysia but as of early june 2020 the country had the second highest number of positive confirmed cases in southeast asia after singapore indonesia became the country with the highest fatality rate in asia with a case fatality rate of 594 among the overall confirmed cases 12 if social restriction is a reference to the success of a country in handling and suppressing the covid19 outbreak then the high number of daily confirmed cases reported in indonesia indicates the poor implementation of the policy and government supervision of the lssr according to the institute for development of economics and finance 13 indonesia is the least successful country in implementing the movement restriction policy among southeast asian countries the number of confirmed cases in indonesia is considered the worst compared with neighboring countries lssr implementation in indonesia indeed has faced many obstacles since its first inception the success of lssr is not merely determined by policy execution by the government but is significantly influenced by public willingness to participate by voluntarily staying at home and not visiting public places therefore it is useful to examine public response toward the implementation of lssr however studies on public response toward lssr effectiveness are limited most prior publicoriented studies have focused on covid19 knowledge attitudes and behaviors 14 15 16 17 18 19 furthermore only few studies discussing public response toward social quarantine policy especially in indonesia are available accordingly this study aims to identify public response toward government policy specifically the lssr in indonesia studies on public response toward policy implementation regarding covid19 prevention are imperative particularly when the government as the policy maker is expected to be sensitive to societal needs and behavior 20 utilizing sentiment analysis this study attempts to identify indonesian public sentiment and emotions toward the lssr from a macro perspective several studies have examined public response toward government rules concerning covid19 prevention in indonesia using sentiment analysis for example djalante et al 11 and raamkumar et al in singapore 21 however both studies looked at responses on specific platforms and cannot be generalized to the larger population therefore this study will offer a macro approach by mining and analyzing big data from more than 500 online news portals and social media platforms such as twitter facebook instagram and youtube this study is useful to gauge public responses in indonesia in detail as guidance to improve existing policy methods study design this study employed sentiment analysis using a supervised machine learning approach to mine covid19related posts on selected media platforms machine learning was chosen as the method for classifying sentiment categories considering its effectiveness to accommodate a larger data set the analysis was also performed on covid19 news published in more than 500 online news platforms recognized by the indonesian press council online news and social media posts included in the analysis are those posted between march 31 and may 31 2020 the whole process of supervised machine learning application is described in figure 1 the first analysis in this study involved sentiment analysis on data from both online news portals and social media platforms the second analysis was an emotion analysis conducted on the twitter platform to identify collective public emotion toward the lssr the whole analysis process on social media and online news portal involved natural language processing on apache solr details of the systematic analysis process are as outlined below data gathering this study applied 2 different methods for data collection from each platform the data from online news portals were collected using perl web crawler while realtime application programming interface provided by perl programming language including nettwitter facebookgraph apiinstagram and webserviceyoutube was employed for each social media platform online news and social media posts obtained were then stored in the apache solr database search profiling was accomplished using the terms pembatasan sosial berskala besar pembatasan sosial and psbb as the main keywords to describe the governmentimplemented social restrictions in indonesia these keywords were deemed sufficient to capture public interest in the lssr as there are no other synonyms in either bahasa indonesia or english that refer specifically to the governmentimplemented restrictions data preprocessing overview additionally a data cleansing process was conducted the supervised machine learning approach enabled the researchers to sort select and also update the data stored in the search engine to ensure that only data associated with the study context will be analyzed the main purpose of data preprocessing is to clean the data set from all noise and outliers the details of this phase are described in the following subsections duplicate text filtering this process was done to remove text duplication and ensure only original data were included for analysis all duplications in social media data and online news were removed to avoid redundancy text normalization all usernames stop words urls hash symbols punctuation marks and other nonalphanumeric characters were removed as those entities would have no influence in determining the value of sentiment besides typos and multiple occurrences of certain characters within 1 word were normalized in this stage case folding case folding is a procedure that helps data normalization in which all texts are standardized to lower case to make it easier for the system to retrieve information more effectively feature selection the partofspeech tagging system is a word processing tool in nlp that refers to the process of tagging text onto a corresponding pos based on its definition and its relation with other words 22 commonly only words that are categorized as nouns adjectives verbs and adverbs were tokenized and tagged by the pos tagger as those words are considered important indicators of objectivities and opinions 23 some studies have been conducted to create an indonesian standardized annotated corpus by applying a probability statistic approach such as hidden markov model 24 and maximum entropy 25 nevertheless none of them are accessible for general audiences 26 thus in this study it was decided that the indonesian language dictionary would be used as the main lexical database algorithm selection and training the naïve bayes classifier is a machine learning algorithm that is commonly utilized for text classification based on probabilistic calculations to predict future possibilities by looking at past patterns 27 although there is still no exact justification on which algorithm is best in classifying text the use of naïve bayes has been proven effective or even more accurate 28 and precise 2329 than other algorithms in previous studies additionally a recent study discovered naïve bayes to be more accurate in determining covid19 sentiment categories compared with other classifiers such as logistic regression 30 therefore it was decided that this algorithm will be used to classify the sentiment into 3 categories from the training data positive negative and neutral the use of naïve bayes algorithm for this study can be described by the following equation where v map is all examined categories v c is the sentiment category p is the probability of the word i falling into category c and p is the probability of v c large amounts of data tokenized into nouns adjectives verbs and adverbs by pos tagging were stored within a training data set and trained using fivefold cross validation to ensure the accuracy of the sentiments to further improve the accuracy a system that allows admin intervention in the sentiment labeling process was developed and interannotator agreement was applied involving 3 annotators in the review process to ensure the validity of labeling in the review process all unrelated contents were removed as they are not suitable for analysis further this process enabled the researchers to fix the sentiment defined on the machine so that the sentiment tendency would fit to the context and demands of the analysis after the selection process we obtained 1934575 mentions of the search terms on both online news portals and social media platforms from march 31 to may 31 2020 the data crawling process placed twitter as the platform with the highest number of data in which the keywords were mentioned 1440062 times the use of twitter for sentiment analysis research is indeed more popular than other platforms twitter is accessed by over 330 million users monthly and has 145 million daily active users 31 the open nature of the microblogging service with numerous daily messages produced and generated has positioned it as the focal point of social media research and nlp 32 lexiconbased approach for emotion analysis the emotion analysis in this study was performed using a lexiconbased or specifically a dictionarybased approach in which the indonesian language dictionary kamus besar bahasa indonesia was utilized as the lexical database the categorization of emotion was derived from the basic emotion concept put forth by plutchik 33 including joy trust fear surprise sadness disgust anger and anticipation there is a slight methodology difference in determining emotion categories for the data collected from both types of platforms on social media public sentiment and emotion were identified based on an analysis of the text in each post 1 post or unit of analysis could represent 1 or more emotions emotion analysis with a lexiconbased approach enables the researcher to conduct pattern matching using the regular expression feature on the perl application in addition emotion analysis was not carried out for online news platform as online news does not represent any form of public conversation trend thus only public sentiment can be obtained on this platform and not public emotion data visualization visualization is the final part of the nlp process where the results of the analysis are translated into visuals to support the statistical data to optimize the data presentation interface all visual presentations in this study were delivered using zend framework results data demography search using the keywords pembatasan sosial and psbb performed on both online news and social media platforms revealed 1934596 mentions of these in news sentences and social media posts twitter yielded the highest mentions 2 presents the data distribution for each platform the data distribution showed that discussions related to lssr on social media mainly took place on twitter this justified the use of twitter to describe the overall sentiment and emotions toward the lssr on social media to identify popular topics discussed by the public the nlp process helped to cluster discourses which were predominantly used and written in online news platforms via topic mapping however on twitter popular topics were identified based on top tweets during the study period figure 3 reports discourses and topic mapping for lssr in online news platforms the most frequently discussed topics related to lssr in indonesia are lssr policy the new normal and the impact of lssr on the economic sector the high level of conversation regarding the relaxation of lssr in online news platforms represents the amplification of various responses from the public and media toward the governments swift plan to implement new norms the discussions about lssr on both online news platforms and social media are mostly in relation to the new normal in addition news crawling found that a number of lssrrelated news are political many assumed that the lssr relaxation in indonesia was not based on careful consideration but was implemented to reduce the economic burden on the government the term political crisis was used to describe what would happen if the government did not take any immediate action to xsl • fo renderx ease the economic burden of its society this assumption is supported by the high number of new reports highlighting the economic impact of lssr on the nation government as the policy maker faced various negative reverberations about lssr relaxation as it was seen to be prioritizing the economy over public health in addition to identify lssr topics with the highest engagement level on twitter tweets with the highest number of retweets were ranked figure 4 describes 5 tweets with the highest engagement overall it can be assumed that the tweets represented public outburst and resentment toward 2 parties the government that is considered indecisive to implement lssr and those among the public who enjoyed the lssr relaxation by going out freely public sentiment toward largescale social restrictions sentiment analysis on online news platforms and social media during the period between march 31 and may 31 2020 showed that public sentiment toward the lssr tended to be positive figure 5 presents the distribution of total mentions of positive negative and neutral sentiments in online news and social media platforms based on the statistics in figure 5 positive sentiment surpasses other sentiment categories followed by negative and neutral sentiments these data suggest that although society in general viewed the governments lssr implementation and relaxation as indecisive the majority still supported and regarded lssr as the best solution to break the chain of covid19 transmission in the country at the same time the negative sentiment on lssr can be considered very high it is not a good indicator of government performance moreover considering that the recovery phase of this health crisis will highly depend on public support and cooperation therefore strategic and proactive efforts are needed to maximize the support from society to deepen the understanding of public sentiment a trend analysis was carried out as outlined in figure 6 figure 6 presents the overall trend in sentiment for both online news and social media it was observed that overall positive sentiments were higher than negative and neutral sentiments there were only 2 days where negative sentiments were higher than positive sentiments precisely on may 11 and 21 2020 tweets with the highest engagement on may 11 2020 highlighted the flaws in lssr implementation wherein the government lacked a firm response toward a mass gathering in sarinah central jakarta the positive and negative sentiments toward the lssr reached the peak on the same day with recorded mentions of more than 30000 interestingly both positive and negative opinions on that day were referring to a particular tweet posted by jeromepolin regretting the publics noncompliance to the lssr a detailed analysis concerning the discussion trend revealed that the negative sentiments referred mostly to the indecisive government and noncompliance toward the lssr a similar pattern of both positive and negative sentiments with high mentions was also recorded on may 17 2020 similar to the sentiment trends on may 14 2020 the topic with the highest mentions on may 17 2020 also referred to skepticism toward the governments implementation of the lssr in addition to this some parties were disappointed with the governments decision to relax the lssr when positive cases of covid19 in indonesia were still on the rise public emotions toward lssr public emotion analysis using a lexiconbased approach and quote extraction was applied to explore collective public emotion regarding the lssr as discussed in the methods section public emotion was categorized based on the basic emotion concept by plutchik 33 including joy trust surprise fear disgust sadness anger and anticipation furthermore this analysis can be used as a parameter to identify how far the government and the lssr garnered public trust public emotions toward the lssr are shown in figure 8 the emotion analysis concluded that although there were many negative opinions toward the government and the lssr the public still believed that the lssr was the best method to break the chain of covid19 transmission the public expected that all members of society would accept and comply with this policy in order to achieve overall success at the same time the public still had expectations that the government would immediately overcome the issue by implementing firmer control although the overall public emotion was still trustful interesting trends were found in 2 other emotion categories namely fear and sadness figure 9 depicts public emotion trends during the study period the sadness and fear emotions showed the most outstanding patterns compared with other emotion categories and were found to reach their peak on april 11 2020 and may 14 2020 respectively on april 11 2020 the most retweeted post suggested public sadness toward the implications of the lssr moreover on that date the number of deaths continued to surpass the total recovered cases in the country the same trend occurred on 22 may 2020 which also indicated fear of public disobedience toward the lssr discussion principal findings this study found twitter as the most dominant platform used by the public when discussing covid19 and lssr public sentiment toward the lssr was largely positive with expressions of support for the government intervention in combating covid19 even so negative sentiments were also quite high especially concerning governments indecisiveness and public defiance of the lssr the emotion analysis revealed that indonesians were mostly trustful with notable peaks in sadness and fear corresponding to increased covid19 death rates a closer examination of tweets with the highest level of engagement showed that a majority of the public were dissatisfied with the government and parties that did not obey lssr regulations this is supported by the trends observed in the sentiment analysis criticisms of governments indecisiveness and lssr relaxation dominated the discussion trends regarding lssr during the study period even though the overall public sentiment was positive the negative and neutral sentiments were still considered high the fact that almost half of the public did not show positive attitudes toward the government and lssr implementation can be worrying particularly in a global health crisis of this magnitude a neighboring country vietnam for example has proven that effective cooperation between the society and the government can successfully allow the country to control the spread of covid19 cases compliance of vietnamese to their government instructions such as wearing masks and implementing selfquarantine 34 has made their country one of the victorious in managing the pandemic with less than 60 deaths as of june 2021 35 the results also show that the indonesian governments inconsistent stance in implementing policies has contributed to the emergence of public emotions such as fear and sadness the indonesian media may have played a role in this as concerns about socioeconomic uncertainty lssr social distancing violations and economic downturn in all sectors were widely reported in the media from march to early april 2020 36 in the earlier phase of the pandemic negative media reports on issues such as insufficient government response patient care and burial of the deceased also caused agitation among the indonesian public 37 a previous study on covid19 news in indonesia also suggested that the distortion of news by both online and mainstream media has caused an increase in public fear and anxiety 38 analysis of sentiments surrounding covid19 has produced similar results in communities across the globe the health crisis has sparked concerns on the spread of the virus and its containment 39 economic survival 40 and physical and mental wellbeing 41 the uncertainty surrounding the pandemic has resulted in expressions of mixed emotions in the public domain an analysis of twitter discussions in the early stages of the pandemic found dominant emotions of trust anger and fear surrounding covid19 cases and deaths 39 a study in italy observed a similar pattern feelings of anger and fear emerged along with trust solidarity and hope 42 while in spain sentiments surrounding the pandemic were that of disgust fear anger and sadness 43 it is important to note that while these sentiments and emotions were dominant at the beginning of the pandemic in early 2020 there has been much polarity and change in the sentiments since then 44 covid19 should be a lesson for governments to affirm the consequential role of strategic public policy and acknowledge the importance of clear consistent and welltargeted public communications in overcoming crisis while public trust is still high the government must be responsive to the needs of its society considering their outlook as the basis for formulating policies and revising those deemed incompatible with public needs economic struggles were one of the biggest drivers of lssr noncompliance in indonesia the large number of violations found in big cities such as jakarta bogor depok tangerang and bekasi 45 is consistent with the findings of wasdani and prasad 46 who reported that the implementation of social distancing among the urban poor is very difficult therefore strategic public policy should be introduced to maintain economic resilience for instance allocating budget for economic stimulus packages as done by the malaysian government which distributed myr 260 billion to its people in the lowerand mediumincome groups 47 even so robust public policy alone may not be sufficient to curb negative emotions surrounding the pandemic mohamad et al 48 have highlighted that the delivery of clear consistent and credible information is key to control and mitigate the disease misinformation resulting from the communication of policies greatly affects public perceptions and trust during the pandemic 49 to ensure successful communication to the public authorities must recognize the important role of mass media in delivering quality information as evidenced by previous studies 43 strength and limitations the strength of this study is in the variety of platforms analyzed to obtain more diverse data analyzing various types of social media and online news platforms with relatively large data sets makes it possible to synthesize diverse results compared with previous studies previous studies involving online media often only analyzed a single type of platform such as twitter 4950 sina weibo the chinese version of twitter 5152 facebook 21 and online news portals 5354 by contrast this study has a relatively larger data set collected by optimizing webcrawling functions on more than 500 online news portals and large amounts of social media data however there were some limitations to this study the large amount of data analyzed on social media platforms made it difficult for the researchers to determine what topics were dominant on social media particularly twitter the textbased approach used on twitter requires a relatively longer issue clustering process accordingly the topic mapping could only be used to analyze the data gathered from online news platforms by applying a clustering method to identify topics that are similar to each other assisted by paragraph segmentation to deepen researcher understanding of the news context in addition this study did not conduct emotion analysis on the comments that appeared in online news future research is recommended to explore public emotions by analyzing comments written in response to news items research implications the results of this study may assist policy makers in being active observers of public responses in online media especially on social media public communications by the government in this new media era must transform from being mere publicity to observing and analyzing public sentiment social listening is becoming an important way to gauge public opinion and response public confusion surrounding the lssr is a sign that the government must develop a comprehensive communication protocol to emphasize the importance of lssr in eradicating the spread of covid19 in indonesia conclusions overall this study disclosed twitter as the most popular platform used by indonesian public in conveying their thoughts regarding lssrs the analysis performed on the major keywords that appeared on social media and online news portals revealed positive sentiment toward the lssr however there were concerns on emerging conversations regarding public skepticism toward effective implementation of the lssr in addition the emotion analysis concluded that a majority of the public still believe lssr as the best method to effectively slow the spread of covid19 this explains why the public still hold high hopes and expectations toward the government as the policy maker in keeping them safe in a health crisis such as this conflicts of interest none declared this is an openaccess article distributed under the terms of the creative commons attribution license which permits unrestricted use distribution and reproduction in any medium provided the original work first published in the journal of medical internet research is properly cited the complete bibliographic information a link to the original publication on as well as this copyright and license information must be included abbreviations

background one of the successful measures to curb covid19 spread in large populations is the implementation of a movement restriction order globally it was observed that countries implementing strict movement control were more successful in controlling the spread of the virus as compared with those with less stringent measures societys adherence to the movement control order has helped expedite the process to flatten the pandemic curve as seen in countries such as china and malaysia at the same time there are countries facing challenges with societys nonconformity toward movement restriction orders due to various claims such as human rights violations as well as sociocultural and economic issues in indonesia societys adherence to its largescale social restrictions lssrs order is also a challenge to achieve indonesia is regarded as among the worst in southeast asian countries in terms of managing the spread of covid19 it is proven by the increased number of daily confirmed cases and the total number of deaths which was more than 621 135121745 of total active cases as of may 2020the aim of this study was to explore public sentiments and emotions toward the lssr and identify issues fear and reluctance to observe this restriction among the indonesian public methods this study adopts a sentiment analysis method with a supervised machine learning approach on covid19related posts on selected media platforms twitter facebook instagram and youtube the analysis was also performed on covid19related news contained in more than 500 online news platforms recognized by the indonesian press council social media posts and news originating from indonesian online media between march 31 and may 31 2020 were analyzed emotion analysis on twitter platform was also performed to identify collective public emotions toward the lssrthe study found that positive sentiment surpasses other sentiment categories by 5184 n1002947 of the total data n1934596 collected via the search engine negative sentiment was recorded at 3551 6868921934596 and neutral sentiment at 12 65 2447571934596 the analysis of twitter posts also showed that the majority of public have the emotion of trust toward the lssr conclusions public sentiment toward the lssr appeared to be positive despite doubts on government consistency in executing the lssr the emotion analysis also concluded that the majority of people believe in lssr as the best method to break the chain of covid19 transmission overall indonesians showed trust and expressed hope toward the governments ability to manage this current global health crisis and win against covid19

introduction the sexuality of young people has been and still remains a subject that has been widely studied across numerous disciplines such as educational social and of course the health sciences sexuality is lived and experienced individually it is conditioned by numerous aspects such as biological economic ethical political cultural and religious factors together these aspects guide peoples sexual behavior 1 2 3 and they must be known to nurses in order to provide quality nursing education 4 this sexual education should be provided by school nurses 5 sexuality is perceived as a taboo subject in many cultural groups which can lead to a lack of transmission of information about sexuality that results in negative repercussions for the sexual health of young people thus sex education is not accepted by all population groups in the same way in this sense there are economic cultural political and religious factors that in numerous ways limit access to information for atrisk populations such as adolescents and young adults 67 among the religious factors the existence of a traditionalist view on sexuality in the major religions has been identified acting as a preventive factor against the early onset of sexual relations thereby aiding in the preservation of virginity until marriage 8 virginity understood as the absence of sexual relations until marriage has been considered a fundamental pillar within the most influential religions for centuries 9 although the current attitude is more open towards sexuality the change in values and the modifications to beliefs about virginity have led to changes in the perception of the importance of virginity worldwide 6 although sexual relations without marriage or partnership are widely accepted worldwide there are still societies in which virginity continues to be considered another value for women and a sign of respect for their families and the institution of marriage 10 many countries that hold islamic ideologies continue to be very strict with rules prior to marriage and prioritize the virginity of women although these rules extend to both men and women stigma is greater among the latter 1112 this traditional concept of virginity maintenance can cause social and health problems among adolescents while this stage of development is characterized by increased sexual desire and relationship seeking the confrontation of tradition lack of knowledge and active sexuality can lead to unwanted pregnancies sexually transmitted infections hymenoplasty family conflicts depression anxiety and exclusion from the social environment 13 sanabria mazo et al 8 found that young christians tend to be unaware of the norms that catholicism imposes upon sexuality before marriage they also tend to separate religious morality and sexual practices more easily than members of other religions thus young believers tend to maintain a more conservative sexual behavior than their lesspracticing or nonbelieving peers so that religion seems to act as a factor that delays the initiation of sexual relations in contrast a higher degree of religiosity may negatively influence the use of condoms or other contraceptive methods because they are considered unacceptable from a religious point of view as they undermine opportunities to increase childbearing 814 apart from the degree of religiosity and in relation to the use of contraceptive methods there are other factors that influence the use of these methods during first sexual relations in adolescents these include the negative view adolescents have of contraceptive methods considering them unnecessary a lack of knowledge about contraceptive methods a lack of access to contraception the spontaneity of relations and a lack of trust in sexual partners that hinders the use of contraceptive methods during the first sexual relations 15 therefore the analyzed research indicates that religion and the degree of religiosity are variables that influence the maintenance of virginity the aim of this research is to learn about the sexual behaviors of young adults regarding the initiation or delay of sexual intercourse and to analyze the culturalreligious influence on these sexual behaviors materials and methods a mixed methodology was used for this research since both forms of research provide knowledge that is useful for obtaining more complete information on the research topic under study a quantitative ex post facto exploratorytype study was carried out in combination with a descriptive qualitative and inductive research approach to corroborate some ideas relating to the concept of virginity intentional nonprobabilistic sampling was used to obtain the sample quantitative study this study was carried out in a frontier city in southern spain in which four cultures coexist christian europeans jews roma and muslim tamazightspeaking berbers the most numerous groups are the europeans and the berbers 16 with muslims representing the 52 of the population 17 this research was carried out at an andalusian university with a total of 355 participants 817 of whom were enrolled in the degree in nursing program and 183 enrolled in the degree in physiotherapy program in the faculty of health sciences these percentages are representative of the total number of students enrolled in both degrees the mean age was 2149 years ranging from 18 to 53 years detailing the sample by age range 275 students were between 18 and 22 years of age 65 students were between 23 and 27 years of age 10 students were between 28 and 33 years of age and only 5 students were over 33 years of age in relation to sex 272 students were women and 83 were men percentages that coincide with the proportion of students enrolled in both degrees as for the religion with which students identified 222 considered themselves christians 79 were muslims and 54 were agnostics in addition among the university students who professed some religion when asked about their degree of religious practice 129 considered themselves not practicing at all 96 were not very practicing 49 students responded that they were very practicing and 27 were quite practicing the group of students belong to the islamic religion demonstrated an increase in the percentage of the very practicing compared to 7 of the christian religion who considered themselves very practicing in addition the variable of whether students had a partner at the time of the study was analyzed with 204 students responding that they did not have a partner compared to 151 who responded that they did of this group 145 considered their relationship to be stable qualitative study regarding the selection of the participants the key criteria of the focus groups were considered such as the composition of the group the characteristics of the participants and the size of the sample it was determined that the group was homogeneous in relation to age sex religion and degree of religious practice thus increasing the opinions experiences and perceptions of the subject matter the sampling carried out was intentional with the criteria including a capacity for dialogue and listening and that the informants had an availability of time with these considerations met 18 participants were selected and divided into two focus groups according to sex each group was composed of three participants of each religion aged between 19 and 24 years old variables the study variables were • sociodemographic variables that included age sex gender university degree attended religion with which participants identified their degree of religiosity the presence of a stable partner and the degree of trust held with that partner and whether participants had penetrative intercoursecoital intercourse • dependent variables that included age at the first instance of penetrative intercourse use or nonuse of a contraceptive method at first intercourse the reason for not having used a contraceptive method at first intercourse the type of relationship had with the first person with whom participants had their first instance of penetrative intercourse and other sexual practices that participants did not consider to have an influence on the maintenance of virginity • it should be noted that when asked about the first instance of penetrative sexual intercourse participants were asked to reflect on and refer to the intercourse in which they considered that they had lost their virginity vaginal or anal coitus similarly when asked about other sexual practices participants were asked to answer about the practices they engaged in that did not interfere with their concept of virginity instrument 231 quantitative study an adaptation of the young adult sexual behaviors i have not practiced it and yes i have practiced it these items were organized into four sections the level of knowledge about contraceptive methods attitudes towards contraceptive use sexual activity and the level of knowledge about familyplanning centers therefore this questionnaire was divided into two main sections one on sexual behaviors and the other on knowledge using only the first part for this study the reliability of the questionnaire on sexual behavior in university students was 0742 a section on sociodemographic variables was added to this questionnaire it included due to the sociocultural context of the city in which the research was carried out subjects belonging to different religionscultures in this sense it should be specified that the participants were asked to identify themselves as belonging to one of the religiouscultural groups so that the researchers did not categorize the participants and they were the ones who identified themselves qualitative study the structure of the focus groups was designed to encourage exploratory conversations between the researchers and participants to avoid being influenced by the opinions of other participants subjects were asked to write down their concepts of virginity and related aspects subsequently a discussion was opened in each group delving into the following categories shown in table 1 table 1 coding of the focus group categories topic of research categories of analysis codification virginity virginity as female repression c1 virginity as respect for the family c2 other sexual practices allowed for the preservation of virginity c3 24 procedure quantitative study for the selection of participants the entire student body of the faculty of health sciences was offered information about the purpose of the study and all those enrolled were offered the opportunity to participate an informed consent form was signed by all participants this study belongs to a teaching innovation project awarded by the quality teaching innovation and planning unit of the university of granada after the students agreed to take part in this research they were asked to complete a questionnaire with questions related to their sexual behavior at this point emphasis was placed on voluntariness and anonymity as well as on answering with the utmost sincerity to this end specific instructions were given on how to complete the questionnaire due to the fact that the topics addressed are part of the privacy of individuals an online modality was chosen for the dissemination and completion of the questionnaire so that it could be carried out at a place and time where the participants felt the most comfortable qualitative study the focus group participants were summoned through institutional mail once the day and time were set a classroom was selected at the faculty of health sciences that met the criteria of having an open space with movable chairs good acoustics adequate lighting and a guarantee of privacy so that the informants felt comfortable and could interact face to face the duration of the session was approximately two hours the researchers used a tape recorder for which prior authorization was requested to record the sessions their subsequent transcription was then carried out data analysis 251 quantitative study statistical analysis was performed using ibm spss 26 software descriptive and inferential analyses were performed using parametric contrast analysis given that the data conformed to normality and correlational analysis the chisquare test was also used to compare categorical variables finally a regression analysis was performed a 95 confidence interval was used to detect significance qualitative study the qualitative data were obtained through the responses of the focus groups conducted this methodology allowed us to get closer to the students and an explanatory description of the concept of virginity was obtained all the opinions of the focus groups were transcribed and reviewed by the three researchers conducting the study a content analysis of the qualitative data was carried out according to the topic of the research and was divided into the three categories of analysis previously mentioned results quantitative results first we analyzed whether the participants had had penetrative sex the results indicate that 93 students had not had sex compared to 262 who responded that they had subsequently the analyses show that there are no significant differences in having penetrative sex as a function of the variable sex but there are significant differences as a function of religion and degree of religiosity with both cases having a large effect size multivariate analysis indicates significant differences with agnostic and nonpracticing christian university students reporting that they had had penetrative sex versus very practicing muslims reporting that they had not with a large effect size next focusing on the group of students who responded that they had not had penetrative sex the results indicate that it was the religious group who defined themselves as practicing muslims who reported that they did not engage in penetrative sex compared to the christian practicing college group furthermore the data shows that there were 76 women and 17 men in the group who had not yet had penetrative sex in the group of women who had not had penetrative sex the data indicate that 21 belonged to the christian religion and 55 belonged to the muslim religion with no agnostic women found in the group of men five identified themselves with the christian religion seven considered themselves muslims and five defined themselves as agnostic in relation to the reasons for not having coital relations table 2 analyses the reasons and the sex of these participants this line shows the group that responded that they had not had penetrative sexual relations the sexual practices they had carried out are shown in table 3 according to sex and religion subsequently an inferential analysis was performed to determine whether there are differences in the sexual practices of the participants according to the sex variable the data indicate that there are significant differences with women being those who practiced more touching masturbation and oral sex and men being those who practiced touching and masturbating with a large effect size in this line there are also significant differences in relation to the religion variable with agnostics practiced kissing and fondling those of christian religion practiced kissing fondling masturbation and touching and those of muslim religion practiced oral sex and anal sex with a large effect size results regarding university students who had had penetrative sex are shown in table 3 the data indicate that the mean age of first penetrative sex s 1644 years with no significant differences according to the sex variable religion variable or the degree of religious practice as is shown in table 3 of the contraceptive methods used during the first instance of coital intercourse the male condom was the most used among the three religious groups this is followed by no method and reverse in which muslim men always used barrier methods in the inferential analysis no significant differences were observed between the variables sex religion and degree of religiosity regarding the reasons for not having used any method for the first instance of penetrative intercourse the results show that it was because the encounter was an improvised relationship and because participants were too embarrassed to buy contraceptives with no significant differences between the reasons according to gender religion and degree of religiosity regarding the relationship that existed with the first person with whom they had sexual intercourse the data indicate that the majority of participants stated that the person was a partner or friend it was observed in the muslim religious group that neither women nor men had their first relationship with strangers the inferential analyses show that there are no differences between women and men nor according to the religious group or the degree of religiosity of the participants in relation to the sex variable of the 272 women who participated in the study 196 had penetrative sex 629 were christian 246 were muslim and 125 considered themselves agnostic according to the religious group to which they belong 100 of the agnostic women affirmed that they have had sexual relations with penetration this percentage dropped to 877 in the group of christian women and only 179 of the muslim women affirmed that they had had sexual relations with penetration in the group of men of the 83 participants 554 claimed to have had penetrative sex of this group analyzing the sample according to religion 902 belonged to the christian religious group 75 were students who considered themselves agnostic and 417 were muslim table 4 shows a profile of the participants who had had sexual relations as a function of the variables sex and the religion they professed in addition linear regression analyses were performed to explore the relationship between the willingness to engage in penetrative sex and the religion of university students after adjusting the model for the variablesreligion and degree of religiositya direct association was found between the religion professed and the degree of religious practice with the willingness to engage in coital sex qualitative results the following are the research results in terms of the categories analyzed in the womens focus group opinions and beliefs were divided according to the culturalreligious groups thus for christian and agnostic women the concept of virginity is an old and sexist concept it seems to me to be a retrograde concept which only puts pressure on women and is a burden that many carries unnecessarily for the group of muslim women the idea prevailed that virginity is a sign of respect towards a future husband a way of expressing the purity of the woman and an important part of the culture i consider that being a virgin at marriage is very important for me my family and a way of reinforcing and respecting my culture and yes of course it is the hymen that matters any other practice can be done on one hand the idea that virginity includes all penetrative sex whether vaginal oral or anal prevails among christian and agnostic women on the other hand the idea of respecting the integrity of the hymen prevails among muslim women who did not give so much importance to other types of penetrative intercourse i have not yet practiced penetrative sex but not because of any religious conviction but because i have not found anyone suitable yes i think it is silly to classify people as virgins and nonvirgins especially when we are only classified as girls i consider that being a virgin is not doing anything at all as for the focus group of men the idea of female virginity and specifically of the integrity of the hymen predominated with the concept of male virginity considered nonexistent because there is no medical evidence that determines the previous existence of penetrative sexual intercourse it was observed that within the group of muslim men the idea of respect for the woman towards the man prevailed being essential or very important for the woman to be a virgin at marriage so much modernity does not have to reach the muslim woman they respect their husbands by preserving their purity the man can experiment before marriage in fact i think it is good for the man to know more about sex to guide his future wife in contrast among christian men female virginity was not so important and was not considered essential for entering into a relationship virginity is a feminine idea but it is not very important anymore i dont go around asking who is or isnt a virgin i would be considered a weirdo in this line are men who define themselves as agnostic who report that virginity is not a subject that concerns them and is not something important to them men dont even look at it it has never been done to me the fact that a woman bleeds the first time she does it is not so important the truth is besides many do not bleed and have been swollen from doing other things that for me are stronger discussion the aim of this study was to determine the sexual behaviors of young adults regarding the initiation or delay of sexual relations as well as to analyze the culturalreligious influence on these sexual behaviors in relation to the sample analyzed 738 had had sexual relations compared to 262 who had not with no significant differences between the sexes a fact that coincides with the study by penfold et al 19 on the contrary significant differences were found in those who had not had sexual relations and professed to belong to the muslim religion according to sanabria mazo et al 8 young people who profess to belong to the christian religion tend to be more labile in terms of the norms dictated by their religion in relation to sexuality referring to the age of sexual debut the young people in this study had their first intercourse at 1644 years a mean that coincides with numerous international studies 19 20 21 22 23 24 25 26 27 early onset of intercourse is associated with a higher prevalence of risky sexual practices and a higher incidence of contracting sexually transmitted infections and unintended pregnancies 19 although the average age of sexual debut has been maintained in recent years the decision to initiate sex seems to currently be influenced by the media greater social freedoms and above all the influence of social networks 222829 the decision to have sex early andor before marriage is therefore influenced by religion as well as by the degree of religious practice in fact the women and men in this study who had not yet had penetrative sex were mostly muslim followed by the christian participants this data coincides with other studies that demonstrate the influence that a religion has on the sexual practices of its believers being necessary to initiate them once married 610 in this line moral de la rubia 30 reported that practicing christians buddhists jews and islamics conceived sex as a couple relationship while nonbelievers pointed more to the physical nature of sex likewise the degree of religiosity also influences the decision to not have sex with the most practicing young people mostly delaying the initiation of sexual relations these results were also reported by morales 31 who described that mostly young people who consider themselves to be very practicing decided to reserve their sexuality until marriage in this line paul et al 25 added that being permanently involved in religious activities is one of the predictors of sexual abstinence in young men and women these data coincide with those obtained in this research where it was observed that religion and the degree of religious practice are predictors of sexual relations in young people in this line the data obtained in the focus group indicate that the religion and the degree of religious practice are related with the christians and agnostics of the focus group regardless of sex being among those who considered virginity in women to be unimportant these data coincide with the results obtained by saeteros hernández et al 22 regarding the lack of existing pressure or social and religious values on men 31 by contrast the group of muslims including both men and women did consider the value of virginity in women to be fundamental and a significant element of respect for their own culture in which sexual relations are accepted within the framework of marriage this aligns with what was indicated by valcarcel 32 in which virginity acquires a very important role in religions and especially in the muslim religion this data highlights that the practice of a religion is a protective factor against sexual behaviors that carry risks 3133 in this sense there are currently still societies in which the maintenance of chastity until marriage is taken as a public health strategy thereby controlling the prevalence of sexually transmitted diseases 6 the majority of young people who expressed that they had not had penetrative sex based this decision on the fact that they had not found the ideal person with the second most prevalent reason being the ideals of their culturereligion this last reason was more frequent among women than among men and these findings coincide with the study conducted by paul et al 25 within the group of young people who had not yet had coital relations it was observed that they engaged in other sexual practices women in the present study engaged in touching and masturbation more than men data that coincide with the research conducted by saeteros hernández et al 22 however these data are not in line with the work conducted by morales 31 who reported that masturbation is more frequent among men the percentages of touching and masturbation are similar among christian and muslim women nonbelieving women did not engage in any other sexual practices paradoxically oral and anal sex were practiced by people professing the muslim religion mostly among women these results were corroborated by the focus group since the informants considered the concept of virginity to be associated with vaginal penetration since it is the hymen that must be preserved as a participant in the study by mehrolhassani et al 6 said not having vaginal sex for example i can have anal sex to maintain my virginity and it means having hymen thus it can be concluded that muslim women consider the idea of virginity to be centered around the hymen and to be very important since there are women who even undergo hymenoplasty in order to be able to reach marriage as a virgin these data highlight the importance that the islamic faith places on keeping the integrity of the hymen intact until marriage and not contemplating in other sexual practices that also involve penetration which leads to the performance of certain sexual behaviors in the lives of adolescents and young people 8 the results obtained in this research coincide with those obtained by mehrolhassani et al 6 in which women possessed a hymencentric concept justifying the permissiveness of other sexual practices the women in this study expressed that it does not mean not having sex it means having a hymen which means you can have other kinds of sex the studies conducted by de la rubia 30 and morales 31 also reported the preservation of vaginal sex while engaging in other penetrative practices such as oral and anal sex in addition to other practices such as masturbation viewing pornography sexual fantasies or cybersex among others in terms of the contraceptives used by the young people in this study at the first instance of penetrative intercourse the male condom was the most used in almost all the religious groups followed by no method and reversal with hormonal contraceptives being the least used women were the ones who used the male condom the most in their first intercourse these data coincide with the study conducted by guleria et al 29 in northern europe in which danish norwegian and swedish women chose condoms to prevent unwanted pregnancies and sexually transmitted infections with the use of hormonal contraceptives being negligible data that agrees with the present study in contrast the results obtained by gibbs 21 reported the majority use of condoms among men and found an association between contraceptive use at first intercourse and subsequent use when asked why they had not used any contraceptive method in their first relationship improvised intercourse was the reason most often given followed by embarrassment about buying contraceptives in relation to the sex variable impromptu intercourse was one of the reasons given mainly among christian women and among both christian and muslim men these data are similar to those reported by sanzmartos et al 18 regarding the partnerrelationship maintained at the first instance of sexual intercourse participants in the present study reported that they were mostly part of a stable couple followed by being friends with the partner with a minority response of engaging with strangers these data coincide with reports by offiong et al 24 and spinola et al 2 regarding the couple relationship no differences were observed between sexes or cultural groups in contrast in the study by gibbs 21 the results indicated that the prevalence of having a stable relationship for the first coital relationship was more frequent among women while among men casual relationships were more common he also found that regardless of sex those who had a stable relationship used more effective contraceptives for their first instance of intercourse the role of the school nurse is essential in educating young people and adolescents the nurse as a promoter of healthand in this case sexual healthmust be trained in ethical religious cultural and affective aspects in order to offer quality health education 45 this work has some strengths and limitations the main strength of this research is that it provides data on sexual behaviors in a multicultural university context another strength is its mixed design including quantitative and qualitative analyses among its limitations are the small size of the sample and the focus on only health science students conclusions human sexuality is influenced by numerous aspects from ethical economic and political factors to individual experiences cultural and religious influences are factors that continue to modulate the behavior of those who identify with their moral precepts although the concept of virginity has lost strength in more liberal societies it is still present in some culturalreligious groups in which the preservation of female purity until marriage is a priority thus we continue to observe how practicing young people prefer sexual abstinence paradoxically the concept of virginity among young practitioners only contemplates vaginal sex and with it the integrity of the hymen on one hand this ancient vision of considering only the virginity of women to be important has caused many to raise their voices and confront the concept of virginity as a legacy of patriarchy thus we observe that there are numerous concepts of what constitutes real sex since performing oral or anal sex is not considered by all young people to be their first sexual intercourse on the other hand we continue to observe how young people face their first instance of sexual intercourse without the necessary tools to face it safely early intercourse lack of use of barrier contraceptives or casual relationships only highlight the shortcomings of sexual education in schools it is necessary to implement the information offered to schoolchildren in order to empower young people to make the decision to initiate their sexual life in this way we will achieve not only the prevention of sexually transmitted infections and unwanted pregnancies but also the sexual fulfillment of young people and adults sex education has traditionally focused on avoiding two major problems sexually transmitted infections and unintended pregnancies however important factors such as respect human sexual response gender identity and sexual identity have not been considered all of which are included in the affective dimension the sexual education offered by school nurses and other healthcare providers during childhood and adolescence must contemplate affective sexual ethical and cultural aspects in order to achieve its objective which is none other than to promote the affective sexual health of the population data availability statement the data presented in this study are available on request from the corresponding author the data are not publicly available so as to maintain the privacy of participants funding this research was funded by the quality teaching innovation and planning unit of the university of granada grant number 2108 the apc was not funded institutional review board statement the ethical review and approval of this study was waived because only students who previously signed an informed consent form if they agreed to participate in the study were interviewed informed consent statement informed consent was obtained from all subjects involved in the study

sexuality is still perceived by some cultures as a taboo subject although there is now a more open attitude towards sexuality the maintenance of virginity is one of the most concerning issues in some religions the aim of this research is to investigate the sexual behavior of university students and analyze how culture and religion influence the beliefs and maintenance of virginity in women and men a mixed methodology was used involving 355 students in the quantitative design and 18 informants for the qualitative study who took part in two focus groups the results indicate that religion and the degree of religious practice are predictor variables for the decision to have penetrative sex with muslim women and men giving more importance to the maintenance of a womans virginity however this hymencentric view does not prevent other sexual practices such as oral andor anal sex among young people who wish to maintain their virginity until marriage religious ethics continue to influence the sexual behavior of young people today therefore nursing education must address these issues to improve the affective sexual health of the population

introduction influencers in norway are now required by new regulations to label when their photos on social media have been retouched the new regulations aim to fight the harmful effect of unrealistic beauty standards on the mental health of young norwegians currently there is a general consensus that social media plays a dominant role in influencing norms and beauty standards about ideal body corresponding studies have detailed the detrimental influences on young females body satisfaction due to acute exposure to idealized images displayed on social media platforms social media influencers are individuals who have built a sizeable social network of people following them and are seen as selfmade microcelebrities they present idealized lifestyles by promoting material pursuit and vanity that speaks to the dreams of many ordinary people by creating attractive and highquality content influencers gain tens of thousands of followers and monetize their popularity through product promotion compared with traditional celebrities social media influencers are attractive to companies because they are perceived as authentic and trustworthy by social media users influencers also present an idealized physical appearance with female influencers commonly adhering to the conventional western female beauty norms of being young trim and feminine for some young females who are socialized to prioritize physical appearance this curated imagery may contribute to the internalization of unrealistic appearance ideals which can foster body dissatisfaction and adverse influence globally most body image studies have concentrated on facebook and instagram mainly in the western context however limited research has investigated chinese social media platforms china as the worlds largest social network market has the most dynamic environment for social media today social media has become an integral part of young chinese peoples daily lives and it is not easy to find someone who is not using it facebook and instagram are widely used in western society but they have been blocked in the chinese market as a result a domestic chinese internet services company has developed an alternative little red book red is a contentsharing site where users can post text images and short videos in the form of notes and can like comment or forward posts to their friends through links red was established in 2014 and attracted more than 300 million registers by july 2019 the most active user group was dominated by the post90s generation red generates three billion note exposures per day 70 of which are derived from usergenerated content as one of the most popular social media platforms red has attracted many active young female influencers they show off their privileged lives while presenting smooth flawless skin perfect faces and trim bodies attracting the gaze of viewers young female influencers tend to upload only their best personal photos which are carefully chosen to maximize their attractiveness beauty and are then augmented by filters and digital alteration when viewing the influencergenerated content other users come to formulate a view of what is normal acceptable or unacceptable in terms of appearance and body shape in their community the end is that comparisons with female influencers on red are most often upward in direction resulting in dissatisfaction with users own body and appearance for this reason red has been receiving increasing complaints and criticism from the public for disseminating distorted beauty standard to date few studies have been conducted specifically on social media influencers imagery and its impact on viewers however previous studies have confirmed that attractive celebrities images reinforce the unattainable ideal of thinness resulting in upward social comparison and body dissatisfaction among young viewers for instance shorter et al found that young females favorite celebrities become unrealistic targets for their upward social comparison individuals who think that their body image are quite different from their favorite celebrities are prone to disordered eating attitudes and behaviors similarly harrison found that the interpersonal attractiveness of thin celebrities seems to be positively correlated with peoples eating disorder symptoms compared with ordinary or heavy celebrities brown and tiggemann explored the impact of instagram photos of celebrities and attractive peers on young females emotions and body dissatisfaction the results demonstrated that experimental groups exposed to images of celebrities and peers had more negative emotions and body dissatisfaction than the control group but there was no significant difference between famous celebrity images and attractive peer images engagement is the key for social media influencers to gauge their success and business value often the metric is an index of engagement that helps describe influencers popularity rankings for example according to ismail those with more than 1m followers and more than 100k followers are considered megainfluencers and macroinfluencers while those with only 1k to 100k followers are microinfluencers similarly de veirman et al believes that the number of followers can easily determine the popularity of social media influencers while others believe that the number of likes can properly reflect the popularity of online celebrities as such social media users are likely to encounter idealized and staged influencer imagery accompanied by a wide range of metrics among other studies the impact of viewing metrics has been examined among young adult audiences sherman et al found that when viewing instagram users photos with more likes young audiences experience greater brain activity suggesting that they scan wellliked photos more thoroughly than less favored photos in this way it is possible that high engagement metrics may work analogously to the warning tags on edited social media images turning the viewers attention to the perfection of influencers body shape and the perceived relative shortcomings of their own body image therefore this study views engagement metrics as a key indicator of influencer popularity status furthermore we will also assess whether the level of selfdiscrepancy moderates the relation between idealized influencer imagery and body satisfaction as many studies suggest that the impact of body image exposure on ones body satisfaction may depend upon the level of selfdiscrepancy one holds therefore the following hypotheses are proposed hypothesis 1 viewing an influencers body images along with both high and low engagement metrics results in greater negative mood and lower body satisfaction than viewing the control images of nature hypothesis 2 viewing an influencers body images along with high engagement metrics results in greater negative mood and lower body satisfaction than viewing the same images along with low popularity metrics hypothesis 3 selfdiscrepancy will moderate the association between influencers idealized body images and young females body satisfaction to address these gaps this study investigates the effect of idealized body imagery of chinese influencers with different popularity on female social media users body satisfaction and mood and whether their selfdiscrepancy moderates this effect to our knowledge this is the first study to test how influencers body imagery affects individuals perception and evaluation of their body image additionally this is one of the few explorations examining selfdiscrepancy as a moderator for the impact of influencers body imagery and body satisfaction of young female users thus this study provides contributions to the media effect literature by offering critical understandings and new insights into the study of body image in the context of china methods participants and procedure female participants were recruited through a famous chinese data company between may 10 2021 and may 19 2021 the participants ages ranged from 18 to 35 they had a mean body mass index of 1937 a total of 7738 of participants were normal weight followed by overweight underweight and obese based on the widely used chinese bmi categories suggested by the national health commission of china the study was approved by the research ethics committee of beijing jiaotong university because this was an online experiment participants logged in anonymously to a survey website provided by the data company through their mobile phones and watched the experimental stimuli after giving informed consent they were randomly assigned to one of three conditions influencers with high engagement metrics influencers with low engagement metrics or control participants first completed measures of body satisfaction mood and selfdiscrepancy next they were shown a series of red influencers posts each participant viewed a slideshow of 3 influencers profile pages and 24 body images on their own mobile phone each image was displayed for at least 15 s during which the participants could not skip the image and go to the next page additionally to ensure that participants viewed the images they responded along dimensions including quality appropriateness interestingness and enjoyableness after the images were shown the participants again reported their mood and body satisfaction and finally answered questions about their demographics experimental stimuli influencer images the stimulus materials were designed to resemble a typical red influencers post to replicate naturalistic mobilebased social media engagement three female influencers from red were chosen we deliberately did not select wellknown and easily recognizable influencers to prevent participants from being influenced by previous impressions for each influencer we selected their profile page and a post including 8 body images each profile page was edited to the same background color and size and the profile picture was a clear selfie the influencers name gender and red id were displayed while the rest of the information on the profile page including location education bio and user level was blurred out to reduce visual interference the images depicted the influencers in artistic lifestyle and travel selfies they were fully clothed in summer attire and most photos appeared to be staged or posed rather than spontaneous for highly popular influencers the engagement metrics on the profile page were manipulated to over 1m followers and over 1m likes and saves the engagement metrics of each post were manipulated to over 3k likes 1k comments and 1k saves1 for lowpopular influencers the same profile pages and images were used with the number of followers and the number of likes and saves adjusted for low popularity defined for this purpose as influencers with fewer than 1k followers fewer than 100 likes and saves and fewer than 10 comments on each post this classification is based on the annual report of the little red book and previous literature on the classification of influencers nature images regarding the control images three red accounts that posted nature photos were chosen participants viewed the 3 profile pages and 24 photos depicting natural objects and scenery both the profile pages and the nature photos were given lower popularity metrics separating the effects that occurred as a product of viewing idealized female bodies versus nature imagery from the effects of seeing popularity metrics measures mood and body satisfaction in this study a visual analogue scale was used to measure five mood dimensions anxiety depression happiness anger and selfconfidence and two body satisfaction dimensions weight satisfaction and appearance satisfaction participants indicated their current feelings by moving a slider on a horizontal line with endpoints marked none to very many capturing responses ranging from 1 to 100 the scores for happiness and confidence were reversed and the individual dimensions were averaged to provide general scores of body satisfaction and mood selfdiscrepancy selfdiscrepancy was evaluated by the bodyimage ideals questionnaire in this study body proportions and body weights were evaluated the scale has two components perceived discrepancy and perceived importance of the ideal both of which are used for the final construct of the crossproduct weighted difference participants were asked to think about their personal ideals and to rate on a 4point scale to measure how much their own body matched the ideal one discrepancy was rated on a scale ranging from 1 to 3 and the importance was rated on a range from 0 to 3 the weighted difference score was the mean of two crossproducts according to szymanski and cash it is crucial to assign 0 to an insignificant ideal which results in a crossproduct of 0 properly discounting the extent of discrepancy while assigning 1 to any matched ideal creates continuity of the weighted discrepancy score from very important selfideal congruities to very important discrepancies the final measurement of discrepancy in terms of body weight and body proportion was moderately correlated r 078 p 0001 r 0634 p 0001 and thus averaged body mass index participants were asked to report their height and weight in centimeters and kilograms which was used to calculate the body mass index statistical analysis all data collected in this study were analyzed using spss 270 pearson correlations were conducted to test the bivariate associations among age bmi body satisfaction and mood oneway analysis of variance was used for the randomization check and manipulation check to test our hypotheses separate oneway analyses of covariance with bmi age and preexposure body satisfaction as covariates were conducted additionally post hoc analyses using tukeys hsd were conducted to compare the nature images control group with a combination of the two influencer groups and then compare the highly popular and low popular images to each other we then tested a moderation model using hayes process model 1 the bootstrapping method was used to test the mediation effects this method produced 95 biascorrected confidence intervals of the estimates from 5000 resamples of the data for a multicategorical independent variable we used indicator coding to produce two dummy variables and the control condition was used as a reference group results preliminary analyses indicated that the experimental conditions had no significant difference with respect to age f 019 p 083 bmi f 931 p 011 and there was no significant difference in preexposure body satisfaction f 07 p 049 and premood f 053 p 058 for the manipulation check for influencers engagement metrics participants indicated whether they believe that the stimuli depicted a red influencer oneway anova revealed significant differences between conditions f 28297 p 0001 a tukey post hoc test showed that highly popular influencer profiles were significantly more commonly identified as influencers followed by less popular influencer profiles and then nature controls all descriptive statistics and correlation matrices for all the variables are provided in table 1 our first two hypotheses predicted the direct impact of red influencers body posts and different levels of engagement metrics on other red users mood and body satisfaction the results of h1 showed that image type had a significant impact on postexposure body satisfaction and postexposure mood f 973 p 001 f 454 p 001 the first planned comparison showed that viewing the highand lowpopularity images led to lower body satisfaction and greater negative mood than viewing the nature control images t 293 p 0004 t 297 p 0001 therefore h1 was supported the result of h2 revealed that there was no significant difference between the image group with high popularity and the image group with low popularity in terms of young females body satisfaction and mood t 109 p 028 t 055 p 013 h2 was not supported for h3 the interaction between influencers idealized body images and females selfdiscrepancy was found to be statistically significant β 934 p 0001 β 815 p 0001 the analysis results of the moderation model are presented in table 2 the conditional effect of influencers body images on females body satisfaction showed corresponding results specifically when a participants selfdiscrepancy was low there was a significant positive relationship between influencer image groups and body satisfaction β 661 p 0001 β 347 p 005 however when a participants selfdiscrepancy was high there was a significant negative relationship between influencer imagery groups and young females body satisfaction β 1872 p 0001 β 1860 p 0001 to better understand the conditioning effect estimated values of body satisfaction are plotted in figure 1 the results show that the relationship between idealized body images and body satisfaction varies with the degree of an individuals selfdiscrepancy discussion and conclusion the primary aims of the current study were to examine the effect of popularity metrics accompanying red influencers body images on young chinese females mood and body satisfaction and to further investigate the moderating effect of their selfdiscrepancy on this effect in so doing this study has added new insights and expanded the current research on the detrimental effects of social media on body image by highlighting the role played by influencers imagery first as predicted idealized influencers imagery causes lower body satisfaction and more negative mood compared to natural environment images however there were no differences between influencers body images with high compared to low engagement metrics second selfdiscrepancy was found to moderate the effect of exposure to influencers images on young females body satisfaction the findings related to the first two hypotheses underscore the detrimental psychological impacts of idealized social media imagery reported in the existing literature specifically acute exposure to thin and attractive female influencer imagery had an immediate negative impact on young chinese females mood and body satisfaction interestingly exposure to influencer images with both high and low metrics had a similar detrimental impact which echoes the finding of tiggemann et al who suggested that thinideal body posts on social media caused lower body satisfaction among young females regardless of the number of likes accompanying body images similarly our experimental results revealed that even if the engagement metrics are clearly indicated individuals are nonetheless affected by the content of the posts not the engagement metrics below the body photos this is contrary to chua and changs conclusion that teenage girls reported they were more attracted to peers photos on social media with a higher number of likes and were more likely to make upward comparisons with their peers photos with a higher number of likes it should also be recognized that the photos displayed in the present study belonged to attractive influencers while in chua and changs study girls were required to respond to known peers in their social network it is possible that likes are especially meaningful to teenage girls who attach great importance to their peers opinions however our research found that likes are no longer significant among adult women because the average age of our research sample was 28 years old a similar result was found in the study of osburn which found that peer comments attached to photographs were associated with body dissatisfaction for girls between the ages of 14 and 16 however another age group ie women aged from 25 to 35 was not found to be negatively affected the findings of the present study can be used to guide daily social media usage however the comparably adverse influences for images across levels of popularity make defining practical guidelines for safe social media use complicated simply avoiding idealized body pictures from a particular group of users is insufficient because idealized images may come from social media influencers with different levels of popularity and even ordinary users like instagram and red social media encourages all users to modify their photos to be ideal our findings suggest that when photos are edited to be equally idealized on social media platforms popularity may not matter given this finding we suggest that china like norway also introduce laws related to social media posts that require all content creators to disclose when they have retouched or added a filter to photos although influencers engagement metrics were irrelevant here the present study nevertheless showed that favored influencers can affect peoples body image attitudes in our experiment participants reported lower body satisfaction and higher negative mood after viewing red influencers body photos compared to those who viewed the nature environment photos currently female influencers dominate social media and they have increasing become key opinion leaders in chinese society they arguably represent ideal beauty in social media and cultural beauty ideals as current beauty ideals emphasize thinness for women it is suggested that this constant presentation of edited female body images in social media reinforces an unattainable thin ideal and causes the prevalence of body dissatisfaction among young women given that the strong influence of female influencers they can be encouraged to upload real images for other users to view as previous finding revealed that exposure to the social media influencers real images resulted in a decrease in body dissatisfaction relative to exposure to the their ideal images additionally we noticed a slight increase in body satisfaction after participants viewed control images portraying a natural environment this finding has been confirmed by previous literature numerous studies have indicated that humans have an innate preference for natural settings and that interacting with nature can positively influence peoples health and wellbeing for example literature reviews and metaanalyses have consistently noted that being in a natural setting is related to an improvement in psychological wellbeing including health improvement higher selfesteem healthier emotions and more physical energy in addition to psychological health in general some scholars believe that spending time in a natural environment improves selfperceptions of body image and reduces body image concerns this is mainly because the natural environment helps limit negative appearancerelated thoughts restrict the influence of internalized negative appearancebased stereotypes and promote speedier recovery from threats to body image time spent in the natural environment also separates the individual to a certain extent from the social environment that values appearance which in turn nurtures the development of the ability to critically evaluate the appearance of ideal images and engage in the behavior of protecting the body notably this study extends previous research about media effects on body image by elaborating the mechanisms underlying social comparison processes the moderating effect of selfdiscrepancy contributes to a more nuanced understanding of body image processes it is often assumed in existing research and widespread belief that idealized thin body imagery inevitably has a negative influence on females body satisfaction our findings challenge this hypothesis and show that exposure to idealized body imagery is not always harmful and may even be beneficial especially for people with low selfdiscrepancy our results partially support the findings of previous studies that is posting idealized body photos on social media does not always have a negative impact specifically our results reveal that this negative effect does exist with one difference for individuals who have a lower discrepancy between their personal ideal and self viewing idealized body images does not always negatively impact their body satisfaction this can be explained by selfdetermination theory which underlines peoples motivations goals and aspirations for perceptions cognitions and other related wellbeing namely exposure to idealized body images may enhance the motivation for selfenhancement more prominently especially among people with low selfdiscrepancy however those with high selfdiscrepancy may not be motivated because of the large differences and gaps that already exist when the portrayed idealized body is considered to be achievable exposure to idealized images can stimulate motivation for selfimprovement rather than selfevaluation therefore for individuals with low selfdiscrepancy the idealized body image may look closer to or like their bodies thus generating greater body satisfaction through selfenhancement motivation in contrast for individuals with high selfdiscrepancy who are dissatisfied with their own bodies idealized body posts may aggravate the original differences and lead to lower body satisfaction limitations and implications this study has a few limitations first we focused only on young womens psychological response to idealized images of social media influencers young males were not included in our sample which may affect the generalization of the results future research should consider the similar negative impact of idealized social media images on young males second the average age of our sample was relatively high ie 28 years old which may further influence the results third as mentioned in the previous section the number of likes on photos posted on social media is more meaningful for adolescent girls while adult women seem to be less susceptible to engagement metrics below the postings in addition online experiments may affect participants attention although we tried to avoid any such effect through quality control 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 ethics statement the studies involving human participants were reviewed and approved by beijing jiaotong university school of language and communication studies ethic research committee the patientsparticipants provided their written informed consent to participate in this study conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest 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

many studies have linked idealized body image on social media to negative psychological wellbeing among young females however social media influencers imagery has not attracted much research attention in either the western or the asian context this study aimed to experimentally investigate the impact of high versus low popular social media influencer images on young chinese females body satisfaction and mood the participants were 420 female red users aged 1835 who were randomly assigned to three groups 1 the influencerhigh group idealized imagery alongside high engagement metrics 2 the influencerlow group the same idealized imagery adjusted for low engagement metrics or 3 a control set of nature images the results revealed that the groups exposed to influencer imagery had lower body satisfaction and more negative mood than the control group nature images notably this comparison showed no significant difference between the lowinfluencer and highinfluencer groups in body satisfaction and mood additionally this effect was moderated by individuals selfdiscrepancy between personal ideals and their own bodies that is exposure to idealized body images does not always produce harmful effects for those with lower selfdiscrepancy idealized body posts somewhat positively affected their body satisfaction the current research contributes to the media effect literature by providing critical new insights into the study of body image in the context of china

introduction the world has experienced a severe crisis that has affected nations economies education and health systems and changed peoples behaviours activities and habits people had to search for effective ways to respond to the pandemic one way of preventing transmission was by delivering precautionary guidelines in a simple fast and approachable manner as most global information about covid19 was probably in english translation needed to play a vital role in conveying and disseminating crucial information in a language suitable for the target audience using english as the official language of international humanitarian and health organisations caused a problem and solved another in other words using english as a tool for instance may deliver relevant information in a unified instant and accurate form but it may prevent the target audience from understanding the intended messages considering the presumed competence levels among nonenglish speakers thus translation is needed which in turn may complicate the process of delivering critical information in time even assuming in specific contexts that audiences have a competent level of english that might have delayed responses to crises for example saudi official institutions tend to produce documents reports guidelines and audiovisual content in arabic despite the significant number of foreign residents in the ksa crisis translation has become necessary for responding to and engaging with crises and pandemics such as covid19 crisis translation is conceptualised in this paper as a specific form of communication that overlaps with principles of risk management… as much as with principles of emergency planning and management although translation is useful in crisis management some factors may hinder the instant delivery of muchneeded information these factors include a lack of sufficient linguistic and cultural awareness lack of access to information lack of effective participation and lack of trained and qualified linguists and translators in such an unstable context the emergence of nonprofessional translators as mediators producers and creators of usergenerated content was expected digital media facilitate the visibility of content produced by fans and unqualified ordinary citizens however the urgency of crises may unveil the value of fansubbers and amateurs who invest in their digital skills and capital to circulate usergenerated translations using digital platforms this paper examines crisis translation within the context of the ksa by analysing how social media users content creators and fansubbers engaged and circulated ugtrelated clips on social media crisis translation is also investigated according to a sociodigital approach in which the engagement of official health institutions in the ksa is tested and their translation efforts are highlighted this paper explores how professional and nonprofessional agents engaged with the pandemic to understand how both sides compete over available resources and forms of capital conceptualised by pierre bourdieus theory of practice however due to time and space constraints this paper will only focus on the ksas ministry of health and 17 saudi fansubbers this paper adopts the following definition of fansubbing subtitles produced by fans with little or no professional training or experience carried out without pecuniary remuneration and normally without the consent of the copyright holders of the source text with this definition in mind i propose a new type of fansubbingsocial media fansubbing smf involves the production of usually short clips posting them on social media platforms allowing instant engagement by online users and recirculating them using other digital means smf shares many similarities with pedersons conceptualisation of fansubbing but it may differ considering its technical and digitalrelated aspects in other words the design of twitter tends to amplify the spread of smf attract more attention to it help in building a network or community around it and offer spontaneous and instant feedback from the users of twitter also twitters design implements some distinctive settings in terms of the clips duration length of tweets posting of sensitive content and downloading content which may restrict or expand the reach of smf after all smf was a valuable and effective tool used in combatting covid19 in the ksa which is discussed later in this paper context responding to covid19 in the ksa the ksa seemed to have managed the spread of covid19 well by being prepared even before its arrival the ksa had a population of 35 million in 2020 with 38 of different foreign nationalities these figures are important when discussing topics such as tackling the pandemic managing peoples daily lives and labour affairs circulating regulatory information and guidelines and providing vaccines masks and medical equipment another relevant factor is the number of nonsaudi residents and nonarabic speakers who may need a specific method of communication and translation according to some reports i the top five nationalities in the ksa in 2013 were indians pakistanis bangladeshis egyptians and filipinos they formed 73 of the foreign nationalities residing and working in the country other recent reports have mentioned that the number of foreign workers in the ksa has reached around 10 million dominating some businesses and professions these statistics highlight the large number of nonsaudis but neglect the languages of these residents such as hindi urdu bengali and tagalog their competence in speaking and understanding arabic and literacy levels are unknown but could be regarded as low and may hinder communicating information during crises english is presumably not among their spoken languages as they have minimal education and are mostly menial workers and labourers which complicates the situation and makes translation even more necessary the first covid19 case in the ksa was recorded and announced by the moh on march 2 2020 following that and in response to the pandemic local flights were suspended schools were shut and a lockdown was implemented from march 23 2020 other early precautions started in january and february 2020 such as regularly checking international passengers arriving in the ksa suspending travel to and from china except for returning saudi citizens and initiating the control operation centre the moh published a full report on the pandemic and how it tackled it highlighting the efforts and procedures followed before and during the spread of covid19 effective and strategic tasks have been achieved by cooperating with other respective authorities to communicate with society under the leadership of the moh these tasks involved using traditional media such as tv radio and text messages but also include new digital technologies like social media whatsapp and other mobile applications to circulate health updates and promote commercials to raise awareness in society the moh used traditional and new media communication including social media commercials and campaigns social participation and digital health to combat the pandemic and prevent its spread using these strategic procedures the moh circulated audiovisual content to disseminate relevant guidelines updates and important instructions to the public the moh invested in technology to reach the residents of the ksa and maximise societys engagement and participation through published materials and content the moh dedicated a website for covid19 awareness and made it available in seven languages english urdu indian tagalog bengali indonesian and pashto ii the website includes visuals infographics and dubbed clips in these languages some clips were originally produced in these languages no subtitles were provided for these clips even though some clips were in arabic thus translation was slightly used by the moh as a strategy for communication subtitling was included in few clips the moh introduced a whatsapp chatbot service for chatting and providing help available in arabic only according to the moh more than 66 billion text messages were sent to this chatbot service and more than 150 million views were received for the posted clips online in addition there were more than 15 million visits to the website and more than 4 million followers to the mohs twitter account the moh seemed to partially acknowledge the relevant role of translating into the most spoken foreign languages in ksa over the early stages of the pandemic but it may fail to implement it effectively statistically the number of the mohs translated material is unknown and the distribution of this translated content across the target languages is not specified the moh has prioritised social media as the main platform for communicating and circulating information and content presumably the digital culture and infrastructure in the communication and translation are expected to be critical in supporting this task informing the workers about the guidelines testing procedures and publicising the campaign on digital media the moh did not specify the communication procedures for this task in sum the ksa probably succeeded in responding to the outbreak of covid19 in its early stages and even before the discovery of the first case in march 2020 the efforts made by the moh the main institution responsible for planning and managing the crisis were exhaustive different strategies and plans were implemented to prevent and control the spread of the outbreak one of these strategies is communication and social engagement the moh attempted to circulate important guidelines promote campaigns and actively engage with digital communities in the ksa via social networks and other electronic means even though it was not largely employed translation was essential to the communication process subtitling and dubbing were also used in some languages however the moh was not the data and methodology the first positive case of covid19 in the ksa was announced in march 2020 before that the saudi government and the moh released preliminary guidelines for managing the covid19 crisis in 2020 multiple strategies and developments shaped how the moh responded to and managed the outbreak for communication purposes the moh harnessed technology effectively to reach the public and circulate crucial information promptly text messages tv coverage and social networks were the most vital tools for communication and social reach thus 2020 witnessed the start of the pandemic in the ksa its peak the lockdown the normalisation period and the testing and vaccination schemes this timeframe facilitates the collection of specific data when observing the digital participation of the moh and selected fansubbers the twitter profiles of the moh and 17 fansubbers were observed from january to december 2020 to explore covid19related topics examine the subtitling activity of these social agents iii determine the strategies and motivations shown by these translations and illustrate the social role played by these agents and the interactions they received the data collection went through three stages the first stage involved searching twitter using the advanced research feature which optimised the search by setting specific timeframes and choosing the media type the search aimed to collect only posted videos that were playable immediately on twitter without the need to watch them on other platforms such as youtube engagement with these clips such as likes retweets and comments were also collected and compared after this initial search the elicited data was inserted into an excel sheet in chronological order with relevant information including the clips date the number of replies retweets likes and views the genre or theme of the clip the source and target languages the hashtag used and any other paratextual features and notes this process took a long time considering the number of tweets that included covid19 and the manual collection and verification of tweets and clips twitter does not have a feature for recognising translated clips therefore the author had to resort to a tweetbytweet scrutinising process to ensure that the clips were subtitled and relevant to this study the final stage included analysing the collected data and examining the emergent in summary this paper adopts a mixedmethods approach to data collection from observation and data gathering to categorisation and examination of the outcomes the data collection process revolved around these practical and necessary steps the implementation of a mixedmethods approach was based on the research questions and objectives but also on the principle that the use of quantitative and qualitative approaches in combination provides a better understanding of research problems than either approach alone the cases selected in this paper serve as an empirical inquiry that investigates a contemporary phenomenon in depth and within its reallife context the data analysis was inspired by sociological and digital studies and insights that deepened the understanding of the case study and its context aside from the concept of crisis translation pierre bourdieus sociology was a critical analytical tool following bourdieus sociology smf is perceived as a social activity influenced and shaped by sociological aspects and motivated by varied forms of capital that the fansubbers as agents attempt to accumulate therefore the fansubbers acts are predetermined by certain forms of capital who try to make a name for themselves it is the notion of capital that this study emphasises as it explains the personal motives of the fansubbers and explores the various forms of capital they try to achieve beyond the economic capital another relevant concept was the notion of digital paratexts thus examining the forms of capital was not only based on an observational process of the online subtitling activities during covid19 but also on their accompanying digital paratexts on twitter the paratexts of audiovisual content play a critical role in meaningmaking for the films and other media products these paratexts support the text or the film and may extend its social reach visibility or popularity among viewers and users of social media for example the list of digital paratexts is not exhaustive but fancreated paratexts are of considerable relevance to this study as they highlight other digital features implemented by fansubbers such as the usage of hashtags logos clips duration and using links or urls moreover this study was generally aligned with the works of ohagan on usergenerated content and usergenerated translation and studies on translation and social media these concepts presented the researcher with a wider understanding and deeper analysis of the case study in the following lines the subtitling of covid19related clips is explored according to a thematic discussion inspired by the abovementioned concepts crisis translation for precovid19 outbreak the saudi government implemented proactive and preventive measures during the first months before the announcement of the first covid19 case in the ksa in march 2020 for example tourist visas and travel to china were suspended the moh provided guidelines on travelrelated issues during january and february 2020 twitter was the main platform for sharing audiovisual content containing these guidelines which were recirculated on youtube and other platforms thirteen clips were posted on twitter during this period however translations were not included in these clips in contrast smf showed a slight interest in participating in subtitling early news and stories on covid19 understandably covid19 was not yet a relevant or worthsubtitling topic for fansubbers at this stage the fansubbers subtitled 6 out of 156 clips on their respective twitter accounts these few clips showed the role of smf in highlighting the various aspects of covid19 and foregrounding fansubbers orientations and motivations the topics discussed in these clips were the origin of the virus news about wuhan and wearing masks however one of the fansubbers addressed the spread of covid19 in iran while considering the political tension between iran and the ksa two outcomes arose from subtitling activities during this period first the moh and smf did not invest much in translation as a means of communication despite the covid19 urgency level and the need for translation while this was true for the moh fansubbers displayed flexibility and a tendency to act rapidly and respond to breaking news and trendy events moreover even though translating covid19related materials is a humanitarian and voluntary task some fansubbers exhibited a degree of ideological orientation in their subtitling activities the subtitling efforts of fansubbers during the pandemic were perceived as voluntary and altruistic without receiving direct financial benefits nonetheless subtitling as a social practice insinuates the involvement of its agents in internal competition over various forms of nonmonetary benefits or capital as translation is usually understood as the main source of cultural and symbolic capital rather than economic capital fansubbers aspired to accumulate social and symbolic capital by subtitling clips the two forms of capital were achieved through social relationships and positions within saudi society and the online community fansubbers digital skills could also produce digital capital moreover the fansubbers participation in social media generated a form of social media capital as a meaningful benefit from engagement in social media therefore fansubbers subtitled covid19related clips not only for altruism but also to make a name for themselves and accumulate a form of capital this interest in capital accumulation and increased social visibility was clearer as the spread of covid19 cases and death rates surged in march and the following months of 2020 subtitling during the crisis since the first positive case of covid19 in the ksa was recorded audiovisual content on both the moh and fansubbers twitter accounts increased this signified the situations urgency and the need for audiovisual material to communicate information subtitling clips during this critical time was perceived as a tool for reducing vulnerabilities and providing efficient communication during recovery reconstruction and preparation which were part of emergency planning the moh acknowledges this strategy and emphasises the importance of harnessing tv and social media to deliver recorded videos on the guidelines and summarising relevant scientific data and presenting it using the most common languages among the residents in ksa however the moh did not implement subtitling effectively despite the increased number of posted clips during march and april figure 1 shows that only eight clips were subtitled with the remaining 91 in arabic considering the urgent situation some useful and important clips needed to be translated for example the moh posted more than 14 frequently asked questions clips that included essential guidelines and answers to common questions and concerns from the online community however none of them was translated subtitled or dubbed this audiovisual activity shown by the moh during the early months of the covid19 outbreak solved a problem but caused another it solved the lack of tools and content but caused an attainability problem nonarabic speakers residing in the ksa could not access these clips and therefore could not engage with them an example of when crisis communication does not work especially when communication is in a second or third language by observing the digital engagements of the twitter community with the clips posted by the moh during the early months of the crisis subtitled clips attracted significant social interaction for example the most viewed clip in 2020 was a speech by the mohs minister urging citizens to stay home this clip received 146 million views as shown in figure 3 however whether these clips were reachable to nonarabic speakers in the ksa remains arguably the moh did not consider the languages these residents spoke and their digital access in terms of the devices they used or access to the internet this digital divide is relevant in such contexts as a gap exists between those who do and those who do not have access to computers and the internet unequal opportunities appear in such a divide and certain digital skills are not obtainable for everyone what might have increased this divide is the developed digital culture in the ksa and the significant shift towards a more digital government under the influence of saudi vision 2030 which was announced in 2016 considering the role of the moh in providing arabic content with limited subtitling the fansubbers provided nonarabic content and subtitled it into arabic they aimed to foreground some international news and stories and kept the arabic speakers connected with these updates and reports for fansubbers subtitling for nonarabic speakers probably seemed less interesting to them or they did not appreciate its importance this could be ascribed to the central and global position of english as a lingua franca and to the fansubbers personal motivation and forms of capital they are pursuing it may not be beneficial to them neither socially nor economically moreover smf is usually based on personal interest audience needs and capital building even though the crisis may be driven usually by altruistic motivations the total subtitled clips declined significantly during june and july 2020 and fewer fansubbers remained active only 5 of 193 clips were subtitled by 3 of the 17 fansubbers compared to previous months this drop was significant and indicated that fansubbers interest and motivation in crisis translation were waning this change does not neglect their social roles but rather gives an idea of the sociodigital dynamics of smf the themes discussed in these five clips differed from those covered by the moh as usual these clips mentioned the announcement of a new vaccine in the united kingdom misinformation in the united states and the safety of wearing masks the fansubbers chose global news and stories rather than health tips and measures they might have opted for this approach given their previous experience in smf or their understanding of their followers needs and tendencies therefore the fansubbers twitter activity could result from these aspects subtitling covid19 clips was significantly reduced after the lockdown was lifted and the peak curve was overcome subtitling postcovid19 peak by july 2020 the saudi government announced the total lifting of the lockdown in all cities and resuming businesses this decision was a step toward going back to normal or living with covid19 but it also came as an antecedent to the arrival of mediarelated paratexts on twitter while the subtitling of clips on covid19 served a humanitarian purpose some digital paratexts features reinforced the social and digital visibility of the subtitled content and its producers digital paratexts offer multiple perceptions considering the diversity of social media platforms and how content is circulated and perceived making paratextual features important components of subtitling and sharing twitter promotes usergenerated paratexts and displays two forms of paratexts concerning subtitling clips during the pandemic in 2020 mohs subtitling activity on twitter showed a form of official paratexts while the fansubbers depended on fancreated paratexts the functions of these forms of digital paratexts varied depending on the clips purpose timing and intended audience more importantly the genre of the clip as filmic material can display a form of intangible paratextuality therefore subtitling covid19 clips served as a usergenerated paratext moreover the mohs posted clips suggest that the moh restored obvious tangible paratexts to foreground the criticality of the crisis and the importance of the clips messages for example the mohs clips used persuasive language and were accompanied by certain slogans on the clip or within the tweets text common slogans included we are all responsible stay home we return with caution and live well these slogans usually appeared at the end of the clips the frequent use of hashtags also allowed more visibility for some subtitled content and promoted certain social campaigns and events for instance the two most popular hashtags were ‫ورﻮﻛ‬ ‫ﻧ‬ ‫ﺎ‬ the temporality of the subtitles offers a paratextual aspect and helps viewers digital interaction with the clips which may lead them to like the clips afterward the subtitles presentation colour font size and position on the screen also act as a prominent fancreated paratext regarding hashtags most fansubbers used their names surnames or titles in the hashtags the hashtags also included translationrelated words such as translatedby translationof or creativetranslation for example if the subtitlers name is ahmed he may use a hashtag like translatedbyahmed every fansubber has a different approach to using hashtags some prefer to use selfidentified hashtags while others prefer trendy hashtags at that moment the latter strategy is probably useful for making content more visible this practice may solve the issue of access to content as not all twitter users can access some content unless they are following the content creator in other words it is likely that were all getting potentially really different their main goal was to accumulate digital and social media capital the mohs paratexts were informative and avoided any ideological elements in contrast saudi fansubbers adopted fancreated paratexts with intentionally selected genres and varied subtitling strategies the fansubbers showed a degree of manipulation considering their obvious ideological tendencies they also used selfidentified hashtags that referred to the subtitlers identity and facilitated the subtitlers visibility conclusion in sum using digital media to circulate subtitled covid19 content highlighted some interesting aspects more importantly social media facilitated visibility and access to this content promptly and easily smf was not solely altruistic during the pandemic it was a multifaceted digital practice with various purposes and opinions arguably the moh could have cooperated with fansubbers to produce subtitled content and ensure its quality and availability to all target audiences audiovisual translation should be included more effectively in future crisis management strategies and communication plans given its likely digital presence and the availability of digital tools that could promote circulation fostering social visibility and social media capital arguably the mohs lack of interest in subtitling covid19 clips motivated fansubbers to fill the gap and provide reachable content for those who needed it regarding digital interaction with fansubbers clips the most viewed clip was a report by msnbc on the increase in oil prices and the role of russia and the ksa in this matter this clip attracted 11 million views and was posted on march 12 2020 however some fansubbers received more attention and interaction with their subtitled content than others considering their subtitling history visibility on twitter social capital and the number of followers they had it is implausible to compare the interaction they received with the moh for example given that the moh enjoyed a wider audience and followers on twitter and was the official source of healthrelated advice and information on covid19 the moh had 58 million followers while the highest fansubber had 28 million followers however the amount of audiovisual content health advice provided by the moh and the subtitled content offered by the saudi fansubbers indicated the importance of early communication in managing the pandemic in other words both the moh and fansubbers played a vital role in raising peoples awareness of the nature of this novel disease and provided them with necessary guidelines surprisingly the flow of audiovisual content posted by the moh and fansubbers decreased over the following months even though covid19 peaked during june and july 2020 the volume of the published clips did not match the urgency of this stage iv moreover a partial lockdown was imposed on some big cities and the most infected areas from the end of april until late july 2020 therefore the peak of the pandemic and the lockdown were two relevant themes that needed some attention from the moh and online users during the lockdown and peak of the pandemic the moh posted 40 clips with only four clips subtitled into arabic and one into english these clips promoted important notes i the specified figures on the residing nationalities in saudi arabia are not well recorded the reports published by the ksas general authority statistics have ignored such details and recorded the overall number of nonsaudis since 2018 the gas has not recorded the number of nonsaudis in its published reports ii the website is iii agent is perceived sociologically as both an institution or individual endowed with agency and the ability to exert power in an international way translators as social agents tend to be heavily involved in the dynamics of translation production iv for a full timeline of the pandemic in ksa you may refer to the ministry of healths reports and website v for clarity k refers to thousands and m refers to millions references

alt alidi b a n d a r 2 0 2 2 th e s o ciodi gi t al m a nif e s t a tio n s of s u b ti tli n g covid1 9r el a t e d cli p s o n s o ci al m e di a pl a tfo r m s in s a u di ar a bi a th e c a s e of s o ci al m e di a fa n s u b ti tlin g o n twit t er th e jou r n al of in t e r n a tio n aliz a tio n a n d loc aliz a tio n 9 2 p p 9 71 1 9 1 0 1 0 7 5ji al0 0 0 2 2 al t p u blis h e r s p a g e h t t p s doio r g 1 0 1 0 7 5ji al0 0 0 2 2 alt pl e a s e n o t e c h a n g e s m a d e a s a r e s ul t of p u blis hi n g p r o c e s s e s s u c h a s c o pye di ti n g fo r m a t ti n g a n d p a g e n u m b e r s m a y n o t b e r efl e c t e d in t hi s v e r sio n fo r t h e d efi nitiv e v e r sio n of t hi s p u blic a tio n pl e a s e r ef e r t o t h e p u blis h e d s o u r c e you a r e a d vis e d t o c o n s ul t t h e p u blis h e rs v e r sio n if yo u wis h t o ci t e t hi s p a p er this ve r sio n is b ei n g m a d e a v ail a bl e in a c c o r d a n c e wi t h p u blis h e r p olici e s s e e h t t po r c a cf a c u k p olici e s h t ml fo r u s a g e p olici e s co py ri g h t a n d m o r al ri g h t s fo r p u blic a tio n s m a d e a v ail a bl e in orca a r e r e t ai n e d by t h e c o py ri g h t h ol d e r s the sociodigital manifestations of subtitling covid19related clips on social media platforms in saudi arabia the case of social media fan subtitling on twitter

adolescent males interested in sex with males are at elevated risk for human immunodeficiency virus in the united states accounting for 93 of new infections among males in their age cohort racialethnic minority amsm are particularly vulnerable hiv infection among amsm often results from early sexual experiences or occurs later as a result of behavior patterns established during adolescence sexual education interventions that serve amsm preferably before sexual behavior patterns are formed are essential to addressing hiv disparities among these youth despite the need there is a dearth of educational resources to prepare amsm for healthy sexual activity amsm are less likely than their heterosexual peers to receive relevant sexual health information in school or from their parents as a result amsm turn to the internet where they obtain sexual health information and make connections with other amsm amsm use sexually explicit online media to learn the mechanics of sex confirm their sexual attractions and learn about gay culture because the internet is particularly influential on the sexual development of amsm and because it can be an effective way to reach hidden populations in research the internet is an ideal location to provide sexual health interventions to amsm limited research has investigated the internets potential to provide sexual health interventions to amsm one barrier to such research is the reluctance of institutional review boards to approve waivers of guardian permission this issue was first raised by mustanski as was a call for research in this area subsequent research has documented guardian permission as a potential barrier to sexual and gender minority youth participation in online sexuality survey research hiv testing studies and preexposure prophylaxis prevention trials this research indicates that for these types of studies requiring guardian consent is likely to decrease participation rates and create a biased sample it could also lead to harm for the participants this is particularly true for sexual and gender minority youth who are not yet out to their guardians for these reasons guardian consent waivers have been recommended by research ethics experts regardless of expert recommendations irbs often fail to consider amsmunique risks related to requiring guardian permission when irbs decline to approve waivers of guardian permission they inadvertently hinder research that could form the evidential base for sexual health interventions for amsm the current study sought to provide irbs and investigators with the information needed to make informed decisions around guardian permission for amsm participation in online sexual health research specifically with regard to amsms willingness to participate in online sexual health interventions designed to increase youths ability to engage in health sexual relationships with male partners and decrease their hiv risk we used mixedmethods to determine the extent to which guardian permission is a barrier to engagement in online sexual intervention research among amsm particularly for amsm who are not out to their guardians this study builds on and extends previous research in this area in multiple ways previous studies included sexual and gender minority youth more broadly and had relatively small samples of amsm our study represents the largest study to date of amsmspecific attitudes toward guardian permission for sexual health research further previous studies focused on sexual and gender minority youth attitudes toward guardian permission for an online survey about sexual health and sexualgender minority identity an hiv testing study and a prep adherence trial our study is the first to assess amsmspecific attitudes toward guardian permission for online sexual health intervention research although guardian permission may serve as a barrier to sexual and gender minority youth participation in sexual health research generally amsm represent a unique population that experiences substantial sexual health disparities in the united states and is in need of targeted online sexual health interventions given this need information on the challenges of obtaining guardian permission for this specific research is imperative method study design closed and openended questions were imbedded in a crosssectional survey designed to inform the development of an onlineadministered sexual health intervention for amsm participants were recruited in june and july 2017 via online advertisements and posts on social media sites social media advertisementsposts included gifs and static images that featured young men and emoji text focused on participating in an online survey to help researchers develop a more inclusive online sexual health program to optimize racialethnic diversity and increase the potential that advertisements posts would be seen by males who are interested in male sexual partners but not necessarily identify as gaybisexual advertisementsposts were broadly targeted to 14to 17yearold males in the united states who were identified by the facebookinstagram algorithms as interested in topics our youth advisory board and our own research generated as popular among racialethnic minority amsm eligibility criteria were age 14 to 17 cisgender male selfidentify as gaybisexual report being sexually attracted to males or report having voluntary sexual contact with a male partner reside in the united states have a personal email address and be new to the study upon clicking on an advertisement or social media post potential participants were directed to the survey web site hosted using redcap which described the study and asked respondents to continue for eligibility questions to protect against fraudulent entries or multiple enrollments screening and survey responses were crossreferenced against date of birth location sexual activity and email address after screening respondents progressed to consent material we adapted procedures used by newcomb mustanski thus capacity to consent was confirmed via four questions that evaluated respondents ability to name things they would be expected to do during the study to explain what they would do if they no longer wished to participate in the study to explain what they would do if they experienced distress during the study and to identify potential risks for participating in nelson carey and fisher the study specifically participants were asked if you agree to be in this study what are we asking you to do what should you do if you no longer want to be in this study what can you do if you experience distress while taking part in this study and what are the potential risks of being in this study respondents unable to answer all four questions after three tries were ineligible those who consented received an email containing a unique survey link the survey took 30 minutes on average participants who completed the survey received a 15 amazoncom gift code by email all procedures including a waiver of guardian consent were reviewed and approved by our hospital irb measures the survey covered multiple potentially sensitive topics in addition to questions about guardians and ethical issues for this article we report on sociodemographics outness to guardians and attitudes toward guardian permission sociodemographics characteristics included recruitment source census region of the united states age raceethnicity enrollment in school highest education level living situation urbanicity employment sexual orientation and age realized sexually attracted to men other in recruitment source includes from a friend or participants who reported other as their source census region was designated using selfreported state of residence guardians participants indicated whether they had told their guardian that they were sexually attracted to other boysmales separate questions assessing primary and secondary guardian were combined to form a variable indicating whether they were out with at least one guardian attitudes toward guardian permission guardian permission questions were adapted from previous work at the end of the survey participants rated if they would have participated in the current survey if a guardians permission had been required researchers should require a guardians permission for this type of survey and they agreed with reasons why researchers should or should not require guardian permission other reasons researchers should and should not get written guardian permission for this type of survey were assessed in an openended format participants then read the following description of a future study involving an online sexual health intervention the next set of questions asks about how you might feel about getting written parentalguardian permission for the study of the online sexual health program we are designing participants will be asked to fill out a survey complete the developed sexual health program or use an alternative source of online sexual health information and then fill out two additional surveys the surveys will contain information similar to what you just filled out the sexual health program will take about 90 minutes to complete and will include a discussion of online pornography participants were then asked questions that mirrored the questions and response options they answered about the current survey analyses quantitative analysis sociodemographic differences by outness with a guardian were assessed using t and χ 2 tests logistic regression models assessed differences in attitudes toward guardian permission by outness with a guardian raceethnicity age and sexual orientation were controlled for in adjusted multivariable logistic regression models of the 206 amsm 34 had missing data on one or more guardian permission attitude variables to assess sociodemographic differences between participants with missing data versus those with complete data we conducted t and χ 2 tests participants with missing data were more likely to live outside a metropolitan area there were no other sociodemographic differences qualitative analysis two coders from the study team independently reviewed answers to the four openended questions and identified emergent concepts the coders agreed upon a set of initial codes which included deductive codes drawn from research questions and inductive codes representing concepts raised in participant answers the codebook was revised guardian permission for adolescent males interested in sex with males sex research throughout data from the openended questions were doublecoded and disagreements were resolved through discussions between the coders finalized codes and the answers assigned to them were entered into nvivo 11 cohens kappa for the final codes ranged from 083 to 100 indicating excellent interrater reliability a framework matrix analysis was conducted to summarize aggregate and establish frequencies of code endorsement a mixedmethods analysis was conducted to explore whether endorsement of codes differed according to whether participants had disclosed their sexual attraction to male partners to their guardians in accordance with prior studies we performed these analyses only on codes endorsed by at least five participants and considered differences by outness in code application rates of at least 20 to be meaningful to assess sociodemographic differences between participants who responded to openended questions versus those who did not we conducted t and χ 2 tests most participants answered at least one of the openended questions participants recruited through facebookother were more likely to have answered at least one of the openended questions compared to those recruited through instagram there were no other sociodemographic differences results participation if guardian permission is required most amsm would not participate in either the current survey or the future study if guardian permission was required compared to youth who were out to one or more guardians youth who were not out had almost three times greater odds of reporting that they would not participate in the current survey and approximately five times greater odds of reporting that they would not participate in the future intervention study if guardian permission was required regardless of outness almost all participants felt that guardian permission should not be required reasons to require guardian permission quantitative data half of the amsm agreed with the investigatornominated reasons that guardian permission should be required for the current survey or future study the only differences by outness in agreement with these reasons was that guardian permission provided opportunities for parents to explain research risks and benefits for the current survey amsm who were not out were less likely to agree with this reason qualitative data of those who responded to the openended question regarding the current survey or the future study one of the most frequently endorsed reasons for why guardian permission should be required was that guardians could support youth as they participated for example one participant noted my papa could help me understand questions after survey another participant wrote they could help me if i was unsure what i was thinking another stated they could go through it with me there was not a nelson carey and fisher meaningful difference in the frequency of endorsement of this potential benefit between those who were out compared to those who were not out with a guardian interestingly in response to this question many participants took this opportunity to voice their opposition to the assertion that parental permission should be required the majority of these responses simply stated as one participant did they shouldnt some participants were specific about reasons why guardian permission should not be required for example one stated its uncomfortable and i would lie on the survey if parental consent was required participants who were out gave this type of response less often than those who were not out for the future intervention study reasons against requiring guardian permission quantitative data most amsm agreed guardian permission might lead to questions about their sexual behaviors and seom use or to being outed compared to participants who were out those who were not out were more likely to feel that they would be punished outed kicked out of the house or forced to speak with a counselorreligious person if guardian permission was required regardless of outness the majority reported that it would be very easy or easy for them to say no to a researcher if they did not want to participate qualitative data of those who responded to the openended question asking them to elaborate on other reasons why guardian permission should not be required for the current survey or the future study the most common reasons given were that requiring guardian permission would be an invasion of privacy it would be uncomfortable and it could be dangerous there 93 94 19 17 they might find out that i am gay bisexual or interested in sex with male partners 157 91 66 138 148 they might kick me out of the house 48 32 16 30 26 they might make me talk to a counselor or religious person 94 53 41 20 19 note aor adjusted for raceethnicity age and sexual orientation ci confidence interval or odds ratio aor adjusted odds ratio guardian permission for adolescent males interested in sex with males sex research were no meaningful differences in the frequency of endorsement of these reasons by outness with a guardian for responses that highlighted privacy most participants stated something like the sentiments of two participants its an invasion of privacy and sometimes kids like to keep this information to themselves some participants were more nuanced in their language for example one participant stated its not their business its not their choice the law should be more considerate to recognize teens as people with rights of privacy too another stated i should have some amount of personal freedom to share my own personal experiences with a researcher without my parents being involved when talking about guardian permission for sexual health research being uncomfortable participants often noted that they did not want to talk with their guardians about these topics as one participant said i dont talk to my parents about stuff like this because i dont feel comfortable doing it and i feel like i dont have to another stated it is awkward to discuss with a person who upholds you to a standard of innocence like being abstinent and heterosexual stated another way s ince these questions are pretty personal a lot of teens would not feel comfortable with their parents knowing many participants stated sentiments similar to this participant it could make people uncomfortable youth felt that requiring guardian permission could be dangerous one participant stated f or some people it could be really dangerous for their guardian to find out if they are unsupportive and the participant is dependent on them another wrote its not always safe to have parents permission on a topic like this some feared consequences to requiring guardian permission two responses included they could kick me out or punish me and because we could be disowned or something discussion amsm experience increased risk for hiv acquisition and decreased access to relevant sex education in lieu of relevant sexual education amsm turn to the internet to obtain sexual health information and to locate sexual healthrelated services although amsm frequently use the internet to find sexual health information and locate services they also recognize that the internet can be an unreliable source online sexual health interventions for these youth have the potential not only to meet them where they are already seeking sexual health information but also to help them develop the necessary skills to critically examine the information available online and dispel myths that may be presented despite the importance of tailored sexual health interventions for amsm that address the misinformation they may be receiving online there has been limited research among amsm under age 18 to guide the development of interventions for these youth a barrier to the inclusion of amsm in sexual health research is the stance that many irbs take in requiring guardian permission for research involving underage amsm federal regulations permit irbs to waive guardian permission when research is minimal risk or when such permission is not a reasonable protection for the youth the few online sexual health studies that have been conducted with amsm have received waivers of guardian permission indicating that waivers of guardian permission can be successfully obtained for this work from some irbs empirical evidence on the barriers and potential harms guardian permission poses to online sexual health research among amsm is essential to making informed judgments regarding the risks and benefits of this requirement to provide irbs and investigators with the information they need to make ethical decisions around guardian permission for online sexual health research with amsm we examined amsm attitudes toward guardian permission for an online sexual health survey and for a future online sexual health intervention trial in this sample amsm overwhelmingly reported that they would not have participated in the current survey if guardian permission had been required and would not participate in a future online sexual health intervention study if guardian permission were to be required this was particularly true for individuals who were not out to their guardian these amsm were three times more likely to say they would not have participated in the survey and five times more likely to say they would not participate in the intervention study further regardless of outness with a guardian almost all participants felt that guardian permission should not be required for this type of research these findings are in line with similar findings that requiring guardian permission would decrease participation in sexualityfocused online survey research hiv testing studies and prep prevention trials among sexual and gender minority youth only about half of the participants agreed with proposed reasons why guardian permission should be required previous research regarding hiv testing among sexual and nelson carey and fisher gender minority adolescents found that less than 10 of participants endorsed similar reasons for requiring guardian permission measurement difference may explain these two findings in the hiv testing study participants were provided a list of potential reasons and asked to check all that apply in the current study participants indicated how much they agreed or disagreed with each potential reason asking participants to indicate agreement may capture more nuanced data about participants attitudes research should examine the best methods for measuring the risks and benefits of guardian permission among amsm most participants endorsed multiple reasons why guardian permission could be detrimental including concerns that it would be an invasion of their privacy lead to unwanted outing and endanger participants participants also felt that requiring guardian permission would lead to uncomfortable conversations with their guardian which could serve as a barrier to participation these findings supplement the results of previous smaller studies with sexual and gender minority youth that found requiring guardian permission would bias samples and may lead to harm for participants guardian permission requirements are predicated on assumptions that guardian decisions reflect the best interest of the child and protect the child from harm and that youth are incapable of making informed decisions on their own or will have difficulty saying no to researchers our results as well as related research indicate that these assumptions may not hold true specifically guardians may make decisions based on their own beliefs about sexuality rather than focusing on the risks and benefits of youth participation further requiring guardian permission has the potential to increase risks for some participants especially for those with guardians who do not support their childs sexual preferences research also indicates that adolescents ages 14 and older understand the nature of research and participant rights at the same level as adults finally our results in line with previous hivspecific research found that the majority of adolescents feel capable of declining participation in online sexual health research on their own as guardian permission appears to serve as a barrier to participation and may not be necessary to protect amsm participating in online sexual health research it is important for researchers and irbs to consider alternative ways to protect amsm participating in this critical work one means to protect these youth is to create a consent process that matches the developmental and educational status of participants research on optimizing consent among youth recommends a process that includes multimedia presentations quizzes to assess understanding and an emphasis on the potential benefits of the research for youth additional research assessing the best way to present online consent materials that are understandable are engaging and optimize adolescents ability to make informed and voluntary participation is warranted the limitations of this study should be considered although this study presents data from a relatively large and diverse sample the findings may not generalize to other youth such as transgender or youth interested exclusively in oppositesex partners further participants were recruited through advertisements on social media platforms it is possible that youth who click on an advertisement for a sexual health study differ from youth who do not as social media web sites are commonly used for recruiting sexual minority youth it is important to assess potential bias that results from these methods notably only 206 of the 661 eligible individuals completed the study and were included in the analyses differential attrition in this study occurred primarily during the consent process lending further support regarding the need for effective and efficient online consent processes for sexual health research although attrition is not unusual in online research additional investigation assessing ways to decrease attrition generally and statistical means to address potential biases introduced by attrition in online research is needed lastly our participants reported on their perceptions of how their guardians would react to their participation in online sexual health research these assumptions may not accurately reflect how guardians would react two us studies found that guardians understand the importance of guardian permission waivers for hiv research and believe that waivers of guardian permission increase study validity and reduce obstacles to participation additional research assessing guardian attitudes toward amsm participation in online sexual health research and guardian permission requirements especially among guardians who are less likely to be accepting of their adolescents sexual preferences is needed in conclusion amsm are getting most of their sexual health information from the internet likely without guardian permission or awareness research on online sexual health interventions for amsm is critical to ensure the creation of efficacious sexual health programs that provide essential information and increase amsms ability to engage in healthy sexual relationships requiring guardian permission for this research would likely exclude youth who are not out to their guardians or do not feel comfortable asking for guardian permission amsm who are not out or have unsupportive families are at increased risk for adverse health outcomes eliminating these youth from online sexual health research will bias our understanding of their needs which in turn will undermine the development of efficacious online sexual health interventions among the advantages of conducting online sexual health intervention research with amsm is the removal of interpersonal geographic logistical and stigmabased barriers to participation given our results guardian permission appears to potentially create a significant barrier to the online sexual health research needed to promote sexual wellbeing and decrease hiv risk among amsm therefore we recommend that investigators and irbs reevaluate this practice and consider alternative procedures and policies to facilitate this research with amsm funding and acknowledgments

institutional review boards irbs that refuse to grant waivers of guardian permission may hinder research to inform needed online sexual health interventions for adolescent males interested in sex with males amsm information on the challenges of obtaining or waiving guardian permission is imperative in june and july 2017 amsm n 206 ages 14 to 17 in the united states completed an online survey on sexual behaviors sexually explicit media use and sexual education exposureneeds a mixedmethods approach assessed attitudes toward guardian permission for the current survey and future online sexual health intervention research logistic regression models assessed differences by outness to a guardian a framework matrix analysis was conducted to summarize then aggregate qualitative responses findings indicated that most amsm would not participate if guardian permission was required current 83 future 87 youth who were not out were more likely to say they would not participate current adjusted odds ratio aor 28 95 confidence interval ci 12 to 68 future aor 47 95 ci 16 to 135 participants reported that guardian permission would be an invasion of their privacy lead to involuntary outing and endanger participants overall guardian permission appears to be a barrier to amsm participation in online sexual health research investigators and irbs should consider alternative practices and policies to facilitate such research

introduction the debate in medical ethics about assisted dying has by and large moved on from the question of whether assisted dying is in principle morally defensible to the specifics of when it is morally defensible 1 these specific issues include but are not limited to questions of scope and requests made in advance of loss of decisionmaking capacity indeed not a year seems to go by without yet another country legalising or decriminalising assisted dying yet not a day seems to go by without debates raging about these other issues these issues have led to many months of acrimonious academic as well as public debate in canada the core of the 20202021 debate was whether natural death on a sufficiently limited time horizon or predictable trajectory should be an eligibility criterion or whether instead access to maid should also be available for decisionally capable people suffering for instance from irremediable severe mental illnesses or a range of diverse severe disabilities in the latter cases death could well be many years if not decades away and the trajectory and ultimate cause of death unpredictable many of the arguments are complex and they have been rehearsed extensively during the debate in canada since 2016 2 we do not intend to review those known arguments here again rather we will focus on two arguments that got a new lease on life in the 20202021 round of maid debates the first is a social determinants of health argument with respect to persons with disabilities and persons with a mental disorder as their sole underlying medical condition do problems with the social determinants of health that might impact decisionmaking justify denying eligibility for assisted dying for those individuals the second is a slippery slope argument do changes to a countrys assisted dying legislation lead to descents down slippery slopes we explore these two questions through the lens of canadas experience both to inform canadas ongoing discussions and because other countries will confront the same questions if they contemplate changing their assisted dying law canadas maid law has evolved through a journey from the courts to parliament back to the courts and then back to parliament along this journey the eligibility criteria the procedural safeguards and the monitoring regime have changed in this article we focus on the eligibility criteria first we explain the evolution of the law and what the eligibility criteria were at the various stops along the way we then explore the ethical justifications for canadas new criteria by focusing on the social determinants of health and slippery slope arguments against the new criteria canadas legislative and judicial journey in this section we begin with an explanation of the first successful law reform effort and then describe the evolution of the law and our understanding of the law up to the 2021 amendments made to the criminal code of canada i ii we pay particular attention to the law as it relates to the ethical issues at the heart of this paper regarding the social determinants of health and slippery slopes feature article this legal overview is essential to ground an analysis of the ethical defensibility of the eligibility criteria in canadas maid regime before one can engage with these two ethical critiques of the law one must first understand what the law actually has been and is carter v canada 2015 scc 5 the criminal code of canada contained blanket prohibitions on aiding suicide and euthanasia these prohibitions were challenged in carter v canada in this case several plaintiffs argued that the blanket prohibitions violated multiple rights protected under the canadian charter of rights and freedoms specifically the right to life liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice and the right to equal protection and equal benefit of the law without discrimination the supreme court of canada agreed with the plaintiffs and declared section 241 and s 14 of the criminal code unjustifiably infringe s 7 of the charter and are of no force or effect to the extent that they prohibit physicianassisted death for a competent adult person who clearly consents to the termination of life and has a grievous and irremediable medical condition that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition iii grievous and irremediable medical condition was not defined by the court irremediable however they noted does not require the patient to undertake treatments that are not acceptable to the individual iii justice smith at trial conducted a robust analysis of the equality arguments for and against decriminalisation of assisted dying with respect to people with disabilities she expressly considered expert evidence about the impact of ableism the promotion of the idea that some lives are more valuable than others the concern that clinicians will be more likely to agree to the assisted death of persons with disabilities than persons with cancer the social construction of disability and unconscious bias in the clinicians who would respond to requests she concluded that the law creates a distinction that is discriminatory it perpetuates and worsens a disadvantage experienced by persons with disabilities the dignity of choice should be afforded to canadians equally but the law as it stands does not do so with respect to this ultimately personal and fundamental choice iv canada v ef 2016 abca 155 the first court decision to offer insight into the meaning of the key eligibility criterion grievous and irremediable medical condition was canada v ef this case involved a woman with a mental illness as her sole underlying medical condition v the iii carter v canada 2015 scc 5 iv carter v canada 2012 bcsc 886 v the case was in court because the scc had suspended its declaration of invalidity of the criminal code provisions for 12 months to give parliament time to amend the law should it want to do so parliament failed to meet this deadline and sought an extension they were granted a 4 months extension but in the meantime individuals were permitted to go to court to seek a judicial authorisation to be permitted to access maid they could get this authorisation if a court found that they met the criteria set out in the carter decision government argued that she did not meet the eligibility criteria from carter arguing that carter was limited to those who are terminally ill and that individuals with a psychiatric illness were excluded from eligibility under carter however the alberta court of appeal disagreed in summary the declaration of invalidity in carter 2015 does not require that the applicant be terminally ill to qualify for the authorisation vi persons with a psychiatric illness are not explicitly or inferentially excluded if they fit the criteria vi ab v canada 2017 onsc 3759 the second case to offer insight was ab v canada this case involved an elderly woman with an advanced and incurable disease suffering enduring and intolerable pain her natural death was not imminent vii justice perell concluded that natural death need not be imminent viii and the physician need not opine about the specific length of time that the person requesting medical assistance in dying has remaining in his or her lifetime viii justice perells decision has frequently been relied on to support the interpretation of natural death has become reasonably foreseeable as sufficient temporal proximity or on a predictable trajectory toward death 3 4 this was then used to justify finding a person had met the reasonably foreseeable criterion even if they had for example a prognosis of many years or had just been diagnosed with als or parkinsons at this point in canadas journey by virtue of court cases it had become clear that some people with disabilities could be eligible for assisted dying as could some people with mental illness even when the disability or mental illness was the persons sole underlying condition bill c14 some 16 months after the carter decision was released the canadian parliament passed bill c14 an act to amend the criminal code and to make related amendments to other acts most notably for the purposes of this paper they included the requirement of a grievous and irremediable medical condition but defined it more narrowly than the scc had done specifically they defined it as follows a person has a grievous and irremediable medical condition only if they meet all of the following criteria feature article that is intolerable to them and that cannot be relieved under conditions that they consider acceptable and ► their natural death has become reasonably foreseeable taking into account all of their medical circumstances without a prognosis necessarily having been made as to the specific length of time that they have remaining ix even as parliament was considering the bill constitutional law experts told the members of the house of commons and the senate that the definition of grievous and irremediable medical condition was inconsistent with the scc decision in carter and even more importantly was not compliant with the charter in that it violated the right to life liberty and security of the person as well as the equality provisions protecting against discrimination on the basis of disability x agreeing with these experts the senate amended the bill to remove the requirement that a persons natural death have become reasonably foreseeable 5 however the house rejected that amendment 6 and the senate backed down xi the bill was passed with the full narrow definition ten days later the bill was challenged in court in british columbia 7 and subsequently also in quebec xii truchon v attorney general and attorney general 2019 qccs 3792 the second charter challenge launched against bill c14 got to court before the first and was successful there in this case two individuals with severe disabilities argued that the eligibility criterion natural death has become reasonably foreseeable violated their section 7 right to life liberty and security of the person and their 15 charter right to equality before and under law and equal protection and benefit of law justice baudouin of the quebec superior court agreed with the plaintiffs and declared that the reasonably foreseeable eligibility criterion violated the charter in part because it discriminated against persons with disabilities to exclude them from access to assisted dying it is important to note that justice baudouin confirmed that individuals with mental illness were not excluded under carter xii it is also worth noting here that the attorney general of canada chose not to appeal the truchon decision explaining his decision the attorney general stated we decided not to appeal the truchondecision because we agreed that medical assistance in dying should be available as a means to address intolerable suffering outside of the endoflife context to ensure the consistency of criminal law across the country we committed to amending the criminal code xiii elsewhere he noted that they decided not to appeal because they thought the decision was sound and that they would lose on appeal c7 some 17 months after the truchon decision was released the canadian parliament passed bill c7 an act to amend the criminal code xv most notably for the purposes of this paper they removed natural death has become reasonably foreseeable as an eligibility criterion for maid xvi therefore all persons with disabilities are now allowed to access maid the legislators also added an exclusion criterion for the purposes of the serious and incurable illness disease or disability provision in the legislation mental illness is not considered an illness disease or disability thus excluding persons with a mental illness as their sole underlying medical condition from eligibility for assisted dying xvii in some ways bill c7 is closer to carter than c14 was c7 removed c14s natural death has become reasonably foreseeable in other ways bill c7 is further from carter than c14 was c7 added explicit full exclusion of mental illness as the sole underlying medical condition implications of the current destination at the end of the journey from carter to bill c7 we have arrived at a position that has among other things the following implications for the ethical issues that will be discussed in the next part of this paper mental illness ► persons with mental illness as their sole underlying condition are not eligible for maid ► persons with mental illness can be eligible for maidso long as they also have a physical condition that is a serious and incurable illness disease or disability ► mental illness can be the cause of the persons enduring intolerable and irremediable suffering for which they are seeking maidso long as their suffering from their mental illness is the cause of their advanced state of irreversible decline in capability ► this is not an expansion of the supreme court of canada decision in carter xviii disabilities ► persons with disabilities that do not make their natural death reasonably foreseeable will now be eligible for maid feature article ► it is not only persons with disabilities who are now eligible as a result of the removal of the eligibility criterion of natural death has become reasonably foreseeable but also people with chronic illnesses ► this is not an expansion of the supreme court of canada decision in carter xix we turn now to the exploration of ethical arguments about the new eligibility criteria for maid in canadaspecifically the arguments relating to the social determinants of health and slippery slopes social determinants of health disability and the social determinants of health in the 20202021 debate over whether to remove bill c14s requirement that natural death be reasonably foreseeable arguments based on the social determinants of health rose to particular prominence xx mostly advanced by antiassisted dying disability rights groups these arguments may be familiar to those who have followed these debates over the years but they might be new to people unfamiliar with arguments grounded in frameworks like the vulnerable persons standard 12 or as made by groups like not dead yet 13 before articulating these arguments a point about representation and terminology is required while many antiassisted dying disability rights activist groups have voiced these arguments it is unclear to what extent theseoften powerfulvoices are representative of the views held by persons with disabilities writ large in 2021 dying with dignity canada an assisted dying activist group commissioned a survey of canadians views on proposed changes to canadas assisted dying law the survey showed no meaningful differences between canadians identifyingnot identifying as disabled in terms of their support for a permissive access regime sixty per cent of people with disabilities wanted to remove the requirement that death be reasonably foreseeable 14 it is also worth emphasising that the plaintiffs in lamb v canada 7 and truchon v canada xii were people with disabilities as their sole underlying condition fighting for the removal of the reasonably foreseeable requirement the survey we cite was commissioned by a proassisted dying advocacy group however we could find no other surveys and of course the plaintiffs are merely individuals their existence and actions do not tell us about the views of other persons with disabilities however while we cannot claim that all persons with disabilities support removing reasonably foreseeable we note that disability activist groups that oppose removing reasonably foreseeable do not speak for all persons with disabilities indeed we cannot know xix some have argued for a narrower interpretation of the initial carter criteria and therefore concluded that c7 is an expansion of the carter decision see for example attorney general of canada and attorney general of quebec in truchon however as explained by justice baudouin in truchon 16 para 7793 this narrower interpretation was rejected by the federal external panel on options for a legislative response to carter v canada 9 the provincialterritorial expert advisory group on physicianassisted dying 10 and the special joint committee on physicianassisted dying 11 xx it must be noted here that many of these arguments were made and rejected by the courts most recently in truchon we go into them here because they have taken on such prominence in the public arena and are likely to play an outsize role in the coming debate that will take place under the auspices of an independent expert panel on the implementation of assisted dying for mental illness and the 5year parliamentary review of the legislation how many or what proportion they speak for therefore rather than perpetuate the misperception that persons with disabilities are overwhelmingly opposed to assisted dying being available to persons with disabilities as their sole underlying medical condition by saying persons with disabilities arguments or disability rights groups we say antimaid disability rights activist group arguments and related variants some antiassisted dying disability rights activists and scholars argue that what is often referred to as disability should be seen as a variety of human existence a mere difference that is unproblematic in its own right 15 oftentimes the struggles of gay liberation activists are mentioned to drive home this point with disabled like gay being said to be mere difference 16 the mere difference view could support the argument that it is never the disability itself that could render a person with disabilitys life not worth living but rather it is the social determinants of health on this view it is the absence of reliable support services when they are needed or poverty homelessness and so on that reduce some or many persons with disabilities quality of life to such an extent that they might ask for assisted dying 17 empirical evidence supports the view that both disability as well as mental illness can reduce peoples social determinants of health resulting in a lower quality of life than would have otherwise been the case for instance for people who acquired disability later in life the reported negative impacts on their social determinants of health oftentimes are a consequence of reduced inflow and increased outflow of finances that had subsequent negative effects on housing transport and social interactions and also personal relationships as one australian study notes 18 a similar case has been argued for persons with intellectual disabilities as reportedly they experience higher rates of common health conditions poorer health outcomes and restrictions to timely access to effective healthcare over a life course perspective the cumulative effects of these inequalities compound over time which essentially means that for people with intellectual disabilities such health inequalities begin earlier in their lives and the cumulative effects have a greater impact on most as they get older 19 based on evidence like this one could hold the view that in the absence of such negative impacts on a disabled persons social determinants of health their disability might be a mere difference but not a difference that would trigger requests for maid mental illness as sole underlying medical condition and the social determinants of health a similar pattern emerges with regard to decisionally capable people experiencing severe mental illnesses some commentators insist that people with mental illness as their sole underlying medical condition are seeking assisted dying because their suffering is caused not by their condition but rather by poverty homelessness racism and other social determinants of health other authors concede that the mental illness could cause the suffering but insist that the patients suffering is remediable and the treatments that could work are not available to the patient on this argument a person with mental illness asking for an assisted death is merely an indication of a healthcare system failing the needs of that patient 20 responses to the social determinants of health arguments in manyif not alljurisdictions many people with disabilities as well as people with mental illnesses suffer from a disadvantage not inherent in their illness and that is a decrease in their social determinants of health which can manifest itself on february what can be questioned is what opponents of making these two classes of individuals eligible for assisted dying claim follows from this observation they essentially hold the view that such patients should not be eligible for assisted dying because their decision to ask for an assisted death might be a consequence not of their direct illnessrelated suffering but rather of these social determinants of health they conclude that such patients should not be eligible for assisted dying until these resource shortcomings are fully remedied the canadian parliament and courts have considered the evidence and arguments with respect to social determinants of health in relation to the policy position on who should have access to maid they have concluded that the evidence and arguments do not support prohibiting persons with disabilities as their sole underlying condition from accessing maid and they only support restricting access to persons with mental illness as their sole underlying medical condition for 2 years a critical conclusion to highlight here is that the canadian parliament and courts recognise the problems with the social determinants of health for many individuals with disabilities and mental illness but are nonetheless committed to individual casebycase assessments rather than groupbased exclusions this is best expressed by justice baudoin in truchon she considered and addressed arguments grounded in concerns about social determinants of health specifically lack of access to appropriate care poverty unemployment ongoing abuse or violence xii socioeconomic factors such as income education race age health insurance and institutionalization xii poverty or financial precariousness xii stigma and discrimination poverty low selfesteem isolation and inadequate resources xii and lack of access to adequate medical resources and services xii she concluded that 252 the court cannot accept the concept of collective vulnerability suggested by the attorney general because the broad protection that results therefrom is too general an application of a precautionary principle vulnerability should not be understood or assessed on the basis of a persons belonging to a defined group but rather on a casebycase basis at least for the purposes of an analysis under section 7 of the charter in other words it is not the persons identification with a group characterized as vulnerablesuch as persons with disabilities indigenous persons or veteransthat should bring about the need to protect a person who requests medical assistance in dying but rather that persons individual capacity to understand and consent in a free and informed manner to such a procedure based on his or her specific characteristics … 309 in the courts view however we cannot in the name of the principle of protecting certain persons from themselves or of socially affirming the inherent value of life deny medical assistance in dying to an entire community of persons with disabilities precisely because of their disability that is what the legislator is doing indirectly by providing wideranging protection of certain groups instead of implementing strict structural conditions to ensure that such persons are well protected should it deem it appropriate again collective vulnerability cannot be conceptually used as a basis to refuse medical assistance in dying 310 mr truchon and ms gladu who belong to this category of persons want to be given the choice to decide for themselves the court agrees with this to do otherwise could lead to discrimination against persons with disabilities on the sole basis of their disability these people are full citizens and consequently have the same rights as all other citizens especially those that involve making decisions of utmost importance to their bodily integrity and dignity as human beings respect for their individual freedom that is expressed thoughtfully freely and clearly also contributes to the affirmation of the inherent value of their lives outside the halls of government and justice additional arguments can be made against the social determinant of health arguments against allowing maid for persons with disabilities and mental illness as their sole underlying medical condition proponents of restrictive access regimes contribute ironically to the continuing stigmatisation of both disability as well as mental illness they essentially advocate to remove such patients agency because they disapprove of the endoflife choice that some of these patients would predictably make the kind of strong paternalismwell intentioned as it may bethat is on display here must be placed where it belongs in a long tradition of views of disability and of mental illness that renders such patients less able than others to make decisions about their own lives much of the sea change in societal views of both disability and mental illness is owed to successfully dispelling precisely such stigmatising myths opponents of patient choice when it comes to assisted dying and the eligibility of persons with disabilities and people with mental illness take this full circle they sacrifice patient rights on the altar of their paternalistic values these arguments also fail to respect the lived experience of some people with disabilities or severe mental illness who insist that their suffering is caused by their condition not by social determinants of health 21 they also fail to recognise that some people with disabilities or severe mental illness seeking assisted dying are privileged and not lacking with respect to the social determinants of health some people with disabilities or severe mental illness have good access to all possible treatments supports and services and some decisionally capable persons with disabilities or severe mental illness reject the treatments supports and services proposed by their clinicians the arguments also fail to recognise that people seeking assisted dying often have comorbiditiesboth mental and nonmental illnesses the social determinants of health arguments in relation to disabilities and severe mental illness can apply just as much where disability or severe mental illness is the sole underlying medical condition as a comorbidity unless one wants to argue that nobody with a disability or a severe mental illness should have access to assisted dying even for for example cancer and als then the social determinants of health argument is not enough to justify excluding persons with a disability or a severe mental illness as their sole underlying medical condition the argument that people with disabilities or mental illness as their sole underlying medical condition should not have access to maid unless and until everyone has access to adequate supports and services has an historical antecedent also rejected by both the canadian parliament and the courtsthe argument that no one should have access to maid unless and until everyone can access palliative care in a timely fashion when they on feature article could benefit from it 22 the argument re social determinants of health fails for the same reason the argument re palliative care failed as justice smith observed in carter the argument that legalization should not be contemplated until palliative care is fully supported rests as dr van delden observed on a form of hostagetaking in other words this argument suggests the suffering of grievouslyill individuals who wish to die will serve as leverage for improving the provision of adequate palliative care iv furthermore while none of the jurisdictions that have legalised or decriminalised assisted dying to date have made an answer to deficiencies in the availability of palliative care a precondition of the policy change that does not mean that the resourcing of palliative care has not been improved in many places that have changed their laws toward a permissive assisted dying regime belgium deliberately and dramatically increased funding for palliative care when it legalised assisted dying legislating that palliative care is a patient right in 2002 23 quebec included an explicit right to end of life care in its assisted dying legislation xxi canadas government has dramatically increased investments into palliative care provision 24 25 but increasing access to palliative care was never a precondition of the policy change and universal access to palliative care is not a standard that has been achieved in any of the permissive jurisdictions in the world it is important at this juncture to recall what the moral basis of permitting assisted dying is at its core it is about respecting and supporting the selfregarding choices decisionally capable patients make when they suffer from a grievous and irremediable medical condition that causes their suffering to be intolerable it is possible of course that in some cases it is not just the diseasecaused suffering that is resulting in a request for an assisted death undoubtedly it is possible that the illnesstriggered harmful impacts on a persons social determinants of health could contribute towards rendering a patients suffering intolerable however even if one were to assume for the sake of the argument that the latter was the case and it is a result of government neglect and not merely a function of limited resources that cannot be overcome it still would not follow that a patient who is unwilling to tolerate their situation any longer should be stripped of their agency to ask for an assisted death proponents of the view that such a patients agency to make such decisions and see them respected should be removed are seemingly ready to condemn such patients to potentially very long periods of excruciating suffering in an attempt to improve a particular healthcare system as well as other contributors to those persons social determinants of health patients are reduced here to a means used to achieve another worthy objective however the decision to partake in such activism should only be by voluntary deliberate choice it should not be a result of decisionally capable people being held hostage by strong paternalists a reply to this stance could note that that is unfair to ascribe such motives to those opposed to respecting patient choice when really theyre focused on keeping vulnerable patients alive until healthcare systems have improved to such an extent that fewer such patients would be motivated to ask for an assisted death one would expect then that only those patients whose suffering is caused by the disease itself and not by social determinants of health that can be addressed would request an assisted death our concern is that that policy stance would in reality translate into potentially permanently making such patients ineligible for an assisted death moreover in keeping with what we have identified as the relevant moral values justifying the legalisation of assisted dying it is clear that even the decision on whether or not to wait for such improvements is a choice decisionally capable patients are entitled to make themselves we agree with riddle that denying people with disabilities the right to exercise autonomy over their own life and death says powerfully damaging things about the disabled their abilities and their need to be protected 26 slippery slopes any changes to assisted dying eligibility criteria bring about slippery slope related claims and concerns 27 we have discussed the logical structure of slippery slopes and their questionable use in assisted dying arguments elsewhere 28 here we wish to address and refute the three slippery slope arguments that arose specifically in the context of the removal of the reasonably foreseeable criterion the first slippery slope argument argued that if reasonably foreseeable was removed canada would descend down a slippery slope to a place where persons with disabilities or mental illness would be coerced into maid proponents of this argument referred to the experiences in the other jurisdictions that were already permissive with respect to persons with disabilities and mental illness as the sole underlying condition the proponents ignored the fact that justice smith had carefully considered the expert evidence re slippery slopes in permissive jurisdictions she concluded t his evidence serves to allay fears of the practical slippery slope the evidence does not support the conclusion that since the legalization of physicianassisted death there has been a disproportionate impact in either oregon or the netherlands on socially vulnerable groups such as the elderly or persons with disabilities iv in carter the supreme court of canada subsequently noted the trial judge after an exhaustive review of the evidence rejected the argument that adoption of a regulatory regime would initiate a descent down a slippery slope into homicide iii even more significantly proponents of this argument ignored the fact that justice baudouin like justice smith before her also considered the expert evidence offered in support of the slippery slope argument she concluded that there was no evidence of slippery slopes in permissive jurisdictions neither the national data in canada or quebec nor the foreign data indicate any abuse slippery slope or even heightened risks for vulnerable people when imminent end of life is not an eligibility criterion for medical assistance in dying xii on this count then it can be said that slippery slope based criticisms of the current legislation have merely claimed that a slippery slope exists but evidence from other jurisdictions fails to demonstrate that it exists in reality furthermore recent evidence from canada runs counter to the slippery slope argument a 2020 study of all maidrelated deaths across ontario between june 7 2016 and october 31 2018 revealed that recipients of maid were younger had higher income were substantially less likely to reside in an institution and were more on february feature article likely to be married than decedents from the general population suggesting that maid is unlikely to be driven by social or economic vulnerability 29 a 2021 study of older adults who died under palliative care between june 1 2016 and june 1 2019 concluded that medical assistance in dying was significantly less frequent for palliative care patients who had low rather than high socioeconomic status are less likely to receive medical assistance in dying under universal health insurance 30 a second type of slippery slope argument claims that canada has moved from eligibility requiring that a persons natural death be reasonably foreseeable to not requiring thatso canada has landed further down a slope and is therefore a cautionary slippery slope tale however as already noted not every change in eligibility criteria reveals slippage down a slope it is acontextual to claim that canadas legislative change is evidence of a slippery slope to do so is to take a snapshot that obscures the entire scene yes the change from c14 to c7 moves canada in a more permissive direction however that ignores where canada was before the change from carter to c14 moved canada in a more restrictive direction the entire scene is that canada has not become more permissive as between the supreme court of canada decision in carter and bill c7 rather there was a period during which canada had an unconstitutional tightening of the eligibility criteria canada is simply back where the supreme court of canada put it through carter a final slippery slope argument that has been raised in this context takes another different form it claims that once reasonably foreseeable is removed there is no conceptual reason to limit assisted dying only to people who consider their suffering to be intolerable due to their for instance chronic disease condition the slippery slope concern here is this logically what would stop us in a next step from making assisted dying available to someone who might find themselves in abject poverty and who might decide to ask for an assisted death they might consider their suffering to be intolerable due to their poverty what this argument fails to recognise is that the removal of reasonably foreseeable did not change the eligibility criterion re the cause of suffering when reasonably foreseeable was in the law the persons suffering had to be caused by a serious and incurable illness disease or disability and the person had to be in an advanced state of irreversible decline in capability and their suffering had to be caused by the illness disease or disability or state of decline the same holds true now this slippery slope argument might have legs if the earlier law required that a persons suffering had to be caused by a condition that made their natural death reasonably foreseeable and then the new law expanded access to maid to people whose suffering is due to a chronic disease condition but that is not what happened conclusion after years of legal action as well as public academic and parliamentary review and debate canada has reached a permissive assisted dying regime that aligns the countrys legislation closer to the eligibility criteria of the supreme court of canada judgment that led to the legalisation of assisted dying than to the legislation that followed that judgment canadian courts have roundly rejected arguments against maid grounded in concerns about social determinants of health and slippery slopes our ethical analysis of social determinants of health arguments opposed to permissive regimes of the kind canada implemented in 2021 demonstrates that they fail to justify excluding decisionally capable patients suffering nonterminal illnesses from assisted dying our ethical analysis also demonstrates that the slippery slope arguments that arose in the context of the canadian legislative change fail to show that the countrys policy changes constitute evidence of movement down a slippery slope or that they set up an inevitable future descent down a slope to an undesirable destination

the question of whether problems with the social determinants of health that might impact decisionmaking justify denying eligibility for assisted dying has recently come to the fore in debates about the legalisation of assisted dying for example it was central to critiques of the 2021 amendments made to canadas assisted dying law the question of whether changes to a countrys assisted dying legislation lead to descents down slippery slopes has also come to the foreas it does any time a jurisdiction changes its laws we explore these two questions through the lens of canadas experience both to inform canadas ongoing discussions and because other countries will confront the same questions if they contemplate changing their assisted dying law canadas medical assistance in dying maid law has evolved through a journey from the courts to parliament back to the courts and then back to parliament along this journey the eligibility criteria the procedural safeguards and the monitoring regime have changed in this article we focus on the eligibility criteria first we explain the evolution of the law and what the eligibility criteria were at the various stops along the way we then explore the ethical justifications for canadas new criteria by looking at two elements of the oftencorrosive debate first we ask whether problems with the social determinants of health that might impact decisionmaking justify denying eligibility for assisted dying of decisionally capable people with mental illnesses and people with disabilities as their sole underlying medical conditions second we ask whether canadas journey supports slippery slope arguments against permitting assisted dying i there is also provincial legislation in quebec s4 bill 52 an act respecting endoflife care 1st sess 14th leg quebec 2013 assented to 10 june 2014 rsq c s320001 s 26 that predates the federal legislation but we limit the scope of this paper to federal maid law

introduction while many highincome settings have achieved relatively high coverage with their covid19 vaccination campaigns almost 321 of the worlds population have not received a single dose of any covid19 vaccine as of july 2022 1 the philippines and malaysia are among two of the most populous countries in southeast asia with an estimated population of 110 million and 32 million people respectively to date malaysia has seen over 46 million cases with a mortality rate of 077 while approximately 37 million cases of covid19 were detected in the philippines with a mortality rate of 160 2 malaysia is doing considerably well with their vaccination efforts with 848 of the population currently considered fully vaccinated as of july 2022 however vaccination campaigns in the philippines have been more difficult with 656 of the population fully vaccinated 3 with the emergence of the highly transmissible omicron variant across the world 4 largescale vaccination coverage remains fundamental to the national and global pandemic response regular scientific assessments of factors that may impede the success of covid19 vaccination coverage will be critical as vaccination campaigns continue in these nations a key factor for the success of vaccination campaigns is peoples willingness to be vaccinated once doses become accessible to them personally vaccine hesitancy is defined by the world health organization as the delay in the acceptance or blunt refusal of vaccines in fact vaccine hesitancy was described by the who as one of the top 10 threats to global health in 2019 5 conversely vaccine confidence relates to individuals beliefs that vaccines are effective and safe in general a loss of trust in health authorities is a key determinant of vaccine confidence with misconceptions about vaccine safety being among the most common reasons for low confidence in vaccines 6 previously vaccination in southeast asia has been associated with mistrust and fear particularly in the philippines who are still suffering the consequences of the dengvaxia vaccine controversy in 2017 7 studies suggest that this highly political mainstream event in which antivaccination campaigns linked dengue vaccines with autism spectrum disorder and with corrupt schemes of pharmaceutical companies continue to erode the populations trust in vaccines for example a survey conducted on over 30000 filipinos in early 2021 showed that 41 of respondents would refuse the covid19 vaccine once it became available whereas malaysia reported 27 hesitancy 8 researchers predict that the controversy surrounding dengvaxia may have prompted severe medical mistrust and subsequently weakened the publics attitudes toward vaccines 79 however there may be many additional factors that weaken confidence in vaccines for example incompatibility with religious beliefs is one key driver of weakened confidence in vaccines 1011 whereas living in urbanised areas predicts covid19 vaccine hesitancy in some countries 12 13 14 possibly due to being more connected to the internet and social media and being more exposed to covid19related misinformation other predictors of vaccine hesitancy and confidence may include digital health literacyones ability to seek find understand and appraise health information from digital resourcesand social media use research has shown that beliefs in available information is integral to perceptions of the vaccine safety and effectiveness 15 16 17 previous studies for example have associated higher vaccine hesitancy with misinformation about the virus and vaccines particularly if they relied on social media as a key source of information 1819 social cognitive theory is a widely accepted theory which may explain individual behaviors including digital health literacy 20 sct consists of three factorsenvironmental personal and behaviouraland any two of these components interact with each other and influence the third as such sct can assist in establishing a link between ones behaviour and environmental factors which may interact to promote medical mistrust and influence vaccine hesitancy and confidence 21 thus health behaviours are often influenced by social systems as well as personal behaviours although vaccine hesitancy and confidence are related concepts they are also distinct 22 thus the main aims of this research were to determine levels of hesitancy and confidence in covid19 vaccines among general adults in the philippines and malaysia and to identify behavioural or environmental predictors that are significantly associated with both outcomes thus developing a deeper understanding of the factors associated with vaccine hesitancy and confidence will provide insight into how specific population groups may respond to health threats and public health control measures methods design subjects and procedure this was an internetbased crosssectional survey conducted from may 2021 to september 2021 in the philippines and malaysia snowball sampling methods were used for the data collection using social media including research networks of universities hospitals friends and relatives filipino and malaysian residents aged 18 years or older were invited to take part the inclusion criteria for participants eligibility included 18 years or older and an understanding of the english language all invited participants consented to the online survey before completion consented participants could only respond to questions once using a single account the voluntary survey contained a series of questions which assessed sociodemographic variables social media use digital literacy skills in health and attitudes toward the covid19 vaccine ethical approval the study received ethical approval from asia metropolitan universitys medical research and ethics committee all participants provided informed consent all study information was written and provided on the first page of the online questionnaire and participants indicated consent by selecting the agreement box and proceeding to the survey measures demographics filipino and malaysian participants indicated their age category gender community type educational level employment religion income whether they were permanently impaired by a health problem and whether they were social media users subjective social status participant then rated their own perceived social status using the macarthur scale of subjective social status scale 23 participants viewed a drawing of a ladder with 10 rungs and read that the ladder represented where people stand in society they read that the top of the ladder consists of people who are best off have the most money highest education and best jobs and those at the bottom of the ladder consists of people who are worst off have the least money lowest education and worst or no jobs using a validated singleitem measure participants placed an x on the rung that best represented where they think they stood on the ladder vaccine confidence and hesitancy participants were also asked about their perceived level of confidence in the covid19 vaccine then participants were asked about their level of hesitancy to the covid19 vaccine these questions were adapted from the world health organization regional office for europe survey 24 the tool underwent evaluation by multidisciplinary panel of experts for necessity clarity and relevance digital health literacy finally participants completed the digital health literacy instrument 25 which was adapted in the context of the covidhl network the scale measures ones ability to seek find understand and appraise health information from digital resources a total of 12 items were asked and answers were recorded on a fourpoint likert scale while the original dhli is comprised of 7 subscales we used the following four domains including information searching or using appropriate strategies to look for information adding selfgenerated content to onlinebased platforms evaluating reliability of online information and determining relevance of online information the reliability statistics for the overall dhl score was 092 while the alpha coefficients for the four subscales ranged from 074 to 087 suggesting acceptable to good internal consistency data analysis data were examined for errors cleaned and exported into ibm spss statistics 28 for further analysis all hypotheses were tested at a significance level of 005 χ 2 tests were conducted for group differences of categorical variables and mannwhitney tests for continuous variables subgroup analyses were performed for filipino and malaysian participants covid19 vaccine hesitancy and confidence were treated as separate dependent variables in a logistic regression model providing the strictest test of potential associations with covid19 vaccine hesitancy and confidence among filipino and malaysian participants low vaccine confidence was operationalised by dichotomising participants responses to the statement i am completely confident that the covid19 vaccine is safe into those who disagreed or neither agreed nor disagreed whereas high vaccine confidence was operationalised by dichotomising participants responses into those who agreed to some extent vaccine hesitancy was operationalised by dichotomising responses to the statement i think everyone should be vaccinated according to the national vaccination schedule into those indicating no or i dont know whereas no vaccine hesitancy was operationalized by dichotomising participants response into those who indicated yes independent variables were age results a total of 2558 participants completed the online survey table 1 shows descriptive statistics of participants from the philippines vs malaysia filipino participants indicated higher rates of education but were more likely to be unemployed further filipino participants were also more likely to indicate lower income and rate themselves lower on subjective social status malaysian participants were more likely to live in urban areas most notably filipino participants indicated higher prevalence of covid19 vaccine hesitancy compared to malaysian participants however there were no significant differences between filipino and malaysian participants in ratings of vaccine confidence malaysian participants were also more likely to report using social media table 2 shows significant predictors of vaccine hesitancy in both filipino and malaysian samples among filipino participants multivariate logistic regression analyses revealed that factors associated with higher vaccine hesitancy included women residing in a rural community and having lower income among malaysian participants women being aged 2534 christians completing tertiary education social media use and informationseeking behaviours were predictors of higher vaccine hesitancy whereas having a health impairment and higher selfreported ratings on subjective social status were associated with lower vaccine hesitancy table 3 shows significant predictors of vaccine confidence in both filipino and malaysian samples factors positively associated with higher vaccine confidence among filipino participants included higher selfreported ratings on subjective social status whereas factors associated with lower vaccine confidence included women and informationseeking behaviours among malaysian participants factors positively associated with higher vaccine confidence included women completing tertiary education and higher selfreported ratings on subjective social status factors negatively associated with lower vaccine confidence included residing in a rural community christians buddhists hindus informationseeking behaviours and determining relevance of online information discussion malaysia and the philippines are among the most populous countries in southeast asia while the economic impact of the covid19 pandemic has been permanent in the philippines it has been shown thus far to be temporary in malaysia 26 between january and october 2020 around 30000 malaysians had been infected by the virus with a mortality rate of 079 while approximately 380000 cases of covid19 were detected in the philippines with a mortality rate of 19 2 further 618 of malaysians had completed their vaccination up until september 2021 while the percentage of completed vaccinations during the same period in the philippines was only 192 27 vaccine uptake is likely to be a key determining factor in the outcome of a pandemic knowledge around factors which predict vaccine hesitancy and confidence is of the utmost important in order to improve vaccination rates thus the core aims of this research were to determine levels of hesitancy and confidence in covid19 vaccines among general adults in the philippines and malaysia and to identify behavioural or environmental predictors that are significantly associated with these outcomes first while there were no significant differences in ratings of confidence in the covid19 vaccine between filipino and malaysian participants filipino participants expressed greater vaccine hesitancy this may be a consequence of previous vaccine scares in the years leading up to the pandemic including the dengvaxia controversy in 2016 79 systematic reviews demonstrated that by the end of 2020 the highest vaccine acceptance was in china malaysia and indonesia 2829 the authors postulated that this elevated awareness was due to being among the first countries affected by the virus hence resulting in greater confidence in vaccines 28 next this study shows that women expressed greater vaccine hesitancy in both countries the evidence base shows mixed findings with other studies reporting higher hesitancy in women 30 or in men 31 in some countries the gender gap is not as substantial as others in a large global study conducted in countries such as russia and the united states it was found that there is greater gender gap in vaccine hesitancy among men and women compared to countries such as nepal and sierra leone 3233 unsurprisingly what drives this hesitancy is the inclusion of pregnant women where studies have consistently demonstrated that this population is more hesitant toward vaccination due to concerns for their babies 34 hence after taking all consideration into account gender differences in vaccine hesitancy cannot be supported with certainty this also emphasises the need for tailored health promotion towards the key populations at risk there are clear differences in predictors of vaccine hesitancy in the philippines and malaysia however when results for both countries were combined women urban dwellers those of christian faith those with higher educational attainment higher selfreported social class social media use and informationseeking tendencies remained as predictors of hesitancy urbandwellers and individuals with more years of education have previously been demonstrated as predictors for vaccine hesitancy 35 but contradictory results have also previously been shown 3637 urban residents are typically more connected to the internet and social media and thus may be more exposed to vaccinerelated misinformation than rural inhabitants who have fewer sources of information available to them 12 13 14 nevertheless reports have shown higher vaccine refusals among those with strong religious beliefs such as the amish community in the united states and the orthodox protestants in the netherlands 38 as well as some muslim groups in pakistan 18 frequent social media use is the only strong predictor for vaccine hesitancy in this study followed by informationseeking behaviours research has identified that the safety and effectiveness of the vaccine is the primary concern that people have including beliefs in available information 15 16 17 unfortunately high internet literacy is a doubleedged sword since participants in this study preferred to seek information through social media and thus may have been exposed to inaccurate information regarding covid19 vaccine previous studies have associated higher vaccine hesitancy with misinformation about the virus and vaccines 18 particularly if they relied heavily on social media as a key source of vaccinerelated information 19 a 2022 systematic review discovered that high social media use is the main driver of vaccine hesitancy across all countries around the globe and is especially prominent in asia 39 furthermore vaccine acceptance and uptake improved among those who obtained their information from healthcare providers compared to relatives or the internet 40 in terms of vaccine confidence our findings show that those with higher subjective social status have higher confidence in vaccination consistent with previous studies describing how those with a higher income had expressed willingness to pay for their covid19 vaccination if necessary 324142 further those of christian buddhist and hindu faiths as well as those with a tendency to seek out information were associated with lower vaccine confidence this is in keeping with the previous findings demonstrating that strong religious convictions are often tied to mistrust of authorities and beliefs about the cause of the covid19 pandemic which is fuelled by social media 43 furthermore concern on the permissibility of these vaccines in their religion reduces its acceptability 10 however it is interesting to note that while the majority in malaysia are muslims it did not reduce the rate of vaccine acceptance and confidence in the country these findings have important implications for health authorities and governments in areas focusing on improving vaccination uptake misinformation about vaccination greatly hampers vaccination efforts thus not only is it important to understand how specific population groups are influenced by digital platforms such as social media but it is imperative to provide the right information driven by governmental and nongovernmental organisations 39 this could be achieved by having communityspecific public education and role modelling from local health and public officials which has been shown to increase public trust 44 since the primary reason for hesitancy is concern about the safety of vaccines it is crucial that education programmes stress the effectiveness and importance of covid19 vaccinations 45 participants in this study coped with the pandemic by seeking out new information but they sought information from social media when information from the authorities was lacking or were viewed as untrustworthy which may have contained erroneous information one way to deter this is to empower informationtechnology companies to monitor vaccinerelated materials on social media remove false information and create correct and responsible content 44 furthermore behavioural change techniques have been found to be useful in stressing the consequences of rejecting the vaccine on physical and mental health 46 the most effective nudging interventions included offering incentives for parents and healthcare workers providing salient information and employing trusted figures to deliver this information 47 finally since religious concerns have been prominent in reducing vaccine confidence and increasing hesitancy in this study it is important to tailor messages to include information related to religion and the use of religious leaders to spread these messages 48 these are all important factors for increasing uptake of the covid19 vaccine but also may be relevant in acceptability of routine immunisations as countries look to transition towards a postpandemic delivery of healthcare a limitation of this study includes its crosssectional design and the heterogeneity among participants which meant that temporal changes in attitudes toward covid19 vaccines across time were not captured further the need for internet access among filipino and malaysian participants limited the representativeness of the sample population thus certain demographic were underrepresented including filipino and malaysian individuals over the age of 45 and people of lower socioeconomic status the surveys were also implemented in english which may have limited the participation of target participants who were not fluent in english in addition due to space limitations vaccine hesitancy and confidence were each captured using one item which raises concerns of the items validity and reliability finally not all independent variables were accounted for including medical mistrust 49 vaccine knowledge 50 and specific social media platforms used 11 we also did not assess whether participants had received any doses of the covid19 vaccine previously future research should include more important predictors to build a broader picture of vaccinerelated hesitancy and confidence in the philippines and malaysia and more items should be utilised to tap into these concepts more comprehensively despite these limitations the core strength of this study relates to its relatively large number of participants from both countries and its comprehensive analysis of predictors to provide as a starting point going forward conclusions the main aims of this research were to determine levels of hesitancy and confidence in covid19 vaccines among unvaccinated individuals in the philippines and malaysia and to identify predictors significantly associated with these outcomes predictors of vaccine hesitancy in this study included the use of social media informationseeking and christianity higher socioeconomic status positively predicted vaccine confidence however being christian buddhist or hindu and the tendency to seek information online were predictors of hesitancy efforts to improve uptake of covid19 vaccination must be centred upon providing accurate information to specific communities using local authorities health services and other locallytrusted voices and for the masses through social media further studies should focus on the development of locallytailored health promotion strategies to improve vaccination confidence and increase the uptake of vaccinationespecially in light of the dengvaxia crisis in the philippines data are available on the osf repository vaccination hesitancy increase confidence and bolster the uptake of covid19 vaccination particularly in light of the dengvaxia crisis in the philippines supporting information

with the emergence of the highly transmissible omicron variant largescale vaccination coverage is crucial to the national and global pandemic response especially in populous southeast asian countries such as the philippines and malaysia where new information is often received digitally the main aims of this research were to determine levels of hesitancy and confidence in covid19 vaccines among general adults in the philippines and malaysia and to identify individual behavioural or environmental predictors significantly associated with these outcomes data from an internetbased crosssectional survey of 2558 participants from the philippines n 1002 and malaysia n 1556 were analysed results showed that filipino 566 participants exhibited higher covid19 hesitancy than malaysians 229 p 0001 however there were no significant differences in ratings of confidence between filipino 459 and malaysian 492 participants p 0105 predictors associated with vaccine hesitancy among filipino participants included women or 150 95 ci 103183 p 0030 and rural dwellers or 144 95 ci 107194 p 0016 among malaysian participants vaccine hesitancy was associated with women or 150 95 ci 114199 p 0004 social media use or 1176 95 ci p 0001 and online informationseeking behaviours or 248 95 ci 172358 p 0001 predictors associated with vaccine confidence among filipino participants included subjective social status or 113 95 ci 154122 p 0001 whereas vaccine confidence among malaysian participants was associated with higher education or 130 95 ci 103166 p 0028 and negatively associated with rural dwellers or 064 95 ci 047087 p 0005 and online informationseeking behaviours or 042 95 ci 031057 p 0001 efforts should focus on creating effective interventions to decrease

background in many communities particularly within subsaharan africa fathers play an important role in decisionmaking within the home providing financial support and are traditionally considered the main breadwinners 1 as pointed out by erzse and her collegues in ssa both men and elderly women support patriarchal gender divisions of labour which means that women are primarily responsible for early life nutrition and care 2 a mothers responsibility in parenting traditionally included all activities within the home such as feeding cooking bathing and cleaning the house p 21 3 their role in parenting is perceived as an authoritarian discipliner and their relationship with their children is often characterized by fear 4 these roles and responsibilities based on a persons gender are reinforced during traditional lessons that a couple undergoes before marriage many fathers still believe that caring for a child is mainly the responsibility of the mother especially during the first one to two years of a childs life 2 a father figure in the childs environment is more likely to help the child learn that caring is part of masculinity as well as femininity 5 moreover both parents involvement in childcare has significant benefits for childrens development 6 survival and health for instance fatherchild interaction has been shown to improve childrens cognitive social language and emotional development 7 other examples of positive longterm effects of father involvement include better social functioning during childhood higher educational attainment and lower incidences of delinquency and criminal behaviour 8 further the involvement of fathers early on in a childs life results in the fathers satisfaction which in turn leads to a greater likelihood of sustained involvement as the child grows older 9 interactions between the father and the child may mirror representations and recollections of the fathers own childhood experiences 10 beliefs about gender roles have also been cited as a major factor hindering fathers participation in childcare 11 other barriers that have been identified include socialcultural issues limited maternal health knowledge and stigmatization of fathers who participate in roles attributed to females health structures and poor information on the importance of fathers involvement 12 such barriers can be addressed through parenting empowerment programs genderresponsive parenting initiatives have shown potential for positive gender norm change in the recent past 13 implementation of such genderresponsive programs with a strong emphasis on the engagement of male caregivers have yielded positive outcomes four initiatives by unicef in nepal sri lanka ghana and tanzania reported improved father involvement in childcare 13 such initiatives integrated stronger gender equity focusing into ongoing work in early childhood development promoting good nutrition despite the importance of such genderresponsive parental programs in changing gender norms few programs have been implemented in countries in ssa such as kenya and zambia the moments that matter program a partnership of episcopal relief development and anglican development services of nyanza in kenya and zambia anglican council outreach programmes in zambia takes a parenting empowerment approach to integrated early childhood development from birth to three years the mtm program mobilizes rural communities for nurturing care and parenting empowerment through a holistic communityled approach engaging the most vulnerable families with a pregnancy andor children aged zero to three years 14 vulnerabilities included hivaffected other chronic or severe illnesses single parent households grandparents or adolescent caregivers parent or child with disabilities and foodinsecurity the marginalized rural communities are characterized by high poverty rates smallholder farming poor maternal and child health and nutrition high hiv prevalence long distances to health services and limited access to financial services the mtm program promotes parental empowerment bonding and interactions in the home between caregivers and their children focusing on responsive care early learning and security and safety so that children reach their full developmental potential trained ecd volunteers facilitated monthly caregiver support and learning groups combined with ecd home visits the mtm program also aimed at improving fathers participation in caregiving practices and intentionally included more time playing and interacting with their children and were more involved in household chores due to their participation in the mtm program conclusion the study findings provide evidence for policy formulation and a guide for implementation of policies that can influence changes in perceived gender roles in parenting keywords fathers roles fathers perceptions fathers practices responsive care childcare stimulation early learning and holistic development early childhood development parenting activities and messages around genderequitable parenting between male and female caregivers and providing genderequitable care for boys and girls in addition mtm training of faith leaders and the use of male ecd volunteers also reinforced male caregivers involvement in parenting the study reported in this paper aimed to establish the effects of the parenting empowerment program on more genderequal attitudes about gender roles in parenting and actual caregiving practices by fathers after participation in the mtm program in kenya and zambia we explored the type of attitudes and practices that existed before the program implementation and pointed out any changes that may have occurred during the program implementation and after two years of the implementation period methods study design the qualitative study reported in the current paper was part of a quasiexperimental study in which caregiverchild dyads were assigned to the intervention and the control arm 14 the villages or clusters were purposively selected taking into consideration such factors as poverty levels and the number of families to make them as comparable to each other as possible with regards to their demographic characteristics kenya three clusters from each of the two sublocations within the program implementation sites and six clusters from a third sublocation where there were no program activities were selected zambia ten communities serving as the clusters were formed by grouping villages within the chamuka area program site within the study area villages were randomly selected from program sites and stratified at the clustercommunity level to reduce potential contamination among study arms three to four villages were clustered into five community program implementation sites from one ward and allocated to the intervention arm and five communities located in a different ward were allocated to the control arm 14 sampling and sampling characteristics in the main study in kenya 244 primary caregivers were recruited at baseline and 121 were followed up at endline surveys in the intervention and control arms the research team also recruited more study participants from the intervention arm who had been participating in the mtm program activities bringing the number of study participants in the intervention arm at endline to 165 in zambia the research team recruited 395 primary caregivers at baseline with children aged below 18 months or were pregnant and were in their third trimester were identified and recruited and 194 followed up at endline the attrition rate was 439 in the intervention arm and 528 in the control arm in both countries slightly above threequarters of the respondents mentioned that they had a father present in their household 14 in the study reported in this paper the research team used two types of purposeful sampling strategies for qualitative data collection purposeful sampling enabled us to identify and select informationrich cases for the phenomena under study the theoretical assumption underlying the sampling of participants for the qualitative interviews is the attainment of the data saturation point that is the point at which no new substantive information is obtained from additional interviews 15 the selection of respondents for the qualitative interviews was based on maximum variation sampling to document or identify unique or diverse variations within a homogenous population and to enable the identification of common patterns that emerge and the selection of homogenous cases to facilitate group interviewing 16 whereas maximum variation sampling allowed us to identify differences among the respondents homogenous sampling focused on identifying similarities among those who were interviewed we purposely selected program volunteers who were directly involved in the implementation of the mtm program activities for the key informant and indepth interviews we conducted structured qualitative interviews with the respondents study setting the study was conducted in two countries kenya and zambia among populations with similar poverty levels and demographic characteristics kenya the study was conducted in border 1 and ayucha sublocations in awasionjiko ward within nyando subcounty in kisumu county kisumu county in the nyanza region is among the 47 semiautonomous county governments which were formed after the promulgation of the kenyan constitution in 2010 every county is further subdivided into subcounties and wards for ease of administration 1718 kisumu county has an overall poverty rate of 325 19 the county has six administrative subcounties nyando subcounty has five wards with a total population of 141 037 males account for about 51 of the total population the infant mortality rate is 24 deaths1000 live births 19 zambia the study was conducted in the chamuka area of chisamba district of central province central province has an overall poverty rate of 37 the level of rural poverty is three times that of urban areas the chamuka area has over 30 villages in two wards mwantaya and chamuka wards the infant mortality rate is 42 deaths1000 live births 14 data collection procedure the researchers conducted qualitative interviews focus group discussions and indepth interviews with fathers primary caregivers community volunteers the mtm program implementers and government policy implementers to establish their perceptions and practices on gender roles in parenting trained field interviewers who had a graduate qualification and experience in conducting qualitative interviews conducted the interviews the field interviewers were trained for 5 days by the research team during the training which involved theoretical sessions role plays and a field pilot to ensure that the field interviewers were conversant with the interview guides we emphasized the need for them to engage in a reflexive approach and strive to be as neutral as possible during the data collection activities in this way we were able to reduce bias and minimize judgmental behaviours the interview guides were further refined based on the feedback from the pilot exercise each interview was managed by a pair of field interviewers ie a moderator who led the discussion and an assistant who took notes from the discussions the fgds with caregivers community volunteers religious leaders and community health workers were conducted in the most commonly used language used in these communities key informant interviews with subcountydistrict officials and program staff were conducted in english we interviewed program staff to understand how the mtm program has been implemented and their perceived behaviour change among parents on gender role in caregiving in addition to taking notes all the discussions and interviews were audiorecorded with the consent of the participants to maximize the completeness of the information collected and reduce the risk of data loss the field supervisor reviewed the notes and the audio files to ensure that all the items in the interview guide were comprehensively covered the length of fgds varied from one to oneandahalf hours while the kiis were between 45 min and 1 h analysis the researchers employed thematic analysis the audiorecorded files from the interviews were transcribed in english and anonymized by a qualified and experienced transcriber in order to ensure that the transcripts were culturally neutral the transcriber excluded colloquial language and corrected all grammatical and typographical errors after the transcription the research team checked each transcript for accuracy and quality assurance thereby ensuring that the transcripts represented the information in the audiorecorded files the research team including the principal investigator a qualitative researcher and three junior researchers then used the interview guides and initial transcripts to identify the main themes and subthemes this informed the development of the codebook which was used to code the remaining transcripts all the coded data were then classified and analysed through word trees and queries in nvivo q 10 software using thematic content analysis 20 to ensure the trustworthiness of the thematic analysis and that the process was credible transferable dependable and confirmable the research team developed an analysis plan 21 the analysis plan was used as a point of reference during transcription coding and analysis in addition the research team recognized that their positionality changed over the course of the three data collection time points when the data collection process began we were considered as outsiders however as more contact and discussion with the research participants took place they increasingly viewed us as being insiders due to familiarity during the followup period the research team held a data interpretation workshop to ensure that there was a common understanding of the emerging themes and that any biases in the analysis process were minimized results we present information on community members perceptions and practices on equitable gender roles and fathers involvement in caregiving after participating in the mtm program for two years this includes changes in attitude knowledge levels and parenting practices attitudes towards gender equality in parenting at baseline most respondents reported that childcare was the sole responsibility of mothers or the primary caregivers fathers were reported to be undertaking childcare responsibilities when mothers were unwell or not at home fathers and mothers narrated that the separation of parenting responsibilities stemmed from how they were brought up postintervention at endline there was evidence of changes in parenting attitudes and practices towards more gender equity they fathers provide money to buy food for the children if you dont have or as a mother you can buy for them some clothes so that they have a better life fgd with primary caregivers zambia at baseline children in the past just like it was when we were growing up werent free around their fathers fathers would chase the child asking the mother to get their child as though the mother was the only person responsible for birthing the child todays children who were born into this program have no reason to fear their parents children and other parents from back in our time get surprised that fathers are taking care of children playing with them they say we have spoiled them fgd with primary caregivers intervention zambia at endline in the past the way we were raised my father or my elder brother were like lions whenever they entered a house i would always look for a door in order to try and escape but these days they teach is to be friendly with the children these days children are not afraid of us we also hug the children fgd with fathers intervention zambia at endline this notion changed at midline and further changes were noted at endline at the endline in both countries some primary caregivers mentioned in the qualitative interviews that fathers had embraced the notion that they could also provide caregiving primary caregivers added that fathers were more involved than before they had become close to their children were involved in play with their children and supported their wives during pregnancy and with different household activities such as cleaning through fathers participation in the program activities their parenting skills seemed to have improved after sharing the knowledge we received through the mtm program with our husbands they are now involved in caring for their families they feed their children take them to the clinic and support wives during pregnancy previously fathers used to think that their responsibility was only to provide materially for their families nevertheless after the training they changed their attitude they now play with children and care for pregnant mothers for instance he postpones other activities to care for pregnant mothers and provides a balanced diet too fgd with female primary caregivers intervention kenya at endline male caregivers are involved more in caring for their children some take time to stroll with their children as their wives care for other activities furthermore fathers take their children to school both in the morning and evening besides making play items for them idi with ecd promoter kenya at endline we also fathers now playing with their children they carry their children around fathers also wash and change diapers for their children children love their parents and they are very close in fact they are closer to their fathers than mothers because of the training this program offered to fathers idi with ecd promoter zambia at endline notably in the control arm some fathers also mentioned attitudinal changes towards caregiving however their sentiments were centered only on the provision of basic needs and psychological support to the mother during pregnancy it was evident in the control arms that many caregivers still held the opinion that caregiving was the sole responsibility of mothers for children below two years the work of a mother in parenting children is to take full care of the children cooking good food like porridge for babies washing their clothes taking the child to the nearest health post for underfive fgd with fathers control zambia at endline the woman is the one who spends the most time with children we men can have things like work but if women spend too much time away from the child then the child will not breastfeed well and their health will go down if the child is one year and six months old and is left with fellow children with no proper food the children will not take care of that child the way the mother would we men can be close to the child even from birth but we only have a hand in the childs life when they are old enough to be away from the mother when we can carry the child to the market or something of that sort fgd with fathers control zambia at endline parenting behaviour change toward gender equal roles in both countries before the implementation of the mtm program parenting responsibilities were delineated according to gender most mothers were entirely responsible for their children activities such as bathing feeding dressing healthcare and spending time with children were perceived to be a sole mandate of mothers fathers were expected to provide enabling means to mothers however both mothers and fathers provided information during qualitative interviews on how the mtm program has influenced gender roles in not only parenting but at the household level in general the participants from the intervention arm mentioned that fathers were more involved in household chores the respondents attributed these changes to the mtm program activities ecd promoters also reported that through the mentorship they provided during household visits and caregiver group meetings male caregivers had become more positive about participating in childcare and household chores after the ecd training both male and female caregivers participated in childcare and doing other domestic chores… they are responding well we can now see fathers cooking for their expectant wives besides going to the facility for clinics even this morning i saw a father carrying a child… the fathers are helping their wives with some chores at home when we are conducting our routine household visits they warmly welcome us even in the absence of their wives idi with lead ecd promoter kenya at endline in the past i used to leave all the house chores in the hands of my wife she was doing everything nowadays i help her with the chores in the house… i hold the baby do the washing and cooking idi with a father intervention kenya at endline youll find that youre tired from working in the field and so is your husband but they will still want you to get home and do all the chores including taking care of the child so we have been taught that fathers are also supposed to take up a supportive role in the upbringing of children fgd with female primary caregivers intervention zambia at endline i never used to play with my child or clean him when he poops and when the child does something wrong i was quick to get a whip to beat the child but i dont do all these things fgd with fathers intervention zambia at endline the program has taught us a lot especially regarding gender we never knew that men could also have a role in the upbringing of their children even if you went far and you come back you will find your husband has cooked fed the children and even put water for you to bathe we would in the old days do all these tasks but thats not the case today fgd with female primary caregivers intervention zambia at endline the mtm program positively influenced sharing of household and parenting responsibilities among mothers and fathers fathers had become closer to increased the time spent with their children and took up more responsibilities thus fathers´ emotional connections with their children improved considerably which in turn provided a more enabling environment for children to thrive in addition to an improved relationship between fathers and children the enhanced participation of fathers in daily household routines also resulted in overall improved relationship quality among spouses through what we learnt i have seen that it is good for us to help each other therefore the only job that i know is strictly for the woman is giving birth but the rest we can help each other all of us can help washing especially should be for men for example when the woman is pregnant and about to deliver they may keep her for some days at the clinic when she is away i have to bathe my children what am i going to lose by bathing my children so everything we need to do is to help each other fgd with fathers intervention zambia at endline yes there has been an improvement in my relationship with my wife in the past she was not happy because she could not express herself properly to me but now that i have learnt she is more open to me so there is an improvement in the way we relate she has the freedom and can count on me for help fgd with fathers intervention zambia at endline it is very true i never had time to listen to a woman and her opinion when she was giving me advice i just thought she was wasting my time but through the lessons i have learnt to value her opinion these days when she says something we sit together to discuss what she thinks fgd with fathers intervention zambia at endline uptake of maternal and child health services in both countries before the mtm program seeking healthcare for children was usually seen as the mothers´ responsibility this meant that mothers had to walk long distances with their children tied on their backs to attend the monthly underfive clinic or seek healthcare when the child felt unwell most fathers did not participate in this task and many did not show interest in a childs healthphysical development at endline the qualitative interviews revealed that the participants perceived that the mtm program had improved male caregivers participation in the mch services such as antenatal care services nutrition and immunization and preventive services including attending sessions on proper handwashing they reported that more male caregivers accompanied their wives to the hospital in the past my husband never bothered with my antenatal visits after the training he now inquires about my clinical visits and even accompanies me to the hospital at home he discourages me from stressful duties and advises me this makes my work easier… previously my husband believed that taking children to the hospital was the role of the mother recently when i was sick he took the child to the clinic when the child became ill fgd with female primary caregivers intervention kenya at endline fathers are now taking children to clinics and are involved in processing birth certificates idi with lead ecd promoter kenya at endline the benefit i found is that long ago things were hard for women because here the health centre is very far but now the fathers help in taking care of the children even taking them to the clinic but in the past he would just leave everything to me to carry the child to the clinic fgd with female primary caregivers intervention zambia at endline me on my part the benefits i have seen in my life are a lot for example when my wife is going to the clinic for under five i will get the child and put it on my back and then she will only get her handbag i even see her get happy fgd with fathers intervention zambia at endline there is change because of the teaching they give us we see fathers carrying their children on the back and going to the clinics that never used to happen they even bathe their children even in our community we have seen the change we see fathers feeding their children and doing things that they never used to do fgd with fathers intervention zambia at endline it is somewhat remarkable that fathers engaged in what is traditionally seen as the responsibility of a woman in the community despite resistance and mockery from other fathers in the community fathers narrated that men who helped their wives in chores that were perceived to be a woman´s responsibility were considered fools weak or bewitched the other issue was escorting the wife to the clinic when our child was sick other men used to laugh at me but these days i just consider them as fools and ignore them even if they laugh because i know the benefits of helping and taking care of my child i just get my bicycle and take the child to the clinic i dont hesitate fgd with fathers intervention zambia at endline helping my wife carry firewood if i help her carry the heavy ones they will say she has finished me as a man and i have just become a fool fgd with fathers intervention zambia at endline the community people used to laugh at me for example when i carry my baby on my back the moment i leave home people will start laughing at me they will say i am a fool and my wife has given me charms fgd with fathers intervention zambia at endline discussion this study aimed to examine whether gender roles and fathers attitudes knowledge and childcare practices changed as a result of participation in the mtm program from the findings participants gained knowledge about gender roles in parenting which was demonstrated through male caregivers involvement in childcare responsibilities the current study showed an attitude and behaviour change on parenting responsibilities especially with regards to responsive caregiving and stimulation practices earlier evidence shows that spending time with the child leads to improvement in language and social skills 22 studies have also shown the importance of a fathers involvement in childcare responsibilities in improving childrens developmental outcomes and womens economic empowerment 5 therefore their increased involvement in caregiving activities has the potential of improving child development outcomes notably some participants still held the opinion that due to the nature of the fathers work in the rural communities they might not find adequate time to engage their children in play and stimulation activities a similar finding showed limited participation in caregiving activities by fathers which have been associated with the fathers childhood experiences 10 in most rural communities in africa parenting roles are delineated based on gender 4 this separation of parenting roles along gender lines often resulted in a complete separation between fathers and their children 4 such gender norms which dictate responsibilities inside and outside the households are often more evident in african rural communities evidence from other studies shows that fathers have unique roles in childcare that may differ from those of mothers as demonstrated in this study some are actively involved in caregiving roles findings from other studies also indicate the importance of fathers engagement on childrens cognitive social language and emotional development widely held societal beliefs that women are responsible for childcare inform women being the main beneficiaries and receivers of information and programs involving children in addition childcare policies emphasize mothers especially women of reproductive age pregnant and lactating mothers such policies on breastfeeding maternal and child health maternity leave have led to development programs that support women in caregiving activities 23 these programs have improved child development and the mothers health outcomes however there are few policies on fathers participation in childcare while women are the primary focus in stimulating childrens development outcomes in the first three years of the childs life in some communities they have limited decisionmaking power and resource allocation 24 therefore policies and programs need to focus on empowering both parents to promote the holistic growth and development of their children study limitations one of the limitations of this study is that since the data were selfreported there was the risk that fathers exaggerated their responses to increase social desirability or underreport on those aspects that they considered being problematic however this was mitigated by qualitative interviews with other respondents such as primary caregivers program implementers religious leaders and policy implementers who reported fathers attitudes and behaviour changes on gender roles in parenting conclusions perception of more equitable gender roles in parenting and fathers participation in childcare improved among the program participants with most of them reporting that fathers were actively involved in parenting and caregiving activities due to their participation in the mtm program those who reported low participation in parentingchildcare pointed out gender stereotypes as major barriers to their participation therefore a communitybased parenting empowerment program could be instrumental in addressing such stereotypes as demonstrated in the current study implications given that gender stereotypes embedded in traditional beliefs on parenting roles may influence fathers engagement with young children a communityled parenting empowerment program such as the one reported in the current paper could be considered instrumental in addressing this situation increased father involvement is important as it impacts childrens shortterm and longterm outcomes future research should consider an exploration of the most important influencers in changing perceptions on gender roles in parenting among community members in addition the role of female caregivers precluding the involvement of fathers should be investigated abbreviations ack anglican church of kenya adsnyanza ack development services of nyanza aphrc african population and health research centre anc antenatal care ecd early childhood development esrc ethics and scientific review committee fgd focused group discussion hivaids human immunodeficiency virusacquired immune deficiency syndrome idi indepth interview irb institutional review board kap knowledge attitudes and practices kcse kenya certificate of secondary education kii key informant interview lmics lowand middleincome countries mch maternal and child health moh ministry of health ngo nongovernmental organization ssa subsaharan africa author contributions ko led the writing of the manuscript data collection and participated in data analysis so participated in the data collection analysis and writing of the manuscript km and gn participated in data analysis and writing of the manuscript dm and kc contributed to the design and supported the implementation of the study participated in data analysis and writing of the manuscript pkw led the design and implementation of the study participated in data analysis and writing of the manuscript all authors read and approved the final manuscript informed consent process the data collectors sought informed consent from all study participants before being interviewed for those who were not able to read the information sheet was read to them in their local language and they were asked to provide a thumbprint to signify their consent the use of a thumbprint or signature was approved by the ethical research committees in both countries competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit 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background fathers are often perceived to be mainly responsible for the provision of the familys economic needs however past studies have demonstrated that fathers involvement in parenting has great significance for the childs holistic growth and development few studies have investigated fathers roles in the nurturing care of young children particularly responsive care and stimulation in subsaharan africa the study reported here was carried out as part of a larger study that sought to evaluate the effectiveness of the moments that matter mtm program in improving the nurturing care of young children in rural communities in zambia and kenya the mtm program uses a parenting empowerment approach to promote bonding and interactions between caregivers and their children within the home focusing on responsive care early learning and security and safety so that children reach their full developmental potential trained volunteers facilitated monthly primary caregiver support and learning groups and ecd home visits fathers were encouraged to participate in the home visits and to attend some of the group meetings on specific topics the study reported in this paper aimed to establish the impact of the parenting empowerment program in promoting more genderequal attitudes and practices on parenting among fathers who were not the primary caregivers methods qualitative data were collected at three time points preintervention before the implementation began midintervention after 6 months of implementation and postintervention after 24 months we conducted focused group discussions with primary caregivers n 72 and fathers n 24 with children below 3 years indepth interviews were conducted with ecd promoters n 43 and faith leaders 20 we also conducted key informant interviews with the mtm program implementers n 8 and government officials n 5 involved in the program implementation we employed thematic analysis to analyse the qualitative datathe findings showed that the mtm program resulted in improved genderequal parenting attitudes and practices among mothersother primary caregivers and fathers study participants reported that most fathers spent

introduction in the last five decades the population of the most developed world regions has become more and more heterogeneous mainly due to a considerable increase of the migrant population 12 upon arrival in a new society migrants are exposed to a new culture and are subject to a process of acculturation 3 the term acculturation refers to the cultural changes that occur when two populations come into continuous firsthand contact and it has been treated in two ways in previous literature as a unidimensional measure of the adoption of values beliefs norms and behaviours of another population or as a bidimensional measure of adherence to each of two cultures 45 children in migrant families often demonstrate betterthanexpected health suggesting that cultural healthrelated practices among migrant families might be protective in some areas of health 267 a number of studies have shown greater caries experience in migrant than native children 8 9 10 11 even after accounting for familys socioeconomic circumstances 1213 what is missing in the literature is studies exploring what factors could explain such oral health differences a recent review of the impact of acculturation on oral health identified 8 studies in children 14 although most studies found that acculturated children had better dental status results varied depending on the indicator of acculturation used and whether differences were adjusted for confounders the authors found conflicting results for mothers length of residence and language proficiency on the other hand childrens place of birth use of local language and length of residence were positively related to their oral health while parental and child age at migration were negatively related with childrens caries experience 14 in spain inequalities in oral health between migrant and native groups have just started to be explored a study in valencia showed that migrant adolescents were more likely to have dental caries than spanish children after adjustment for age social class and intake of cariogenic foods 15 the 2010 national oral health survey found greater caries experience in foreignborn than spanishborn children these differences persisted in the primary dentition but not in the permanent dentition after controlling for sociodemographic factors furthermore foreignborn children had more teeth with untreated decay but fewer fillings than spanishborn children 16 the 2015 national oral health survey also found greater caries experience in foreignborn than spanishborn children however differences were significant for 56and 15yearolds but not for 12yearolds 17 similar results were reported in a populationbased survey of the autonomous community of madrid in 2016 as spanishborn children had lower caries experience than foreignborn children aged 6 12 and 15 years although these differences were only significant among the oldest group 18 it is important to know how the acculturative process affects child health to reduce health disparities and inform public health action to fill this gap in knowledge a study was set out to explore whether different indicators of acculturation were associated with caries experience in children of madrid spain methods data collection data were collected from supervised questionnaires and clinical records the questionnaire collected information on childrens demographic background and migration status as well as on parents demographic factors socioeconomic characteristics and migration status acculturation was measured using four proxy measures generational status age at arrival length of residence in spain and language spoken at home generational status was defined based on childrens own nativity and that of their parents it consisted of three categories foreignborn children with both migrant parents spainborn children with one or both migrant parents and spainborn children with both spanishborn parents the first two groups together make up the overall migrant category consisting of children born to one or both migrant parents whereas the third category consists of nativeborn children 71920 covariates included were child and family factors family socioeconomic position was determined by social class based on the head of households occupation following the spanish society of epidemiology classification 21 that grouped individuals with similar levels of occupational skill using an ordinal scale with five main categories higherlevel professionals senior technical staff managers of large companies intermediatelevel professionals and managers of small companies administrative workers clerks safety and security workers and selfemployed workers skilled and semiskilled manual occupations and unskilled manual occupations these classes were collapsed into managerial skilled and semiskilled worker and unskilled worker for analysis 2223 marital status was classified as cohabiting and not cohabiting maternal education was defined according to the highest educational level achieved data on childrens caries experience were extracted from dental records dental caries was diagnosed at the cavity into dentine threshold following the dental clinic examination protocol the number of deciduous and permanent teeth as well as the number of decayed and filled deciduous teeth and the number of decayed missing and filled permanent teeth were extracted from the dental records depending on the age of the child the sum of the two indices for each participant was the outcome measure for analysis statistical analysis all analyses were carried out in ibm® spss® statistics version 22 for windows poisson regression was used for modelling childrens caries experience as the latter was a count variable rate ratios were therefore reported the sum of deciduous and permanent teeth was used as the offset variable in regression models the modelling strategy was first to estimate the crude association between each indicator of acculturation and childrens caries experience and then gradually adjust for confounders of the association hence the crude association of generational status with caries experience was first estimated this association was then sequentially adjusted for child factors in model 2 and additionally for family factors in model 3 we repeated the modelling strategy with age at arrival length of residence in spain and language spoken at home in separate set of regression models when reporting estimates from regression models spanishborn children were the reference category for comparison we run two sets of sensitivity analysis in the first set we repeated the set of regression models for each dentition separately that is using the number of deciduous and permanent teeth with caries experience as separate outcomes in second set we repeated the set of regression models using the number of decayed teeth rather than caries experience as the outcome measure results this study used data from 313 children who agreed to participate and had complete data on relevant variables the migrant group was mainly represented by moroccans ecuadorians and eastern european table 1 shows the composition of the study sample by generational status firstgeneration migrant children were older than spanishborn and secondgeneration migrant children in addition migrant children had mothers with higher levels of education but lived in lower social class than their spanishborn counterparts there were on average 73 teeth with caries experience per child only 77 of children were cariesfree and the dd component represented 833 of the caries experience table 2 shows variations in childrens caries experience by indicators or acculturation and covariates caries experience was the highest among first generation children those who arrived in spain before 6 years of age those with 10 or more years living in spain and those speaking other language than spanish at home in addition male children the oldest those living in the lowest social class and children whose mothers had the lowest education showed the greatest caries experience no differences were found by marital status generational status was significantly associated with childrens caries experience firstand secondgeneration migrant children had respectively 15 and 19 greater caries experience than spanishborn children these differences remained significant after adjusting for child factors in model 2 however they were no longer significant for secondgeneration migrant children after further adjustment for family factors in model 3 only firstgeneration migrant children were significantly different from spanishborn children having 18 greater caries experience when firstand secondgeneration migrant children were combined in a single group they had 13 greater caries experience than spanishborn children after controlling for child and family factors table 4 shows the results for the association of other indicators of acculturation with childrens caries experience by age at arrival firstgeneration migrant children arriving in spain before 6 years of age had 34 greater caries experience than spanishborn children by length of residence firstgeneration migrant children with 10 or more years in spain had 38 greater caries experience than spanishborn children by language spoken at home children in families speaking spanish and other language and children in families speaking other language only had respectively 31 and 25 greater caries experience than those in spanishspeaking families similar results were found when modelling dental caries experience in deciduous and permanent teeth separately and when replacing caries experience with the number of decayed teeth as the outcome measure discussion this study provides some support for the role of acculturation in explaining inequalities in child oral health inequalities in dental caries between migrant and native children were evident and independent of familys socioeconomic circumstances we also found evidence of greater caries experience among specific groups of migrant children more specifically firstgeneration migrant those who arrived in spain at an early age who have been living in spain for a longer time and who spoke a language other than spanish had more teeth with caries experience some limitations of this study need to be borne in mind when interpreting the present results first this study is based on crosssectional data and thus we are only able to test for associations not causal relationships although our findings suggest that acculturation may play a role in the oral health of migrant children they should be confirmed with longitudinal data second this study was based on a convenience sample of a single dental clinic in madrid and thus it does not represent the entire population of migrant children in spain what is more recruitment from a dental clinic implies that participants had access to and sought out dental care these children might have caries experience different from those that do not have access to dental services therefore the present findings cannot be extrapolated beyond the study sample third although our sample size was large enough to test the hypothesised relationships it did not allow for further stratification by country of origin or nationality this is an area that requires further investigation fourth we measured acculturation with proxy measures despite recent criticism about their usefulness because they do not directly measure elements of acculturative change 4 however these measures are commonly used in research on acculturation particularly in new settings where validated instruments are not available 524 in addition we used four different proxies to cover different aspects of the acculturative process finally no attempt to control for dental behaviours was carried out as our aim was to assess the overall impact of acculturation on childhood caries experience it was considered inappropriate to adjust for dental behaviours indeed dental behaviours are considered as merely intermediates of the relationship between the broader social determinants and oral health 25 26 27 migrant children exhibited greater caries experience than spanishborn children this finding agrees with previous studies in spain 16 17 18 despite methodological differences among studies such as the definition of migrant and lack of adjustment for social conditions 1718 our definition for migrant children was consistent with current frameworks 62028 and recent international evidence 719 we also found that caries experience and untreated caries were higher among certain groups of migrants children who use another language at home had greater caries experience and untreated caries than spanishborn children and migrant children who only speak spanish at home language proficiency gives migrant families greater availability of healthrelated information while also reducing barriers to accessing and interacting with health care and social services 2629 however in madrid differences in restoration indexes have not been found for permanent dentition 18 probably because the healthcare system in madrid provides free preventive and restorative care for the permanent teeth of children language spoken also reflects country of origin and as such epidemiological differences in caries profile between world regions 30 most migrants from south america will speak spanish as opposed to those coming from eastern europe and north africa our findings for age at arrival and length of residence were quite consistent with each other although not necessarily in line with those found in previous studies 31 32 33 children who arrived before age 6 years and those who have spent 10 or more years in spain had greater caries experience and untreated caries than spanishborn and secondgeneration migrants these findings suggest that the process of childrens acculturation in spain is not associated with better oral health at least not at first changes in eating habits after arrival can have repercussions on childrens oral health possibly due to greater exposure to cheap food high in sugar 10 however once migrant families are settled in spain they could enjoy greater food choices and healthier dietary patterns which will be reflected on their childrens oral health the present findings have some implications for policy and research in spain most public health policies have been traditionally based on equal rights to healthcare for all regardless of immigration status in madrid several public health programmes specifically target the migrant population it would be advisable to include childrens oral health in that list particularly those described above as for research further studies should analyse the influence of acculturation in childrens oral health specifically looking at factors underlying such association such as health behaviours the use of valid multidimensional instruments may also help exploring other aspects of the acculturative process in conclusion this study shows the existence of clear inequalities in dental caries between migrant and native children which were not fully accounted for by their families socioeconomic conditions other factors may therefore play a role in explaining these inequalities children who arrived in spain at an early age who have been living in spain for a longer time and who spoke a language other than spanish exhibited greater caries experience conflicts of interest the authors declare no conflicts of interest in relation to this study

background this study explored the relationship between different indicators of acculturation and childrens caries experience methods data from 313 children attending the dental clinic of the european university of madrid were analysed acculturation was measured via generational status age at arrival length of residence and language spoken at home the association between each indicator of acculturation and caries experience was assessed in poisson regression models adjusting for confounders results firstand secondgeneration migrant children had greater caries experience than spanishborn children these differences only persisted for firstgeneration migrant children after adjustment for confounders children who arrived in spain before age 6 years who lived in spain for 10 or more years and who spoke a language other than spanish at home had greater caries experience than spanishborn childreninequalities in caries experience between migrant and native children were evident favouring the local children and independent of familys socioeconomic circumstances

introduction approximately 10 per 1000 births are affected by congenital heart defects of which a quarter is considered to be critical 12 these defects constitute the leading cause of death among children with birth defects during the first year of life 3 despite this around 138 to 295 of these infants receive a significantly delayed diagnosis 4 5 6 previous studies have shown the association between socioeconomic factors with delayed diagnosis and mortality of chd inequalities in access to health care seem to play a key role in these results 7 in panama amerindian groups account for 116 of the population and have been important contributors to the genetic diversity of the country 8 these indigenous groups remain relatively isolated in part due to geographical limits but mostly because of cultural barriers and they are known to have disadvantaged socioeconomic conditions 9 this is the first study done in panama and central america that has included indigenous populations in an analysis of the impact of socioeconomic factors on the disease outcomes of chd very little is currently known about the influence of ethnicity on these outcomes 10 11 12 the objectives of this study are to assess the association between socioeconomic variables and delayed diagnosis of chd and also to explore the association between socioeconomic variables and mortality due to chd methods study design inclusion and exclusion criteria a retrospective observational study was conducted including all public health care institutions with paediatric cardiologists in panama the cases included were born from january 1 2010 to december 31 2014 and had a diagnostic code from q200 to q269 according to the icd10 all cases included were diagnosed by a paediatric cardiologist using echocardiography and doppler studies with colour flow mapping high resolution computed tomography or magnetic resonance imaging was used in some infants for a better characterization of the defects children with prenatal diagnosis were considered as diagnosed at birth for time to diagnosis analyses purposes we excluded all cases of patent ductus arteriosus born with less than 37 weeks marfan syndrome congenital arrhythmias cardiomyopathies mitral valve prolapse and bicuspid aortic valve based on reported definitions of chd 1314 definition of critical congenital heart defect infants were considered to have a critical congenital heart defect when diagnosed with at least one of the defects listed as primary or secondary targets of newborn pulse oximetry screening such as dextrotransposition of the great arteries truncus arteriosus total anomalous pulmonary venous connection tricuspid atresia pulmonary atresia hypoplastic left heart syndrome tetralogy of fallot doubleoutlet right ventricle ebstein anomaly coarctationhypoplasia of aortic arch aortic interruptionatresiahypoplasia and single ventricle children with these twelve defects are likely to present with hypoxemia 415 definition of outcome based on previous studies the diagnosis of cchd was considered delayed when made after the third day of life 56 for the non critical congenital heart defect group the median of diagnostic times was used as a cutoff value for defining delayed diagnosis sensitivity analyses were made using different values for the ncchd group observing similar results study variables homebirth was defined as delivery outside a health facility maternal age was categorized in three groups according to legal adulthood age in panama and the age for defining a high risk pregnancy 16 low maternal education was defined as 6 years of education or less noncardiac congenital anomalies were reported when major structural defects or syndromic chromosomal abnormalities were found 4 indigenous ethnicity was defined as meeting at least one of the following criteria indigenous parental origin reported in the clinical record place of residence or parental identity card number from an indigenous territory the institutional review boards of the participating paediatric centers that authorized the analysis of clinical records approved the research protocol we used identity card numbers instead of infants names to guarantee confidentiality of data data sources institutional lists from the medical records departments were used to locate cases with chd since those lists only contain infants identification and diagnosis and panama does not have electronic clinical files or national databases on chd all variables had to be obtained from paper based clinical records mortality from 2010 to 2014 was verified with the national database of mortality elaborated by the national institute of statistics and census of panama statistical methods an estimated 440 infants were diagnosed per year between 2010 and 2014 using information on live births from the national institute of statistic and census and an estimated annual prevalence of 65 cases of chd per 1000 live births for latin america 14 sample calculation was performed using an expected frequency of delayed diagnosis of 295 and a confidence level of 95 6 because of underdiagnosis due to a reduced amount of paediatric cardiologists and in order to guarantee a representative sample we preferred to use an estimate of diagnosed cases as the population size instead of institutional numbers of cases we added an additional 25 to the sample and a sample size of 1156 infants was obtained after applying exclusion criteria the final sample size was 954 infants using statistical software we randomly selected infants from lists of health care institutions and then proceeded to locate their clinical files the frequency distributions of the most common defects and of socioeconomic variables were calculated and expressed as percentages the presence of these variables was compared between indigenous and nonindigenous infants these characteristics were also examined according to time of diagnosis logistic regression model univariate logistic regression models were used to estimate crude odds ratios for associations between each socioeconomic feature and delayed diagnosis we also performed an adjusted logistic regression model which included the following variables maternal age ethnicity maternal education delivery institution type noncardiac congenital anomalies and severity of defects adjusted odds ratios with 95 confidence intervals were calculated the validity of the model was evaluated using an omnibus test with a significance level of 5 the results are expressed as or aor and 95 ci survival analysis survival curves were made for the associations between each socioeconomic variable and mortality due to chd and hazard ratios and their respective 95 ci were calculated using logrank tests an adjusted cox proportional hazards model was performed to examine these associations including maternal age ethnicity maternal education delivery institution type noncardiac congenital anomalies time to diagnosis and severity of defects adjusted hr and 95 ci were also calculated the model was evaluated using a likelihood ratio test all statistical analyses were assessed with ibm spss statistics 19 and graph pad prism 6 results from 2010 to 2014 we reviewed the clinical records of 954 infants with diagnosis of chd s1 fig summarizes the most common defects found vsd in 360 asd in 184 pda in 142 and tapvc in 94 infants socioeconomic variables overall low maternal education was documented in 258 infants and homebirth in 64 infants a total of 217 infants belonged to an indigenous group among the indigenous infants we observed that 126 had mothers with low education 51 infants were born at home and 147 had a delayed diagnosis of the 737 non indigenous infants 132 had mothers with low education 13 infants were born at home and 356 had a delayed diagnosis table 2 shows the frequency of distribution of study variables by severity category and timing of diagnosis cchd was found in 345 cases and ncchd in 609 overall 503 infants had a delayed diagnosis while 451 had an early diagnosis for the cchd group 199 infants had a delayed diagnosis while for the ncchd group 304 infants had a delayed diagnosis of the infants with cchd born at home 30 had a delayed diagnosis while for those born in a health facility 169 had a delayed diagnosis among infants with cchd from indigenous groups 70 had a delayed diagnosis compared to 129 in the nonindigenous group in infants with cchd and low maternal education a delayed diagnosis was observed in 76 infants in comparison to those with high maternal education in which 97 infants had a delayed diagnosis among infants with ncchd and homebirth 26 had a delayed diagnosis while 278 born in a health facility had a delayed diagnosis in infants with ncchd and indigenous ethnicity delayed diagnosis was observed in 77 in comparison to the non indigenous group in which 227 infants had a delayed diagnosis for those with ncchd and low maternal education 96 had delayed diagnosis while for those with high maternal education 164 had a delayed diagnosis delayed diagnosis table 3 presents results of models for the associations between socioeconomic features and delayed diagnosis after adjusting for all variables an increased risk of delayed diagnosis was observed in infants with indigenous ethnicity low maternal education and those born at home infants with noncardiac congenital anomalies were at a decreased risk of delayed diagnosis these same associations persisted when we used different values for defining delayed diagnosis in infants with ncchd survival analysis from 2010 to 2014 284 infants with chd identified in our study died fig 1 shows survival curves and associations between socioeconomic variables and mortality due to chd table 4 shows crude and adjusted hr for associations between socioeconomic variables and mortality due to chd for maternal age a lower risk of dying was observed in infants born to mothers aged 18 to 34 years and in infants born to mothers aged 35 years or more in comparison to infants born to mothers less than 18 years old the reported one year survival rate for infants born to mothers less than 18 years old was 65 in comparison to 72 in infants born to mothers 18 to 34 years old and 72 in infants born to mothers aged 35 years or more regarding ethnicity indigenous infants were more likely to die due to a chd in comparison to non indigenous infants we observed a one year survival rate of 63 for indigenous infants versus 75 for the non indigenous when examining the association between maternal education and mortality infants born to mothers with low education had a higher risk of dying in comparison to infants born to mothers with high education the one year survival rate for the low education group was 59 while it was 76 for the high education group we did not observe any statistically significant associations between delivery institution type and mortality survival rates at one year were 69 for infants born at home and 72 for infants born in a health facility when performing an adjusted model infants at a higher risk of discussion time to diagnosis delayed diagnosis was found in 527 of the infants a proportion that is approximately twice as high as the ones reported by previous studies 4 5 6 a delayed diagnosis of chd was associated with low maternal education homebirth and belonging to an indigenous group variables that are associated to poverty and reduced access to health care previous studies have found an association between the levels of care received in hospitals by the newborn and delayed diagnosis in infants with cchd a retrospective study conducted in massachusetts from 2004 to 2009 which evaluated 460 467 live births found 916 cases of cchd in this study a delayed diagnosis was found to be associated with delivery outside a tertiary care hospital 5 similar results were observed in another retrospective study done in florida between 1998 and 2007 where 3603 cases with cchd were analyzed in this study there was a higher chance of having delayed diagnosis if the newborn received care at a level i nursery or at a level ii nursery as compared to those that received care at a level iii nursery 4 we were not able to find studies that compared delays in diagnosis of chd between infants born at home and infants born at hospitals but we assume that there is a higher chance of delayed diagnosis in the former especially in the setting of a low socioeconomic status the association between late detection of chd with homebirth indigenous ethnicity and low maternal education reflects the unfavourable socioeconomic status and multiple other disadvantages present in many indigenous communities in panama and in many countries of the region there are large disparities in distribution of health human resources between indigenous and nonindigenous areas a report by the panamerican health organization recommends a minimum density of 25 health professionals per 10 000 population 17 while in some regions of panama this number is as high as 491 per 10 000 population one of the most densely populated indigenous areas of panama has the lowest hhr density in the country 18 although we found studies reporting that some socioeconomic variables were factors associated with delayed diagnosis 45 we were not able to find studies that showed a relationship between delayed diagnosis of chd and indigenous ethnicity we were only able to find a study conducted in canada which reported that there is a higher prevalence of chd in indigenous populations 19 mortality infants that belonged to indigenous groups and were born to mothers with low education had significantly higher chances of dying due to a chd and also had lower one year survival rates while an association between ethnicity and mortality has been found in studies done in the united states with africanamerican and white infants with chd 10 11 12 we were not able to find any studies describing an association between indigenous ethnicity and mortality from chd there is a spectrum of determinants present in indigenous communities favoring poor health outcomes that goes beyond the prognostic and clinical factors associated with the severity of chd these factors encompass social economic and cultural characteristics that condition the lower oneyear survival rates found in the indigenous groups studies have shown the high costs and multidisciplinary approach required to provide optimal care for children with chd 2021 although we did not analyze the capacity of the panamanian health system to deal with chd we believe that serious deficiencies in the public health care system and socioeconomic barriers are the main factors that keep many indigenous children with chd from reaching adulthood beyond this we observed a high amount of indigenous infants with chd contributing to 227 of all the study cases while representing 116 of the country total population factors like exposure to teratogenic substances consanguinity or genetic predisposition could be playing an important role on these findings 22 23 24 25 26 the main limitations of this study reside in the fact that we were unable to include all infants diagnosed with chd in our analysis due to a lack of national databases on congenital malformations this study does not include data on missed diagnoses of chd and as a result we are lacking data on neonatal and infant mortality for those cases with missed diagnoses most of the infants were diagnosed at tertiary care facilities which most likely led to a higher proportion of cchd cases we did not include infants treated at private hospitals because they give care to less than 15 of the population also we did not include variables like income maternal nutritional status and alcohol consumption because the data was unavailable the main strengths of the study reside in the accuracy of the diagnoses all made by paediatric cardiologists and in the fact that all deaths were verified using a national mortality database our results highlight the importance of social determinants in the management and outcomes of chd we believe that better access to quality health services should produce a positive impact on both diagnostic times and mortality 7 the socioeconomic disparities that are revealed in this study are part of the contrasts seen in a nation with a gini index of 517 27 which has changed little in recent years despite a marked and sustained economic growth that has elevated panama to the rank of an upper middle income country 28 to address these health deficits panama needs to strengthen the quality of cardiac care not only at regional levels but also at the level of local health care centers by increasing the quantity and quality of health care professionals capable of diagnosing and caring for infants with chd 29 30 31 also creating a surveillance system of birth defects would provide the epidemiological data needed to guide evidencebased national health policies regarding chd 32 our results suggest that inequalities in access to health care conditioned by unfavourable socioeconomic features such as indigenous ethnicity homebirth and low maternal education may play a key role in the disease outcomes of chd specifically time to diagnosis and mortality further studies are required to study the relationship between indigenous ethnicity and these adverse health outcomes we recommend that these indicators be strongly taken into consideration by health authorities when evaluating strategies for improving the quality of cardiac and paediatric health care especially in countries with high levels of inequality and with an important quota of vulnerable groups such as indigenous populations data from this study are available from the institutional databases of the supporting information s1

this is the first study in panama and central america that has included indigenous populations in an assessment of the association between socioeconomic variables with delayed diagnosis and mortality due to congenital heart defects chd a retrospective observational study was conducted a sample calculation was performed and 954 infants born from 2010 to 2014 were randomly selected from clinical records of all panamanian public health institutions with paediatric cardiologists critical chd was defined according to the defects listed as targets of newborn pulse oximetry screening diagnoses were considered delayed when made after the third day of life for the critical chd and after the twentieth day of life for the noncritical a logistic regression model was performed to examine the association between socioeconomic variables and delayed diagnosis a cox proportional hazards model was used to assess the relationship between socioeconomic features and mortalityan increased risk of delayed diagnosis was observed in infants with indigenous ethnicity

introduction indonesia is a nation of many tribes its culture is rich but all tribes have the same goal to achieve common welfare and prosperity so ethnic differences do not limit us indonesia must have its own identity as a country rich in culture natural resources and human resources 1 with todays technological advances the social system and culture of society are changing with the development of technology culture which is the basis for human relations and society also develops in terms of customs religions and traditions held by regions in indonesia however the development of culture supported by technology can also have a negative impact on the development of customs religions and traditions to the identity of the nation 2 ichelss the pressure of changing times has a significant impact on indonesias young generation the goal of education in indonesia is not only to grow potential and educate but also to build religious individuals however the fact is that schools today emphasize the inculcation of concepts formulas and theories subjects and lesson hours in the field of general science and not much religious education as a result education in indonesia seems secularized it is beneficial but not moral so it is clear that religious values play a very important role in any educational process carried out in schools 1 technological changes that facilitate the transfer of information from one country to another often make people carried away by the flow of information in the form of culture owned by other countries this has caused the identity of the indonesian nation which is reflected in the younger generation to begin to fade due to the younger generation who prefer the culture of other countries therefore this article will discuss about building national identity through the historical traces of sheikh yusuf as one of the important figures in the spread of islam in indonesia which can be an effective means to foster a sense of love for the country and nationalism of the younger generation in building the identity of the indonesian nation method this research uses a literature study to collect various information about the life traces of sheikh yusuf as a means of strengthening national identity in the midst of globalization which is full of influences from other countries identities this research uses primary and secondary sources such as books articles journals research reports and information from websites the literature study was conducted to strengthen the issues discussed and became the basis for providing an understanding of national identity as one of the factors of development as well as the nature of the nation 1 result and discussion definition of national identity identity comes from the english identity which according to the general indonesian dictionary means the state special characteristics of an object or person and identity which in the political dictionary means the characteristics or special state of a person or his identity however the word national comes from the word nation which in the political dictionary comes from the words nation which in latin means birth tribe doi 1018502kssv9i214870 ichelss and nation which in english means state or nationality the word national also means a people who share a common history customs culture language and territory this fosters awareness loyalty and a desire to unite in an independent state terminologically speaking national identity is a characteristic that distinguishes a nation from other nations in other words every nation on earth will have a unique identity based on its own characteristics traits features and character national identity or better known as national personality is the core of national identity national identity is defined as the manifestation of cultural values that grow and develop in aspects of the life of a nation with distinctive characteristics and with these distinctive characteristics a nation is different from other nations in its life on the other hand the definition of national identity is defined as the expression of unique cultural values that distinguish a nation from other nations national identity is the attribute that makes a country unique national identity on the other hand never ends and will continue to exist the cultural values held by the majority of a countrys people and reflected in the national identity are not normatively and dogmatically fixed rather they are everchanging due to the desire for progress of the society that supports them in other words national identities can be given new meaning to remain relevant and effective in modern societies 3 the components of national identity reflect the diversity of the nation all the elements that make up national identity including ethnicity religion culture and language are considered pluralistic 4 fundamental identity consists of pancasila as the nations philosophy state foundation and state ideology instrumental identity consists of the 1945 constitution and its laws the natural identity which includes the archipelago and pluralism of ethnicity culture language and religion and belief is the identity used here the language used is indonesian and the national anthem is indonesia raya biography of sheikh yusuf the full name of sheikh yusuf almakassari is muhammad yusuf abu mahasin tajul alkhalwati almakassari or better known in south sulawesi by his honorary title tuanta salamaka ri gowa which means our noble teacher from gowa his childhood name was muhammad yusuf the addition of sheikh to his first name was given after he returned from the holy land to perform the hajj 5 his father was abdullah khaidir and his mother was sitti aminah binti gallarang montjong loe sheikh yusufs life journey in the historical record of his life struggle and his long journey from one place to another in the search for islamic knowledge he received his islamic education from daeng ri doi 1018502kssv9i214870 ichelss tassamang a teacher in the kingdom of gowa when he was fifteen years old later he studied with sayyid ba alawi bin abdul alallamah attahir and sayyid jalaludin alaidid sheikh yusuf then migrated to aceh and banten after returning to cikoang and marrying the daughter of the sultan of gowa at the age of 18 in banten he became friends with sultan ageng tirtayasa in aceh he studied with nuruddin arraniri and learned the qadariyah order these lessons helped him to become closer to allah swt at all times sheikh yusuf made the hajj in 1644 and stayed in mecca for some time he learned from shaykh abdullah muhammad bin abdul albaqqi in yemen and from shaykh abu albarakat ayyub bin ahmad bin ayyub alkhalwati alquraisy in damascus sheikh yusuf then studied in the middle east for about twenty years 8 after studying in the middle east for approximately fifteen years sheikh yusuf returned to banten in 1664 at that time the ruler of banten was prince surya also known as sultan ageng tirtayasa whom he knew before traveling to the middle east when sheikh yusuf returned to banten for the second time the people of banten welcomed him with great respect this was due to sheikh yusufs broad religious understanding especially in terms of sufism 9 prince abd alqahhar the crown prince of the sultanate of banten was one of sheikh yusufs disciples from the banten family anticipatory steps were taken immediately on july 7 1693 sheikh yusuf was finally sent to south africa by the dutch 10 the name sheikh yusuf is one of the most recognized and learned indonesian islamic scholars in south africa although there was no freedom of religion at the time it is alleged by some authors on cape muslim history that during sheikh yusufs shortlived stay at the cape muslims and islam were able to flourish however other authors believe that this may not have been possible because sheikh yusuf had limited freedom of movement since he was located far away from central cape town to a very dry and sandy compound called zandvliet in the macassar faure region near stellenbosch is moreover sheikh yusuf appears to have been strategically placed there in isolation by the dutch conglomerate rulers while he and his many followers and family who came with him were allowed to practice islam in their place of isolation as muslims they were not allowed to practice islam openly or to spread islam because of a lack of religious freedom 11 yet despite this today there are 600000 people who follow islam in cape town at the age of 73 sheikh yusuf died in south africa city on may 23 1699 however at the request of his family his body was brought to his hometown of lakiung gowa regency six years later 12 this explains the location of his two main tombs one in south africa and one in indonesia after his death sheikh yusuf had and continues to have great influence in south africa former south african president nelson mandela one of the famous figures of the 20th century who forgave those who opposed apartheid called sheikh yusuf the father of islam in south africa and even said that doi 1018502kssv9i214870 ichelss the sheikh was one of africas best sons sheikh yusuf was also named a national hero by former south african president thabo mbeki in 1995 the indonesian government named him a national hero according to the first president of the republic of indonesia a great nation is one that honors its heroes the great scholar sheikh yusuf is honored by south africans as one of the founding father s of islam in south africa his keramat in cape town is well preserved and regularly visited there is no dust on his nisan which is covered by an iron fence locals still respect and honor the master and cleric from makassar who at the time of his arrival there was the most learned scholar of islam in south africa 13 sheikh yusufs life trajectory as an effective means of fostering a sense of patriotism and nationalism in the younger generation in strengthening national identity the footsteps of sheikh yusuf have great potential to be an effective tool in nurturing the love of country and nationalism of the younger generation in building the identity of the indonesian nation here are some ways in which this can be realized the footsteps of sheikh yusuf have great potential to be an effective tool in nurturing the love of country and nationalism of the younger generation in building the identity of the indonesian nation here are some ways in which this can be realized 1 adherence to religion and patriotic ideals sheikh yusuf is recognized for upholding the beliefs of both his home nation and exile while residing far from it his life story demonstrates to the next generation the need of upholding ones religious and national allegiance particularly in tough times 2 the spirit of life in struggle sheikh yusufs perilous voyage during his exile which was full of turns and tribulations may serve as an inspiration for future generations to endure through hardships it teaches that the spirit of effort is the key to success and that obstacles shouldnt be allowed to stand in the way of achieving objectives through the process of learning from one expert to another he was able to obtain an islamic education which ultimately had a significant influence on his development upward mobility and course of life 8 the narrative emphasizes how crucial education is to forging a strong feeling of national identity the younger generation will likely be motivated to study more and advance the nation 5 cultural diplomacy and international relations sheikh yusufs life has included crossborder encounters notably with south africa this might inspire the following generation to engage in cultural diplomacy and forge constructive relationships with other countries so overcoming cultural gaps and widening their worldviews the younger generation may find it easier to interact with other cultures as a result of the ease of contact between people in different countries 6 respecting historical and cultural heritage sheikh yusufs narrative serves as a reminder of how crucial it is to protect and preserve our rich cultural and historical legacy the younger generation may learn to not only respect and learn about the history that creates their identity but also to look to the future the younger generation can obtain a greater understanding of the virtues and potentials of the indonesian country via the tales and values found in sheikh yusufs life trajectory they may be motivated to actively take part in creating a strong and competitive national identity as a result conclusion indonesia as a pluralistic country consisting of various ethnicities races languages and cultures makes indonesia a multicultural country indonesias plurality does not necessarily make the people of this nation lose their national identity the cultural values held by the majority of a countrys people and reflected in the national identity are not things that have been normatively and dogmatically established instead these values are always changing due to the desire for progress of the society that supports them in other words national identity can be given new meaning to remain relevant and effective in modern society reflecting on the life of sheikh yusuf one of the great scholars in indonesia can be used as a learning tool for the younger generation in strengthening national identity doi 1018502kssv9i214870 ichelss sheikh yusuf was born in 1626 ah acquiring religious knowledge at the age of 15 in cikoang from daeng ri tassamang a teacher of the kingdom of gowa after marrying the daughter of the sultan of gowa at the age of 18 he then migrated to aceh and banten in banten he befriended sultan ageng tirtayasa and in aceh he studied with nuruddin arraniri and learned about tarekat qadariyah due to the dispute between sultan ageng and his son as well as his prominent role in the kingdom sheikh yusuf

this study aims to build national identity through the historical traces of sheikh yusuf as one of the important figures in the spread of islam in indonesia this can be an effective mean to foster a sense of love for the country and nationalism of the younger generation in building the nations identity this study used a literature study including books or journals about sheikh yusuf the results show that the life of sheikh yusuf can be an effective means to foster a sense of patriotism and nationalism in the younger generation in building the identity of the indonesian nation which can be seen from loyalty to religious values and the motherland the spirit of struggle in life interfaith tolerance and crosscultural brotherhood the importance of education and learning cultural diplomacy and international relations to respect for cultural and historical heritage through the narratives and values contained in sheikh yusufs life trajectory the younger generation can gain a deeper insight into the strengths and potential of the indonesian nation thus they can be inspired to actively contribute in building a strong and competitive national identity

background due to aging of the brain and declining physical health latelife mental disorders are expected to increase with around 15 of older persons aged 60 years and above suffering from a mental or neurological disorder worldwide 1 cognitive function is defined as a set of thinking abilities that can be measured through performancebased tasks such as memory executive function and processing speed 2 agerelated diseases result in less resource for mental tasks and reduce cognitive resources in older individuals which may impact their daily functional abilities 3 given the greater socioeconomic distributional disparities in developing countries like india it is important to understand what factors contribute to the differing levels of cognitive health among people from lower and higher socioeconomic groups notably older adults among the general population tend to experience a higher incidence of poverty and deprivation of basic services 4 whereas the ability to deal with health problems in older age is associated with access to resources and such access is hindered by poor socioeconomic circumstances 5 therefore leading to increased susceptibility to the deleterious effects of aging and cognitive deficits there is a wealth of literature showing independent association between socioeconomic status and cognitive function in later life 6 7 8 9 however it is documented that an adverse socioeconomic status with accumulating disadvantages reflects an increased risk of cognitive impairment 10 11 12 thus it is recommended in health disparities research to add cumulative and aggregate measures of socioeconomic status such as education wealth social class and asset ownership which may perform better than measures of current position 13 similarly recent evidence suggests that selfperceived income sufficiency is a useful indicator of individuals socioeconomic resources as a determinant of health 1415 education on the other hand one of the important indicators of socioeconomic status has been most extensively studied in the cognition research 9 16 17 18 a study that examined the influence of education on cognitive performance controlling for household economic variables concluded that although the educationcognition relationship partially reflected an ses gradient the association was more likely due to the process and consequences of education itself 19 but studies that examined the association of other socioeconomic indicators such as income household wealth and occupation with latelife cognition showed inconsistency in their findings 20 21 22 23 throughout the literature in india being a rural resident belonging to households with poor economic situations experiencing violence and other sociocultural factors that make older individuals less important in their households were also found to have a negative impact on their cognitive health outcomes 12 24 25 26 thus with the current demographic structure in india that is evolving rapidly increased inequality in major socioeconomic indicators across different subpopulations may be associated with inequality in older adults cognitive functioning in this regard understanding the contribution of specific factors to the latelife cognitive inequality in a country with higher rates of illiteracy may help policymakers develop strategies targeting the subpopulations at greater risk therefore in this study we examine the socioeconomic and healthrelated factors associated with cognitive impairment among older adults and the contribution of those factors to the concentration of low cognitive functioning among older adults from poor households by employing a decomposition technique also subjective income status as a potential covariate of the cognitive impairment among older adults that has rarely been analysed in an indian context is included in the present study we hypothesize that there is a significant wealthbased inequality in latelife cognitive functioning in india also we hypothesize that low levels of perceived income status poor wealth low education and lack of asset ownership are positively associated with cognitive impairment among older indian adults methods data data for this study were derived from the building knowledge base on population ageing in india survey which was carried out in india the survey was carried out in seven major states of india which covered a total of 9852 older adults from 8329 elderly households in rural and urban areas these states have a higher percentage of the 60 population compared to the national average and these states represent all regions of the country in terms of geographical location the individual dataset was used which covers the sociodemographic profile work history and benefit income and assets living arrangement social activities the health status of the elderly social securityrelated questions 27 the bkpai sample design entails a twostage probability sampling where first villages were classified into different strata based on population size and the number of primary sampling units to be selected was determined in proportion to the population size of each stratum using the probability proportional to population size technique the psus have been chosen and within each selected psu elderly households were selected through systematic sampling a similar procedure was applied in drawing samples from urban areas 27 the final sample size for the analysis after removing missing cases and outliers was 9176 older adults aged 60 years and above variable description outcome variable the outcome variable was binary and was assessed through verbal recall strategy which was used to measure cognitive functioningimpairment in previous studies 2829 a scale of 0 to 10 was created to assess cognitive impairment lower cognitive impairment is associated with higher scores and vice versa bus house chair banana sun bird cat saree rice and monkey were the nouns used to measure cognitive abilities while dichotomizing five or more words were recoded as 0 low indicating lower cognitive impairment and four or fewer words as 1 high indicating higher cognitive impairment equity stratifier the household wealth index was the equity stratifier in the current study the wealth index is created based on the bkpai survey with the following 30 assets and housing characteristics household electrification drinking water source type of toilet facility type of house cooking fuel house ownership ownership of a bank or postoffice account and ownership of a mattress a pressure cooker a chair a cotbed a table an electric fan a radio transistor a black and white television a colour television a sewing machine a mobile telephone any landline phone a computer internet facility a refrigerator a watch or clock a bicycle a motorcycle or scooter an animaldrawn cart a car a water pump a thresher and a tractor the range of index was from poorest to richest ie ranging from lowest to highest explanatory variables due to a higher proportion of missing data in the objective income status selfperceived income sufficiency was used as an indicator of individuals income status it was recoded as work status was recoded as educational status was recoded as marital status was recoded as asset ownership was asked regarding homeownership land ownership jewellery ownership and other monetary savings and was recoded as age was recoded as gender was available as men and women coresiding with children was recoded as several healthrelated variables were selected based on the abovementioned literature selfrated health had a scale of 1 to 5 and was categorized as 0 good and 1 poor ability to do activities of daily living and continence was having a scale of 0 to 6 where higher the score higher the independence a score of 6 was recoded as 0 high which represents full independence and five and less was recoded as 1 low which represents not being fully independent to do activities of daily living 30 the ability to do instrumental activities of daily living had a scale of 0 to 8 representing the higher the score higher the independence a score of 6 was recoded as 0 high representing high iadl and a score of 5 and less was recoded as 1 low representing low iadl the 12item version of the general health questionnaire was used to measure the psychological health psychological health had a scale of 0 to 12 based on experiencing stressful symptoms and was recoded as 0 high and 1 low 3132 the 9item subjective wellbeing questionnaire was used to measure low subjective wellbeing subjective wellbeing was having a scale of 0 to 9 and was categorized as 0 high experiencing better experience and 1 low experiencing negative experience 33 twelve questions on psychological health and nine questions on subjective wellbeing were asked to assess the outcome all the questions were asked on likert scales and were recoded and used accordingly as per literature 34 religion of the respondent was recoded as hindu muslim sikh and others caste was available as scheduled castes scheduled tribes other backward classes and others and place of residence was either rural or urban states were available as himachal pradesh punjab west bengal orissa maharashtra kerala and tamil nadu statistical analysis descriptive statistics were reported along with the results from bivariate analysis which was conducted to find the plausible associations between exposure and potential risk factors and cognitive impairment using the chisquare test multivariable logistic regression 35 was used to explore the relationships between the explanatory variables and cognitive impairment the estimates were adjusted for all the covariates considered in the study including age and education the software used was stata 14 36 the significance level was set at 5 the variance inflation factor was used to check the presence of multicollinearity in the explanatory variables which showed no evidence of multicollinearity 37 concentration index on the yaxis the cumulative proportion of outcome variables is plotted against the increasing percentage of the population ranked by the socioeconomic indicator on the xaxis to generate the concentration curve 38 such curves show whether or not socioeconomic inequality in the outcome variable prevails with the index value being negative if the curve is above the line of equality indicating that the outcome variable is disproportionally concentrated among the poor and vice versa 3940 the concentration index and the concentration curve were used to quantify wealthrelated inequality for cognitive impairment using the wealth score as the socioeconomic indicator and the binary outcome as cognitive impairment the concentration index is the area between the concentration curve and the line of equality multiplied by two 3940 the concentration index compares the distribution of one variable to another variables distribution the index runs from 1 to 1 with 0 indicating no socioeconomic disparities the indexs positive score on the other hand indicates prorich inequality and vice versa 3940 furthermore the higher the value on either scale the greater the degree of socioeconomic inequality the concentration index was decomposed using wagstaff decomposition methodology 3940 the breakdown of the concentration index by wagstaff illustrates that the wealthrelated inequalities may be dissected into the contributions of each element 41 for any linear regression model on a health outcome such as y α k β k x k ε the concentration index for y c can be written as follows where μ is the mean of y x k is the mean of x k c k is the concentration index for x k and gc ε is the generalized concentration index for the error term eq 2 shows that c is equal to a weighted sum of the concentration indices of the k regressor where the weight for x k is the elasticity of y with respect to x k η k β k x k µ the last term captures the socioeconomic inequality in health that is not explained by systematic variation in the regressor by wealth which should approach zero for a wellspecified model 3940 the elasticity of each contribution is multiplied by the degree of economic disparity furthermore the estimates are generated by dividing each absolute contribution by the overall absolute contribution multiplied by 100 to give the percentage contribution 3940 results table 1 presents the socioeconomic and demographic profile of older adults while 335 of the older adults perceived that the income was not partially or completely sufficient about 43 of them reported that they had no income nearly 67 of older adults did not work in the last year almost half of the older adults had no education and nearly 40 of older adults were not in a marital union about 18 of older adults had no asset ownership onetenth of older adults were from the oldest old age group more than 50 of participants were women about 29 of older adults were not coresiding with their children more than half of the older adults reported that they had poor selfrated health about 57 reported that they had low iadl and about 7 had low adl nearly 27 and 24 had low subjective wellbeing and low psychological health about 24 of older adults belonged to the poorest wealth status and 15 belonged to the richest wealth status nearly 80 of the population belonged to the hindu religion and 21 belonged to the scheduled caste category about 26 of the study population resided urban areas at the time of the survey figure 1 presents the percentage of older adults with cognitive impairment according to socioeconomic status it was found that cognitive impairment was highest among older adults from households with the poorest wealth quintile and lowest among those from households with the richest wealth quintile table 2 presents the percentage of older adults with cognitive impairment the highest percentage of older adults who had income and was not sufficient were cognitively impaired a higher percentage of older c k c k gc ε µ adults who never worked were cognitively impaired the prevalence of cognitive impairment was high among older adults who had no education the prevalence of cognitive impairment was high among older adults with no asset ownership the higher percentage of older adults with poor selfrated health low iadl low adl low subjective wellbeing and low psychological health were cognitively impaired the prevalence of cognitive impairment was highest in west bengal followed by orissa and kerala figure 2 reveals the concentration curve for cognitive impairment among older adults it was found that cognitive impairment was concentrated among older adults from households with the lowest wealth quintile table 3 presents estimates of decomposition analysis for the contribution of various explanatory variables for cognitive impairment among older adults the coefficients in the table are the regression coefficients with 95 confidence interval to represent how cognitive impairment is associated with other explanatory variables for instance it was found that the likelihood of cognitive impairment was high among older adults with a low level of selfperceived income sufficiency coefficient 029 ci 007052 compared to older adults with higher levels of perceived income status on the other hand older adults who were retired had a lower likelihood of cognitive impairment coefficient 026 ci 046007 in comparison to older adults who never worked in the last year similarly older adults with more than 10 years of education were less likely to be cognitively impaired coefficient 127 ci 150104 in comparison to those with no education the cci indicates concentration index and negative cci denotes that cognitive impairment was concentrated among economically poor older adults for that particular predictor and viceversa the absolute contribution is the product of elasticity and cci whereas the percentage contribution is the proportion of absolute contribution multiplied by 100 educational status wealth status and psychological health were the significant factors that contributed to the inequality for cognitive impairment among older adults for instance educational status among older adults explained 446 of socioeconomic inequality followed by 318 by wealth status and 115 by psychological health apart from these factors iadl caste and selfperceived income sufficiency explained socioeconomicinequality in cognitive impairment among older adults discussion in the present study we found a higher concentration of cognitive impairment among older indian adults from poor socioeconomic backgrounds as evidence suggests selfperceived income sufficiency is considered a useful tool to assess resources and health disparities in underserved populations 1442 the results of the present study also show that subjective income status measured by selfperceived income sufficiency had a significant association in cognitive functioning in older ages it is noteworthy that the measure of subjective income status has been used in past studies to assess the economic wellbeing as well as satisfaction and stress levels 4243 and is recommended to assess the resource availability among underserved populations 14 in a study using data from world health organizations study on global ageing and adult health perceived income adequacy was found to be significantly associated with selfrated health among older adults 44 again our results are consistent with studies in lessdeveloped societies that found a significant positive association of latelife perceived insufficient income with cognitive impairment 45 further older indian adults often tend to work beyond the age of retirement due to a lack of pension and social security in the informal labour market 4647 however although the result was not significant the current analysis showed a possible beneficial effect of working status in the last year on cognitive abilities however cognitive difficulties were found to reduce individuals ability to work in multiple studies 4849 and the current finding may be explained by the possible reverse causality in the association where older adults who are cognitively healthy may continue to work in later life 25 also as evidence suggests the protective effects of the reserve may be established early in life before people enter the workforce 50 suggesting that the work status of the older individual may not affect hisher cognitive health but the age maybe a common cause in such association as documented after retirement older adults may enjoy better health conditions and have more time to spend in social life 51 consistently the present study found a significant negative association of retirement with cognitive impairment the finding is substantiated by the theory of relieved effect on mental functioning which suggests that retirement from a stressful occupation may reduce mental worries 25 while examining the direction of the effect between retirement and cognitive functioning multiple studies have revealed that poor physical mental and cognitive health may affect retirement decisions and lead to the early retirement of older individuals 52 53 54 our finding that higher levels of education act as a major contributing factor to higher cognitive performance is consistent with previous studies 7 18 55 further the substantial contribution of lower levels of education to the cognitive health disparities can be explained as increased resource availability and access to higher education may mediate ones health behaviours to some extent and could enhance hisher overall health especially cognitive functioning 57 it is again explained by the hypothesis of brain reserve capacity that argues that those people with higher levels of education may have a larger brain reserve capacity than people with no or low levels of education 58 it is also shown that more educated people tend to experience less cognitive decline because high educational attainment is a protective factor against neuropathology 11 in the decomposition analysis we found the largest contribution of education to cognitive health inequalities with higher education contributing more to increased socioeconomic inequality in cognitive impairment another study found education as contributing to the capacity for cerebral reserves 59 furthermore in addition to biological effects education can also increase competencies and enhance cognitive abilities 17 these can all lead to improved cognitive abilities and cognitive networking efficiency among older adults although education overwhelmingly determines the pathway studies show that household wealth has the same causal linkage as education by which cognitive ability could be enhanced 19 the study also found a significant contribution of household wealth index and asset ownership to socioeconomic inequalities in cognition previous studies support the association of household economic status with older individuals cognitive abilities and the contribution of household factors to the cognitive inequalities among the ageing population 21246061 such an association of higher economic status that associates a greater cognitive ability could partially be explained by the fact that having material possessions or equipment appears to be beneficial for cognitive functioning in terms of reduced risk of indoor air pollution the poor economic status triggering cognitive deficits may also be attributed to the earlier evidence that shows that lack of material resources may result in increased stress or inflammation and poor neural health that leads to cognitive deficits 62 evidence from studies of cognitive function and marital status indicates that for both genders married people are less likely to suffer from dementia than those who are divorced separated or single 63 decomposing the factors in the present study has shown that marital status had a significant contribution to cognitive inequalities among older adults also married individuals are at lower risk of developing cognitive problems mainly because of better mental conditions and lifestyle behaviours 6465 furthermore all the healthrelated variables in the current study show significant contributions to the inequalities in old age cognitive impairment among all the substantial contribution of poor psychological health shows a lack of a healthy brain that can stimulate the cerebral nervous system and positively affect cognitive health which may worsen sesrelated inequality in cognitive functioning among an aging population consistent with earlier studies 6066 difficulty with two or more activities of daily living among study participants was also shown as a significant factor that intensifies the inequalities in cognitive functioning however functional ability in many studies also has been documented to be associated with cognition with reverse causation where older adults with higher cognitive abilities may have better functional health 6768 finally the higher prevalence of cognitive impairment in the states of west bengal odisha and kerala suggest the need for future studies focusing on regional variations in latelife cognitive impairment in india the study has the merit of decomposing the contribution of several socioeconomic and healthrelated factors in socioeconomic inequalities in latelife cognitive health using a large survey data however the study has certain limitations too firstly cognitive impairment is measured only through the word recall method and did not consider other measures of cognitive functioning such as orientation and executive and arithmetic functioning although the analysis was adjusted for education assessing the cognitive abilities using word recall method in a population with higher rate of illiteracy might have resulted in higher prevalence of cognitive impairment and may bias the current findings secondly the estimates provided are just the association of the past as the survey was conducted in 2011 and further investigation is required using more recent datasets lastly the respondents were selected from seven states of india which represent different regions of india therefore one should be cautious while generalizing it for pan india apart from limitations the survey was well structured and focused entirely on the issues of older adults hence the estimates and associations are reliable conclusions findings suggest that older adults with lower perceived income lower levels of education poor physical and mental health and poor physical and social resources were more likely to be cognitively impaired hence these factors can be adopted further to evaluate the health inequalities and develop better policies and programs for table 3 a dementing population education wealth and psychological health are major contributors in socioeconomic inequality in latelife cognitive impairment in the current study which may be target areas in future policy formulation to reduce the inequality in cognitive impairment in older indian adults the finding that education has a significant largest contribution to cognitive impairment late in life which is in line with existing studies suggests that educational attainment may bring positive changes in the fundamental brain functions and allow older adults to cope up with the agerelated cognitive changes 6970 this has particular significance in the indian context where a major chunk of older adults are illiterate further longitudinal studies are warranted to investigate the factors contributing to differential declines in cognition and establish causal relationships between associated factors and cognitive impairment variables coef competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which 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the rapidly aging population is a major concern for countries especially where cognitive health in older age is poor the study examined the socioeconomic and healthrelated factors associated with cognitive impairment among older adults and the contribution of those factors to the concentration of low cognitive functioning among older adults from economically poor households methods data this study were derived from the building knowledge base on population ageing in india bkpai survey which was carried out in seven major states of india the effective sample size for the analysis was 9176 older adults aged 60 years and above results from descriptive and bivariate analysis were reported in the initial stage multivariable logistic regression analysis was conducted to explore the associations additionally the concentration index and concentration curve were used to measure socioeconomic inequality in cognitive impairment among older adults wagstaff decomposition was employed to explore the key contributors in the concentration index results nearly 60 of older adults suffered from cognitive impairment in the study the likelihood of cognitive impairment were higher among older adults with a low level of selfperceived income sufficiency coefficient 029 confidence interval ci 007052 compared to older adults with higher levels of perceived income status older adults with more than 10 years of schooling were less likely to be cognitively impaired coefficient 127 ci 150104 in comparison to those with no education cognitive impairment was concentrated among older adults from households with the lowest wealth quintile concentration index cci 010 p 005 educational status explained 446 of socioeconomic inequality followed by 318 by wealth status and 115 by psychological health apart from these factors difficulty in instrumental activities of daily living 37 caste 37 and perceived income sufficiency to fulfil basic needs 30 explained socioeconomic inequality in cognitive impairment among older adults conclusions findings suggest that older adults with lower perceived income lower levels of education poor physical and mental health and poor physical and social resources were more likely to be cognitively impaired education wealth and psychological health are major contributors in socioeconomic inequality in latelife cognitive impairment which may be target areas in future policy formulation to reduce the inequality in cognitive impairment in older indian adults

introduction alice monroe is a famous female writer in contemporary canadian literature and her short stories also enjoy a high reputation in the contemporary international literary world in 2013 monroe beat haruki murakami and atwood to win the nobel prize in literature she devoted her life to the creation of short stories focusing on womens issues from the identity and perspective of female writers such as female identity or the relationship between women and ecology the novel gravel from the fourth of monroes 2014 collection of short stories dear life gives readers a stunning reading experience with its unique narrative techniques and concise words many of the works in the dear life have left a deep impression on the readers such as the final song and drift to japan munros excellent narrative skills and structural design of the story give the short stories deep and rich connotations in fact in just a few pages you can even feel the complex emotions of reading a novel alice munros works based on their own personal experience and saw and heard no grand historical narrative instead of the background of daily life in remote areas of canada with all kinds of details about ordinary women in family life and struggle draw the outline of elegas if women exist around us 1 in a small ordinary thing she will be the female heart of the ups and downs of the psychological activities described lifelike in the seemingly unchanging remote rural life of canada like stagnant water these ordinary women are not willing to continue to escape numb or rise up against the shackles of tradition break all kinds of invisible chains and bravely pursue independence and freedom these vivid female images are the charm of alice monroes works and their fate makes readers and one of the reasons why she is favored by the judges of the nobel prize in literature the development process of ecological feminism the concept of ecological feminism originated in the 1970s and was a combination of feminism and ecoism proposed by e 2 in the continuous improvement of selfdevelopment and progress the core of ecological feminist theory has developed from the emphasis on the correspondence between women and natural experience to the analysis of the relationship between women and nature and slowly stepped onto the historical stage of literary criticism and began to form in peoples analytical vision ecological feminism is characterized by pluralism on the one hand it is a branch of feminism so it is committed to the deconstruction of patriarchal centrism on the other hand it inherits the essence of ecofeminism namely to liberate life oppose the destruction of science and technology to nature and pursue the complete thought ecofeminism also rewritten the concept of anthropocentrism believing that its essence comes from male centrism which means that human oppression of nature essentially stems from the oppression of nature in patriarchal society ecological feminism calls for a reconstruction of human society from a feminist perspective in ecofeminist literature the works tell the story centered on women women are ecological and ecology is feminine ecological feminism believes that nature has many similarities with women for example at the physiological level the ecological cycle of nature is often compared to the production process of women and even the theory that the earth mother gives birth to their children is also related to women therefore nature has close ties with women monroes works often show the fate of women and nature by expressing the bond between women and nature so as to give dual attention to both nature and women overview of alice monroes short story collection dear life dear live dear life is a collection of short stories by alice monroe published in 2012 a total of fourteen articles is a collection of short stories written by alice monroe in the late world war ii living in a remote canadian town as the stage and featuring a woman the book is divided into two parts where the first ten are short stories and the last four are mainly the authors personal memoirs top ten short stories independent of each other on the plot and characters but all in the remote town in ontario canada with all kinds of female image as the leading role describes them in trivial daily depression of life struggle after four articles mainly by the author personal experience actual description the author reflects the octogenarian memory of former life also from the side reflects the influence of the authors personal experience on its literary creation dear life won the canadian cui lin literature prize in 2013 the highestranking literary award in ontario canada aiming to encourage and promote the development of native canadian literature in the same year alice monroe won the nobel prize in literature becoming the 13th female writer in the history of the nobel prize in literature and also the first canadian writer to win the nobel prize in literature alice munro specializes in describing married life and sexual relationships and often incorporates her own personal experiences in her characters and storylines in the collection of short stories dear life she gives a calm look at the women who are oppressed by marriage and family life in the monotonous smalltown life for example in the drift to japan the poetess greta escapes her breathless marriage because her husband did not understand her artistic pursuits and always suppressed her poetic creation the novel is hardly one not to think of alice monroes own experience alice monroes first marriage ended in failure also because her first husband was busy running a bookstore allowing alice monroe to support her family affairs alone ignoring her spiritual needs and squeezing her room for literary creation in the end alice monroe left her first husband exactly to gretas decision the gravel the fourth novel in dear life mainly tells the story of a middleaged mother of two children who escapes her former life divorced her exhusband and then starts a new life with her new boyfriend the story is narrated in the firstperson perspective and the narrator as the mothers second child is only five years old shortly after her nineyearold sister carlo moved with her dog briz to neil tragedy happened carlo and briz drowned in the water bringing shock and remorse to the young i so that they did not emerge from the shadow of the tragedy many years later this paper explores the perspective of ecological feminist criticism in the gravel women and the ecological relationship between nature men the self explore their struggle and get rid of the dilemma of patriarchal center approach and reveal the ideal of ecological feminism struggle to get out find the way in men and nature an ecological destination ecological feminism believes that nature has many similarities with women for example at the physiological level the ecological cycle of nature is often compared to the production process of women and even the theory that the earth mother gives birth to their children is also related to women therefore nature has close ties with women monroes works often show the fate of women and nature by expressing the bond between women and nature so as to give dual attention to both nature and women women are natural friends and nature is the destination of women the first natural image in the novel is the pet dog briz at the beginning of the novel the mother and two children first took briz to the trailer puppies clearly prefer spacious lawns and tall houses to the crowded narrow streets in the town it is worth noting that the title of puppy briz in gravel has been used she instead of it which shows that they regard it as the family in their hearts every time carlo came back from school bliz always waited for her by the roadside every time he went to the roadside mailbox bliz followed his master closely when neil didnt want to have a dog caro told him im not going to disappear ill always take care of her visible out of the dog as a symbol of nature and female harmony even monroe will be the fate of caro and the dog briz closely together briz in the relationship with caro has gone beyond their own biological attributes monroes description of female relations with animals is mostly about nonanthropocentrism and gives women a unique humanistic care the novel shows that all life in the world is equal including those species that look lower than humans dogs are the most emotional species of all domestic animals and monroes description of dogs highlights the friendly relationship between people and dogs and emphasizes the innate symbiotic relationship between women and animals represented by carlo another natural image also often runs through the full textsand and gravel as the title of the novel gravel is like the beacon of plot development always pushing the plot forward step by step 3 here gravel refers to a deserted gravel pit near the home which has been abandoned because it is too shallow to build a house the novels description of the gravel pit is also to convey the emotional tone of the next plot for example the novel describes that the snow miraculously shrinks the trees are still bare and without leaves and under the clear sky the lake is calm and sparkling although it seems to be just the gravel pit every step of the change indicates the next plot development the melting of snow and ice in the gravel pit in late winter has turned into a gravel lake which describes its calm and sparkling lake but behind the calm of the lake foresees the tragedy that soon happened here ecological feminist critics often use metaphorical relationships to view the relationship between women and nature 4 monroe is also good at applying this metaphorical relationship in his works and using its concepts to emphasize the closeness of the connection between the two therefore by describing the enthusiasm of women for nature the work also shows that nature is the destination of human beings but also the destination of women the helpless situation attached to men dear life the main social background is the remote areas of canada late world war ii the women here even have their own work and recipient before marriage most after marriage will give up work as a housewife they do not have independent economic status have to attach to men and life this is the root of the tragic endingamenson in the young female teacher vivian was married by the doctor alister the whole process vivian did not have any doubt and resistance selfish and ruthless allister afraid of the marriage affect him even asked her to leave the train originally life and work of the city away from their own life circle as a typical representative of women in that era vivian was attached to men for a long time had no selfspirit in ideology passively accepted the unreasonable demands of men and even imagined that allister could change his mind at the train station in the short story of leaving mavery alice munro portrays several people living in isolated towns due to a variety of reasons attached to male female characters long bed english teacher originally isabel is a cheerful and lively in the local middle school professor of english language and literature teacher loved by students sick she had to helplessly left the teaching position recuperate at home she not only economically depends on her husband but also have to rely on her husband in life daily life but also because cant give birth to a child for her husband and very remorse apart from isabel there was the girl leah and whose mother were completely attached to leahs father without any personal freedom and without her fathers permission father did not even allow leah to see the movies aunt dawn in shelter always looks at her husbands face everything in the family has to get the permission of her husband and even the selfish husband does not want to have children because she had children that distract her care and carecolly in the rich woman colly was unmarried because she was disabled but she did not have the courage to live alone so she committed to a married man even in knowing that the man cheated his money still rely on him did not tell the truth these women who are attached to the men live helplessly in the invisible wall slowly lose themselves and live in the pain day after day in 5 analysis the helpless situation attached to men dear life the main social background is the remote areas of canada late world war ii the women here even have their own work and recipient before marriage most after marriage will give up work as a housewife they do not have independent economic status have to attach to men and life this is the root of the tragic endingamenson in the young female teacher vivian was married by the doctor alister the whole process vivian did not have any doubt and resistance selfish and ruthless allister afraid of the marriage affect him even asked her to leave the train originally life and work of the city away from their own life circle as a typical representative of women in that era vivian was attached to men for a long time had no selfspirit in ideology passively accepted the unreasonable demands of men and even imagined that allister could change his mind at the train station in the short story of leaving mavery alice munro portrays several people living in isolated towns due to a variety of reasons attached to male female characters long bed english teacher originally isabel is a cheerful and lively in the local middle school professor of english language and literature teacher loved by students sick she had to helplessly left the teaching position recuperate at home she not only economically depends on her husband but also have to rely on her husband in life daily life but also because cant give birth to a child for her husband and very remorse apart from isabel there was the girl leah and whose mother were completely attached to leahs father without any personal freedom and without her fathers permission father did not even allow leah to see the movies aunt dawn in shelter always looks at her husbands face everything in the family has to get the permission of her husband and even the selfish husband does not want to have children because she had children that distract her care and carecolly in the rich woman colly was unmarried because she was disabled but she did not have the courage to live alone so she committed to a married man even in knowing that the man cheated his money still rely on him did not tell the truth these women who are attached to the men live helplessly in the invisible wall slowly lose themselves and live in the pain day after day in germination of female independent consciousness dear life takes the small town life as the main stage and performs the joys and sorrows of ordinary people in this vivid scene of life the female characters with distinct personalities gradually sprout their own sense of independence in drift to japan greta gradually realizes after getting married and having children that in addition to her housewife and mother another important identity is a poetess the identity of a poetess was highly valued and cherished by greta and was not accepted by the society at that time this reflects the germination of gretas independent consciousness aunt dawn in shelter had everything around her husband but she did not get her respect 6 she even cooked new dishes for her husband at dinner but attracted her husband scolded even when aunt dawn invited her neighbor and her husbands sister to the house he made no secret of his dislike of the guests and made no affection for her finally at her husbands funeral aunt dawn realized that she could not care about her husbands emotions and realized that she was an individual the independent girl in eyes doesnt care about the town people pointing at her and people talk about her without a boyfriend but go to dance alone she said go alone go alone and go for yourself although she lives in a traditional closed town her heart has a sense of independence in a closed remote town in canada where unmarried girls stay at home sady seems to be a different color she also hosts programs and performs songs on the towns radio stations which seemingly unconventional local behavior highlights the germination of womens sense of independence this budding of a sense of female independence reflects alice monroes own experience as living in the fifties and sixties of the remote canadian town girl alice monroe only 20 years of college and her first husband married in canada at the time girls generally no longer work and study after marriage become a fulltime wife while alice monroe is still writing continue his writing career pursue their independence in spirit and literary creation female consciousness refers to the conscious consciousness of the status role and value of women in the objective world 7 it is the internal motivation to stimulate women to pursue independence and autonomy and give full play to initiative and creativity specifically speaking female consciousness means that women can consciously realize and fulfill their historical missions social responsibilities and life obligations and clearly know their own characteristics participate in social life in a unique way and affirm and realize their social values and life needs female consciousness unifies person and woman reflecting the pursuit of value including gender and surpassing sex in a patriarchal society political economic and religious things can only be done by men while women imprisoned in the family have no place to display their talents except to be a good wife and good mother we call this orientation of women a female role female roles exist before female consciousness and before women establish their female consciousness they habitually appear as the female social role given to her by the society female role is cultivated by social education and social customs which is the restriction and disrespect of female consciousness which can only emerge from these restrictions before the feminist movement people did not see men rule over women as clearly as they are today nor did they realize that this rule was accepted and recognized by the whole society and men and women voluntarily accepted the order since women are raised in such circumstances they learn much less than men in caring for themselves their wishes purposes and needs in the long history of patriarchal human civilization the development of female selfconsciousness was in a chaotic state for a long time 8 for a woman to accept to the men they must think and act as they do or they will treat you like a monster and loneliness will be your fate household image a woman herself is a house in the process of interpretation of alice monroes novel it is not hard to find the description of the family environment is very fixed mainly reflected in the edge of the quiet town or at the end of the road is a surface calm and peaceful the actual undercurrent of small family there is a busy mother in the home and seemingly silent but great power father the relationship between parents is not close at the same time plus a stamp character i munros description of the family environment is usually in a seemingly complete and peaceful position which some researchers call the family environment for the food edge family we mean the complete family can see between family members family members can appear in common time but the socalled key family is that we can only see the indifference and alienation between family members no affection show just calm self sustaining and restraint but also in different periods mixed with certain gunpowder the basic bond to maintain family members in a feeding family is not traditional love and responsibility but an instinct for survival and inheritance just a family gathered together for diet monroes description of household women as the house the angel who is busy in the unfathomable cave and imprisoned in the family and house is a female cultivation history term described from the perspective of feminism independent woman image different if you were a man alice monroe also experienced job hunting and worked between work and children so she became an independent woman in her novels as a reflection of her work period they include a wide range of women such as traditional european girls female doctors in higher education and successful women in the workplace they are the representative of masculine women is the representative of women with a very high level of knowledge but also represent the basic characteristics of women independent aloof and aloof monroes independent female images usually have a fixed occupation including writer nurses presenters and so on 9 munro has a deep choice of career types including nurses who can face the vulnerability of life every day a host who suffers but performs perfectly a columnist who is alone in a big city and a professional manager who is more capable than men they are displaced alone in the busy era and will inevitably encounter some resistance in a society with prevailing traditional ideas and eventually their essential independence will gradually become isolated from monroes works it is not difficult to see whether the female intellectuals can do ideological emancipation work through their own efforts，opinions because they also have many problems and contradictions for example in daily life they usually face the public as a savior thinking that their thoughts can be above ordinary people but they have no ability to change those women who are bound by traditional consciousness women on the edge we are each others demons the description of women on the edge of society in his work may be monroes portrayal of his despair on the edge of life a womans life goes through three doors that is the relationship between parents and herself her husband and her and the relationship between children and herself if a woman leaves her parents husband children and herself what will be the true meaning of existence in monroes writing women often wander between their qualified selves and their true selves whether they accept the responsibility of society or put all their eggs to follow themselves and constantly explore the true identity of women at the same time these women will also have a certain psychological gap and confusion in the face of the great social unrest and these psychological changes are shown one by one through monroes description in escape kara encouraged by female professor to break through the bondage of society for their own but was forced to halfway back office in the i also under the influence of virginia woolf want to have their own a room but found in the actual implementation process to realize the idea the motherdaughter relationship has always been a very important part of monroes mind and the generation developed from the motherdaughter relationship has always brought different degrees of trouble to monroes female characters monroe in a very limited space for us to describe a very typical female family history grandma messed in the mother control the control of the self for the final tragedy at the same time it will impose the tragedy in the third generation but due to the lack of father education management the girl may has a strong idea to change their own fate at the same time as the modern consumption concept of the traditional society times in constantly changing make the overall structure of the family has changed dramatically selfbecome the main body of action is constantly amplified in the contact collapse at the same time the individual is thrown out of history and family tradition the description of the female generations in the work is monroes revelation of the hidden female pains 10 through its unique narrative techniques and concise words the short story dear life shows readers the survival struggle of women in a family in a male power society and their ultimate destiny munro gives the novel a shock to a seemingly calm narrative from the perspective of ecofeminism readers can more clearly understand the efforts of ecofeminists to deconstruct masculine centrism from the ecological relations between women and nature women and men and women and selfspirit of course as a new theory that is still progressing ecological feminism indeed needs to be developed for example some scholars believe that ecological feminism praises femininity freely and does not have certain objectivity however it is undeniable that ecological feminism as a new method of literary criticism indeed provides a new method and a new way for the study of texts and the establishment of correct womens values making people more focus on the relationship between women and ecology and make necessary contributions to the diversified development of feminism conclusion understanding dilemmas is getting out of them alice monroe in her novel presents a series of womens dilemmas but the purpose is not just to blame the patriarchal society and make women complain about themselves but to let women learn from it and find a better way out for themselves therefore the author believes that if women want to get out of the dilemma they should first be psychologically independent according to beauvoir many women are both mentally and physically independent in the dear life women are also not mentally and physically independent in monroes other novels for example the women in escape are influenced by traditional culture always dependent on men instinctively seeing themselves as others passive and vulnerable they have lost their sense and confidence just like carla however aware of the problem carla did not try to solve the problem but ignored the problem the old son day by day she resisted the temptation to do that until the end of the story carla did not pursue the independence and self she sought at the beginning of the story of course carla like others may eventually find an opportunity to seek the truth and free herself through selfawareness and selfsufficiency the interpretation of alice monroes works shows that the description of different female images is the thinking on the establishment of the new female concept brought by monroe since ancient with the change of times the overall image of women has been people through different ways to shape misunderstanding is in the problem of women should use their own methods to respond to the society society family and responsibility reveal the true value of self alice monroe is committed to guiding women to create a happier life so in her later novels it mainly expresses womens sense of selfactualization womens selfpursuit consciousness can only make women have the idea of insisting on the pursuit while womens selfrealization consciousness can help women realize their own pursuit which is a kind of deep cognition and the sublimation of thought this change of thought is closely related to the change of social environment

the inequality of social status between men and women has always been one of the social problems warmly discussed in novels alice munro is a contemporary canadian woman author awarded the 2013 nobel prize in literature is known for describing womens lives inspiring them and guiding them william faulkner is an american the representative writer of the southern renaissance who won the nobel prize for literature in 1949 represented women in the american south through a series of female characters the sympathy of tragic fate led the trend of female consciousness in america at that time this paper discusses the female consciousness in alice monroes novel and analyzes the awakening of female consciousness

introduction quilombola are populations descended from enslaved africans who fled to the forests in resistance during the imperial period in brazil today they are predominantly concentrated in rural areas of the country the inhabitants practice subsistence activities based on slashandburn agriculture extraction of natural products from the forest production of handicrafts for sale traditional fishing and hunting and raising small animals for family consumption 1 2 3 the brazilian government recognized the rights of quilombolas as traditional populations and the national constitution of 1988 formally granted them ownership of their lands 4 however most quilombola areas are still not legalized resulting in inadequate infrastructure and restricted access to health and education services leaving them vulnerable and with a low quality of health and life 5 6 7 8 formal education in quilombola communities is challenging because there are few schools and a lack of trained teachers to promote quality education respecting their cultural norms 9 this is an aggravating factor for the insertion of this population in the sociocultural and economic spheres of the country in addition knowledge of sexuality is essential for general health and quality of life and covers aspects related to sexuality itself such as sexual function and satisfaction desire lubrication orgasm and resolution in addition to affective feelings values beliefs and even knowledge about sexual expression diversities and sexually transmitted infections 10 11 12 sexual health according to the world health organization who 13 is a state of physical and psychological wellbeing in relation to sexuality as well as the possibility of having pleasurable and safe sexual relations and who also added pleasure as a key factor in sexual health for clarity it is necessary to differentiate between the concepts of sexual function and sexual satisfaction sexual function refers to physiological changes in sexual response and sexual satisfaction is defined as the degree of fulfillment in aspects of a persons sexual life therefore sexual satisfaction is essential for sexual health overall wellbeing and improved quality of life 14 limited knowledge about sexuality sexual response adequate hygiene and pathologies affecting the urogenital system can trigger problems in the individual and profoundly impact sexual health it is worth pointing out that sexual satisfaction or dissatisfaction is influenced by culture beliefs and sexual and gender diversity prejudice which play a fundamental role in the attitudes and values of individuals regarding sexuality this fact involves not only physical pleasure but also emotional satisfaction and is a critical element for the quality of life and social relationships 1516 there is ample evidence of the importance of sex education for preventing early onset sexual intercourse as well as for increasing awareness about the use of condoms and other contraceptive and preventive methods it also reduces exposure to the risk of sexually transmitted infections unintended pregnancy and vulnerability to other diseases and promotes sexual health 121718 according to the territorial plan for sustainable rural development of the lower tocantins in quilombola communities the education system results in unequal distribution of information this hinders the production of knowledge and autonomy regarding health care since a learning process regarding the performance of sexuality and knowledge about the risk of stis occurs at school 1920 currently we found no studies that address sexuality and quality of life among quilombal communities in the equatorial amazon it is essential to elucidate the sexual health of populations of rural black origin to allow the implementation of tailored promotion prevention and treatment strategies with these communities following the national policy of integral health of the black population 21 thus this study questions how knowledge about sexuality can influence the quality of life of young quilombolas from the brazilian eastern amazon and aims to analyze the sexuality of young men and women residents of quilombola communities in the brazilian eastern amazon regarding sexual knowledge and their beliefs and the impact on the quality of life of these individuals materials and methods type of study this is an observational crosssectional quantitative study with descriptive and inferential analysis sampling the study used simple random probability sampling with the purpose of allowing each element of the target audience the same probability of being selected after defining the target population and identifying the sampling frame a unique number was determined for each element and after calculating the sample size the random selection was made by drawing lots from the specific number of elements of the target population elegibility criteria individuals of both sexes and young adults aged 1835 years classified by petry 24 were included participants belonging to and residing in quilombola communities recognized by palmares cultural foundation for more than five years sexually active inactive or asexual who agreed to participate by signing the informed consent form were included individuals were considered sexually active if they had any sexual activity in the three months prior to the beginning of the study they were considered sexually inactive if they had no sexual activity for more than three months prior to the study 25 an asexual individual was considered to have a lack of sexual attraction or lack of interest in others 26 sexual activity was defined as any mutually voluntary activity with another person that involves sexual contact whether or not intercourse or orgasm occurs 27 data collection the individuals were first approached by physical therapy students trained to apply the questionnaire under the supervision of the responsible researcher these individuals were then oriented about the research and afterward signed the icf with simple and objective language to measure sexual knowledge the following questionnaires were applied by an interviewer to optimize collection time and solve any difficulties the participants may have 1socioeconomic and sexual profile questionnaire 2female sexual functioning index 3international index of erectile function 4index of sexual satisfaction 5questionnaire on values and beliefs about sexuality 6scale of prejudice against sexual and gender diversity 7questionnaire on knowledge of sexually transmitted diseases 8questionnaire of quality of life was also applied questionnaires 1 2 4 5 6 7 and 8 were assigned to females questionnaires 1 3 4 5 6 7 and 8 were used for males the socioeconomicdemographic and sexual profile questionnaire was applied to draw a profile of the population to be studied in an objective way and the sample was then submitted for the evaluation of quantitative aspects to evaluate sexual feelings and responses the female sexual functioning index was used which is a 19item questionnaire that evaluates six domains of sexual function the lower the score the worse the sexual function is considered 27 the adapted international index of erectile function was developed exclusively for men and validated with the objective of measuring erectile function in a culturally linguistically and psychometrically valid way divided into five domains it has 15 questions with a value from 1 to 5 the result consists of the sum of the values of the answers with low values indicating poor quality of sexual life 2829 the sexual satisfaction index is a psychometric scale developed so that the degree of sexual satisfaction can be measured the index is validated and contains 25 points classified on a likert scale from 1 to 7 this questionnaire addresses questions about the quality of sexual life but in a noninvasive or nonoffensive manner 30 the questionnaire of values and beliefs about sexuality consists of 17 items using a likert scale of 5 points to measure values and beliefs about female sexual functions pregnancy desire for motherhood and abortion thus through this it becomes possible to better understand the factors that lead a woman to continue or terminate a pregnancy and female sexuality 31 the sexual and gender diversity prejudice scale is a 22item instrument rated from 1 to 5 composed of 2 other instruments that assess prejudice against gender and another against gender and transgender nonconformity and higher scores evidence greater prejudice 32 the sexually transmitted diseases knowledge questionnaire consists of 28 items and after adaptation to brazilian portuguese deals with seven sexually transmitted diseases it is a questionnaire with answers categorized as true false and dont know which is easy to fill out 3334 the world health organizations quality of life instrument abbreviated version includes 26 items is divided into four domains and has an overall score and a specific score per domain it was translated and validated and the global score refers to the average of two items that do not belong to the four domains but to the global health item and the global quality of life item in addition the items are rated on a 5point scale higher scores indicate better quality of life quality of life domain scores was calculated as usual by multiplying the domain mean score by a factor of 4 resulting in a range of 4 to 20 for each domain 3536 after filling out the forms all data obtained were tabulated in excel ® software 2013 for further data analysis the research participants were not identified maintaining total secrecy and respect for the confidentiality of information and privacy at all times and circumstances minimized by means of numerical identification in the questionnaires in addition the data collected were only used for research by those responsible for the study and the participants were instructed about the total freedom to withdraw from the research at any time if they so wished variables this study adopted gender as the independent variable and had as dependent variables sexual function and all its domains sexual satisfaction and all its domains values and beliefs and all its domains sexual prejudice and gender diversity and all its domains knowledge of sexually transmitted diseases and all its domains and quality of life and all its domains statistical analysis for the descriptive analysis absolute and relative frequencies were used in addition to variables that direct the analysis after verifying the normality of the data through the shapirowilk test additionally the mean standard deviation or median and 95 confidence interval were calculated for inferential analysis the following tests were performed unpaired ttest and mannwhitney u test for intergroup comparisons analyzed with parametric and nonparametric distributions respectively the relationship between variables was assessed using pearsons correlation test or spearmans rank results the characteristics of the sample are presented in table 1 there was no significant age difference for either sex participants identified themselves as black and single up to two people contributed to the family income with up to four people surviving on that income most participants had an active sex life as for education the women had completed high school while the men had not the womens monthly income ranged up to 26000 reais and the mens ranged from 78100 to 130000 reais most women reported having no income of their own regarding the number of pregnancies 40 of the women did not get pregnant and 92 did not have an abortion regarding the number of children the proportion did not differ significantly table 2 shows the difference in the level of sexual satisfaction values and beliefs about sexuality level of prejudice regarding diversity and gender knowledge about stis and quality of life between the sexes among the participants the results of sexual satisfaction showed that women showed greater dissatisfaction when compared to men women had more negative values and beliefs about motherhood men indicated better quality of life in the physical psychological and environmental domains table 3 shows the overall correlations between sexual satisfaction values and beliefs about sexuality prejudice toward sexual and gender diversity stdkq and whoqolbref26 tables 4 and5 show the correlations divided by sex with an analysis of male and female sexual function respectively almost all five domains of male sexual function were correlated except sexual desire which was not correlated with erectile function sexual satisfaction and orgasm greater knowledge of stis was correlated with greater overall sexual function erectile function satisfaction and orgasm greater sexual satisfaction overall sexual function and erectile function were correlated with lower beliefs about motherhood lower beliefs around motherhood were related to higher sexual satisfaction orgasm and overall function finally better overall quality of life including the physical aspect was related to higher sexual desire and orgasm fsfi s 0160 p 0162 fsfi in females we observed that greater desire was associated with greater lubrication and less knowledge about stis arousal correlated positively with lubrication orgasm pain overall sexual function and sexual satisfaction it correlated negatively with overall quality of life and the physical psychological and environmental domains lubrication correlated with less prejudice quality of life in social relationships and the environment it was associated with an increase in overall sexual function orgasm sexual satisfaction pain and knowledge about stis the orgasm was related to higher sexual satisfaction pain overall sexual function and lower quality of life in general and in the environmental domain sexual satisfaction as assessed by the fsfi was positively related to almost all items assessed for sexual function except desire increased pain was related to higher sexual function and sexual satisfaction finally overall sexual function was correlated with higher scores for sexual satisfaction abortion beliefs and quality of life in the environmental domain regardless of sex a better quality of life correlated with higher sexual satisfaction in males there was no correlation between sexual satisfaction and other variables however when analyzed by sex the best quality of life was correlated with higher sexual satisfaction in females all domains of the questionnaire on values and beliefs about sexuality were correlated that is high beliefs about motherhood being the primary function of women were correlated with higher beliefs in reproduction as a primary function of female sexuality as sharing of affections negative representations of abortion and higher beliefs in considering pleasure as a primary function in female sexuality greater prejudice was correlated with greater beliefs about reproduction affectivity motherhood abortion and pleasure less knowledge about stis was related to stronger beliefs about reproduction affectivity and motherhood the higher belief around reproduction was correlated with better quality of life in social relationships the greater belief around affectivity was related to the lowest quality of life in the physical and environmental domains in men the stronger beliefs about motherhood were correlated with the highest beliefs about affectivity stronger beliefs around abortion and pleasure were correlated with higher beliefs about the other domains stronger beliefs around reproduction were correlated with a higher quality of life in the psychological and social relations domains greater prejudice was related to the stronger beliefs around motherhood and abortion less knowledge about stis was associated with higher beliefs around reproduction and maternal pleasure in women stronger beliefs about motherhood as their primary goal were associated with higher beliefs about the need to share affections negative representations of abortion and stronger beliefs about pleasure as a primary function in female sexuality higher prejudice was related to stronger beliefs about reproduction and affectivity maternal beliefs about reproduction were correlated with greater pleasure affection and motherhood improved quality of life in the physical and environmental domains was associated with negative beliefs around affectivity less knowledge about stis was related to stronger beliefs about motherhood for prejudices against sexual and gender diversity regardless of sex there was a negative correlation with knowledge about stis in males higher prejudice against diversity was associated with a higher quality of life in the environment domain and lower knowledge about stis for females higher prejudice against diversity was associated with lower knowledge about stis and lower quality of life in the psychological domain knowledge about stis correlated negatively with quality of life in the social relations domain regardless of gender for males less knowledge about stis was associated with higher quality of life in the psychological social relations and environmental domains however there was no correlation of knowledge about stis with other variables among females when analyzing the population independent of sex and female sex alone quality of life was correlated with all domains regarding correlation by sex for males more positive general perceptions of quality of life were related to worse quality of life in the physical and social relations domains the physical domain was related to a higher quality of life in all domains higher quality of life in the psychological domain was associated with a higher quality of life in the social relations and the environmental domains therefore the social domain correlated positively with quality of life in the environmental domain when analyzing the population independent of gender and female sex alone quality of life was correlated for all domains regarding the correlation by gender for males a more positive overall perception of quality of life was associated with worse quality of life in the physical and social relations domains the physical domain was related to a higher quality of life in all domains higher quality of life in the psychological domain correlated with a higher quality of life in the social relationships and environmental domains therefore the social domain correlated positively with quality of life in the environmental domain discussion the aim of this study was to analyze the sexuality of young adults living in quilombola communities in the eastern amazon of brazil and the impact on their quality of life despite the emergence of research among quilombola communities in recent years there remains a dearth of articles with welldeveloped methodologies related to sexuality to our knowledge this is the first study to examine sexuality among quilombolas in the eastern amazon and quality of life due to the lack of data on quilombolas we will refer to studies based on other populations to compare our findings according to a study by almeida santos queiroz and mussi 37 most individuals in their sample classified themselves as black and had a family income of up to 78000 reais in the brazilian institute of geography and statistics 38 the inequality factor in the income distribution of the black population showed that blacks are among the poorest groups in brazil another study by vieira and monteiro 39 showed that the national population had completed elementary school however our study showed that males had incomplete schooling while females had completed high school this could be because educational conditions in quilombola have improved in recent decades albeit to a limited extent in quilombola education conditions in addition most individuals in this study reported being single unlike in the study by almeida et al 37 in which the general population lived with a partner in addition vieira and monteiro 39 showed that most individuals lived in a committed relationship these results could be related to associated with the age profile of each study pechorro diniz and vieira 40 found no relationship between the dimensions of the sexual response and sexual satisfaction in a sample of 152 women this indicates that satisfaction and sexual function are interdependent variables in women however they also found a strong relationship between sexual satisfaction and sexual behavior in women relating this finding to behaviors such as tenderness and foreplay and not necessarily to oral or vaginal sex itself in contrast our study found that in our correlation by sex greater sexual satisfaction was associated with greater sexual function in women the difference in samples in the respective studies may justify this discrepancy in addition sexual dysfunction affects approximately 40 of women and the academic community is increasingly interested in this area new diagnostic proposals have therefore classified these problems more comprehensively allowing multiple aspects of womens sexual responses to be assossed a crosssectional study by pacagnella martinez and vieira 41 using the fsfi showed higher correlation rates between orgasm and arousal satisfaction and orgasm arousal and desire orgasm and lubrication and arousal and lubrication a lower correlation was found between pain and all other domains including satisfaction these results are consistent with ours however we observed that an increase in pain was associated with an increase in function sexual satisfaction and orgasm age is an important factor influencing the different results of the various studies rossi barbosa and oliveira 42 used the iief and found that in healthy men aged up to 59 years 358 had some degree of erectile dysfunction ranging from mild to complete dysfunction although our study was also conducted with healthy individuals our population consisted of young adult men aged 18 to 35 years and this group did not exhibit erectile dysfunction in addition the participants in our study reported being black whereas rossi et al 42 had a majority of a white sample a study by nelas chaves coutinho and amaral 43 among college students found high scores for beliefs and values around pleasure followed by affectivity consistent with our study low scores were found for beliefs and values around reproduction however all domains tend to be causally related thus when beliefs are high in one domain other domains have similar results in addition the level of education and access to information is correlated to the degree of prejudice against sexual and gender diversity costa et als study 31 found that men scored higher on prejudice followed by religious and rural residents and people with lower education in our study quilombolas both men and women showed prejudice in sexual and gender diversity with no significant gender differences consistent with costa et al 31 our sample consisted of rural residents who had less access to information and less education about sexuality the sexuality of an individual is beyond his or her genital anatomy that is sexuality is directly related to the sociocultural context of the individual thus the socioeconomic and cultural conditions faced by young quilombolas leave them exposed and vulnerable to sexual violence regarding knowledge of stis cardoso 44 found that the majority of the youth in his sample knew about stis while a minority were completely unaware the commonly known diseases were gonorrhea syphilis and aids the selfperception of the risk of contracting any sti was low demonstrating a commonly adopted risk behavior by the disuse of condoms our stdqk results showed that the mean score for men was 759 ± 4375 and 698 ± 4605 for women demonstrating limited knowledge about stis these results indicate a higher risk of contracting stis among quilombola populations due to a lack of access to prevention information as well as a lack of health education and implementation of health policies in these communities 45 quality of life is an individuals perception of their position in the context of the culture and value system in which they live and in relation to their goals expectations standards and concerns and involves dimensions such as physical and psychological health independence social relationships environment and spiritual standards 46 almeidabrasil 47 assessed the quality of life of individuals seen at ubs in belo horizonte using the whoqolbref and concluded that the score in the social relations domain was higher with lower means in the environment domain the negative quality of life results are related to worse conditions of health housing education and income in addition to problems in social relationships and psychological conditions 46 horta cruz and carvalho 48 studied the quality of life of african refugees and 4838 of the participants rated their quality of life as neither good nor bad followed by 2903 who rated it as bad regarding satisfaction with health 352 described themselves as dissatisfied however while the quilombola population has less access to the factors mentioned by almeidabrasil et al 47 the perception of quality of life was not lower in our sample in addition other factors such as sexual function and beliefs correlated with a higher quality of life scores in the setting limitations of the study due to the sarscov2 pandemic we had difficulty entering communities and collecting data because of the risk of exposure to researchers and respondents which limited the number of interviews in this sample although there were individuals who reported having a high school education the application of the questionnaires showed gaps that were inconsistent with this indication suggesting possible significant educational deficits in this population in general another limiting factor of our study was the classification as sexually inactive in those whose sexual activity had occurred more than 3 months ago without taking into consideration autoerotic activity in addition we were able to find limited indexed articles with welldeveloped methods and a similar research design that addressed sexuality and quilombola communities to add to the discussion conclusions in the communities included in this study we found that women had greater sexual dissatisfaction and poorer quality of life than men most men did not have sexual dysfunction in addition both men and women had similar values and beliefs about reproduction affectivity abortion and pleasure however women had negative attitudes toward motherhood because they felt pressured to become mothers men had more biases related to sexual diversity and gender this can be attributed to the cultural expectations associated with historical gender roles of masculinity in brazil in which heterosexuality and marked masculinity are expected and the sexualized being with natural desires is disregarded this again underscores the importance of discussing forms of identity that defy the heterosexual norm moreover many people in brazil fear that relationships with people of the same sex are acceptable or forbidden samesex intercourse is acceptable only in secret and those involved publicly assume stable heterosexual relationships 49 we also conclude that educational aspects may influence the sexuality of the quilombola population as limited knowledge about stis and values and beliefs make them more vulnerable therefore this study highlights the importance of implementing public policies to promote health and education for ethnic and racial equity and to ensure the active participation of quilombos to improve their quality of life 921 this study also confirms that among quilombos as among other groups factors such as sexual satisfaction reproductive values and beliefs and affectivity directly influence quality of life our study is the first to address these issues among quilombolas in the amazon region therefore further research is urgently needed among these populations in brazil data availability statement the datasets generated andor analyzed during the current study are presented in this article informed consent statement informed consent was obtained from all subjects involved in the study

quilombola communities are descended from african slaves who escaped in resistance to imperial rule in brazil today these communities suffer from inadequate health care and health promotion programs due to socioeconomic geographic and political factors this generates greater vulnerability among these groups because they have limited information about prevention to improve their quality of life this research aimed to analyze the sexuality of young quilombola adults and the impact on their quality of life through an observational crosssectional quantitative study with descriptive and inferential analyses our study is the first to address these issues among quilombolas in the eastern amazon region the participants were 79 individuals of both sexes aged between 18 to 35 years belonging to seven communities in the state of pará the questionnaires were designed to assess sexual behavior and satisfaction values and beliefs about sexuality prejudice regarding sexual and gender diversity knowledge about sexually transmitted infections stis beliefs about maternity and quality of life women reported greater sexual dissatisfaction and lower quality of life than men men reported no dysfunctions however they were highly prejudiced towards sexual and gender diversity low education negatively impacts the health of quilombola populations as knowledge about stis and values and beliefs influence sexual behavior exposing individuals to diseases the research also confirms that both among quilombolas and other groups factors such as sexual satisfaction values and beliefs about reproduction and affectivity directly influence the quality of life

background parents play a significant role in enabling participation of children with a physical disability at home at school and in the community participationthe involvement in life situations to fulfil social roleshas a positive impact on childrens health and wellbeing 1 2 3 children with a physical disability often come across restrictions in their everyday participation 4 5 6 the most important factor influencing successful participation of children and adolescents with disabilities is the interplay between the childs environment and activities 7 8 9 10 11 12 parents have knowledge and experiences how to involve childs social environment to support engagement in preferred and desired activities 13 familycentred service is considered best practice in service for children with a physical disability 14 its effectiveness is related to the understanding professionals have about needs and actions of both child and parents including what parents do to support their child with a physical disability 1516 a recent scoping review of the literature on this topic 17 revealed 14 studies which identified several parents actions challenges and needs that were summarised in a preliminary thematic framework the framework includes two major themes parents enable and support performance of meaningful activities of their child at home at school and in the community and parents enable change and use the environment 17 connected to the major themes the framework includes three categories and several subcategories with a total of eight actions eight challenges and four needs as presented in fig 1 however the scoping review 17 also underlines how little information is available on what parents actually do every day to enhance their childs participation timeuse diaries are particularly relevant and suitable instruments for studying the daily lives of families including families with a child with a physical disability as they give insight into what they as a family actually do in context 18 participants who fill out the diaries are both observers and informants providing the researcher a view from within 1920 the aim of this study is to gain insight into parents own daily actions challenges and needs while supporting their child with a physical disability at home at school and in the community additionally the study results will be used to refine the preliminary thematic framework methods between may 2012 and july 2012 a qualitative research inquiry was performed based on using a diary over a 7day period direct content analysis was used as theoretical framework to systematically organise data into a structured format 21 22 23 study population potential participant families of children with a physical disability were selected from the electronic database of the dutch association of people with disabilities and their parents all potential families had a child aged between 4 and 12 years with a physical disability that is neurological and nonprogressive in nature and who was living at home persons identified in the database of the bosk as the contact person for each family were considered eligible for this study in total 47 parents participated in this study recruitment procedure in may 2012 559 eligible parents of children who fulfilled the criteria received an information letter from the bosk inviting them to participate in the study a stamped returnenvelope an informed consent form information about the study and a diary covering a 7day period were included this study was conducted jointly with a quantitative study aimed to give a wideranging portrayal of the number domains and priority of needs expressed by parents using the family needs inventory pediatric rehabilitation 2425 parents had the choice to refuse cooperation to fill in the diary or the questionnaire or both parents who did not respond to the first invitation received a reminder from the bosk after three weeks data gathering participating parents returned the completed diary andor questionnaire as well as the informed consent form in the return envelope directly to the centre for data and information management in maastricht solicited diaries with optimum length between 1 and 2 weeks provide a rich source of data and are often utilised to elicit specific information 182627 participants were asked to complete the diary each day over a 7day period reflecting on issues that are of interest to the studyactions challenges and needs while supporting their child with a physical disability at home at school or in the community a pilot study including fifteen parents revealed that the 7day period solicited diary was feasible and took about 15 min per day to complete participants used a printed diary with worksheets for each day of the week and an example of the worksheet with participant instructions on each sheet columns were created for time of start of the activity activity the child was engaged in actions parents performed challenges parents came across needs parents experienced and the possibility for additional remarks participants were asked to write down all activities their child did over 24 h name the actions they did to facilitate those activities and mention challenges and unmet needs they experienced next an option was given for possible additional information data analysis for the dataanalysis of the diaries both deductive and inductive reasoning was used 2829 directed content analysis 2327 using deductive reasoning was conducted to validate or conceptually extend the existing fig 1 a preliminary thematic framework 17 preliminary thematic framework as described above 17 in this deductive analysis the existing framework guided development of an initial coding and categorising scheme and operational definitions for the codes were used 30 inductive reasoning was also used in this way potentially new major themes categories andor subcategories could be identified from the data through the researchers careful examination and constant comparison 31 after transcription of all diaries into a wordprocessing package a coding scheme was developed and subsequently applied by means of manual coding the first author prepared the coding scheme and the second author inspected it to ensure congruence with the elements of the preliminary thematic framework then the first author applied the identical coding and categorising scheme to all data using techniques of memoing constant comparison and questions nvivo software was used to organise the data during analysis two debriefing sessions took place between the user as coresearcher and the first author to discuss the findings leading to small changes in the wording of the codes of actions challenges and needs in this study lincoln and gubas 32 33 34 four criteria for evaluating interpretive research work were applied in accordance with elos et al 35 aspects of trustworthiness in relation to qualitative content analysis credibility was ensured with organising debriefing sessions between the first researcher and a coresearcher and by using random sampling transferability was guaranteed by passing information to the reader about the boundaries of the study and providing characteristics of the study population dependability is assured by reporting in detail the processes within this study thereby enabling a future researcher to repeat the work as is confirmability by reporting findings that are solely the result of the experiences and ideas of the participants results in total 51 diaries were returned three diaries were largely unfilled and one completely empty and so these were excluded leaving 47 eligible for the analysis participants were all biological parentsmainly mothers who have a child with a disability who is between 4 and 12 years of age in comparison with the original framework two previously identified major themes parents enable and support performance of meaningful activities at home at school and in the community and parents enable change and use the environment remained the same additionally the categories actions challenges and needs did not change however in all three categories new subcategories were identified two in the category actions two in the category challenges and three in the category needs on the contrary the previously named challenge regarding financial burden and the need for service and information were not identified in the current analysis figure 2 portrays the presentation of all the major themes categories and subcategories that were identified in both studies previously identified major themes with categories and subcategories of the fig 2 preliminary framework of parents actions challenges and needs based on the results of the diary study preliminary framework 17 that remained the same are marked italic new subcategories that emerged from the inductive analyses are marked bold two subcategories that were not identified in this study are underlined major theme 1 parents enable and support performance of meaningful activities at home at school and in the community this theme concerns actions challenges and needs of parents while supporting their child with a physical disability to engage in meaningful activities at home at school or in the community category actions to support meaningful activities one new action was identified and four previously identified actions emerged in this study the new action role taking implies how parents are taking up a new role that allows supporting meaningful activities of their child parents in this study act as a volunteer in scouting to help their child to complete tasks like cooking or assisting a swimming teacher parents also gave assistance to teachers at school during physical education the action choosing for refers to parents making choices regarding the kind of activities in which their child will be socially engaged a number of examples were described in the diaries deciding on joining a birthday party with peers without a disability playing at a friends home or playing outside the house with neighbours parents mentioned that they chose a team sport such as judo or grasshockey as a leisure activity for their child to enable contact with peers without a disability parents also described their choice for doing normal family activities outside their house such as visiting an openair museum by bus or going to a playground structuring describes the parents action to organise daily routines at home in such a way that their child can engage in meaningful activities one parent explained the change of a daily routine of eating a warm evening meal at 6 pm to be in time for horse riding the action educating applies to teaching the child a new strategy to be able to participate in activities parents described this action with different examples such as showing their child an easier way to use the computer showing their child how to perform a domestic task such as preparing cutlery for seven people using a strategy to count aloud one two three… and by using modelling while practicing with a flute examples related to school were also described such as teaching their child how to reach his classroom independently and showing an alternative way of doing mathematics the action modifying stands for adaptations of activities to support the childs independence and social interaction one example in this study was about a family walk in a forest a mother described that she walks next to her bicycle while her child with a physical disability sits on it another example is buying clothes with velcro tape that enables a child to dress himself at school category challenges while supporting meaningful activities parents reported several challenges that emerged while supporting their childs meaningful activities one new challenge and four formerly identified challenges have been identified the challenge choosing the right type of activity at home refers to the struggle over how to decide what kind of activities their child can engage in with other children at home an example is that parents go through great effort to find an appropriate activity suitable for their child to play together with a brother or sister without a disability the challenge being supportive in a correct manner is about deliberating whether the child is capable of doing an activity alone and estimating what would be appropriate support several examples were given in this study parents explained that it is a dilemma during breakfast whether or not to cut bread the child had the ability to do it alone but it might slow down the morning routine resulting in being too late for school or the schooltaxi other examples were parents struggling with whether they should tie their childs shoes or to explain how to do it and how much support should be given during bathing showering dressing or cycling coping with child safety is about parents having difficulties coping with situations with no parental control activities provoking these challenges were learning how to make a fire at scouting playing at a friends home and going with another family to a playground the challenge choosing the most appropriate leisure activities indicates problems finding a leisure activity that fits the childs abilities and brings a sense of accomplishment parents reported challenges finding suitable team sports and appropriate swimming lessons for their child selecting the best type of education is a challenge parents also faced in this study for example one parent explained that it was difficult to make the choice for the type of education for their child as they got dissimilar advice from different professionals category needs while supporting meaningful activities parents provided information about unmet needs while supporting meaningful activities of their child in this study one new need emerged and one existing need was confirmed the need instructions or coaching is about receiving written or verbal support one parent wrote in the diary that having instructions or coaching in how to put their child into the car and how to put her in the seat would be helpful other parents expressed a need for instructions to support independence during meals one parent showed a need for coaching on how they can support their child while playing in a play garden in addition parents expressed a need for coaching in understanding laws and regulations or in choosing a new type of educational program identifying and obtaining information is a need for more information about meaningful activities for example one parent expressed the need for an overview of suitable leisure activities for children with a physical disability major theme 2 parents enable change and use the environment this theme relates to actions challenges and needs of parents while using enabling and changing the social and physical environment at home at school and in the community to make participation of their child with a physical disability possible category actions to enable change and use the environment one new action was identified and four previously discovered actions were confirmed the new action changing the physical environment demonstrates how parents take the initiative to change the physical environment into a more suitable one to support their childs participation one example of such action is an adaptation of a bathroom at home to aid the child in becoming independent another example of this kind of action is that some parents made a school entrance accessible to their child networking refers to the establishing of connections with people with similar experiences parents in this study explained their attempts to find people through their social network to connect and share experiences and their attempts to connect with people through social media like forums the action educating is defined as the giving of instructions to others on how to support the participation of their child examples in this study are parents educating employees of the day care centre or educating a judo trainer to optimise assistance of their children advocating refers to the competing of resources supports and services within the system one parent reported in the diary about her way of going up against a taxi service to make sure their child would get extra support and be taken on board as a passenger creating opportunities means the creation of events by parents in order to shape opportunities for their child to get acquainted with other children one example in this study concerns parents organising a get together meeting where their child could connect to other children additionally this action is also about making and keeping connections at school one parent described in the diary that she organised extra afterschool lessons to make sure her child will be able to stay in the same group of children next year category challenges to enable change and use the environment one new challenge and three previously recognised challenges emerged during the analysis customised products pertains to a new challenge faced by many parents in this study several examples were described about difficulties in trying to find appropriate clothes that support independence and the challenge of finding fitting shoes mainly for children that need to wear a splint parents also noted that it is difficult to find shoes with velcro tape particularly in bigger sizes the attitudes of others refers to the experience of parents facing negative attitudes from other children or adults towards their child with a physical disability examples in this study are negative attitudes of friends during play activities and negative remarks about disability from friends parents similar attitudes were experienced with professional services like taxi service employees reacting negatively towards a child with a disability and not being willing to help a child to get in and out of the taxi the challenge insufficient system support concerns unsupportive social structures parents in this study described that teachers and sports instructors lack knowledge of how to support children with a physical disability at school and during swimming lessons parents mentioned that support assistants are not always capable of supporting their child such as while eating a meal or engaging in play activities with their child at home others wrote that it is difficult to get a support assistant between 6 am and 8 am one parent described the complication of getting assistance for an empty wheelchair tire when visiting a museum a barrier in the natural and built environment refers to the physical accessibility of buildings and public places parents examples of these challenges concern the built environment nonuserfriendly public toilets as at the zoo inaccessible walking paths in an openair museum and family cars that are unable to fit in a special swingauto chair or a wheelchair similar challenges were described for the natural environment like the impossibility to use walking paths in the forest with a wheelchair category needs to enable change and use the environment two new needs and two previously identified needs emerged accessible products and environments shows a new need for products and environments designed to be usable by all people parents gave examples of this need in relation to the built environment but also to shoes and clothes tailored advice about equipment devices and adaptations illustrates a need for personalised advice about equipment devices and adaptations examples from this study describe a need for advice about adaptations in the house or in the day care centre furthermore parents expressed a need for advice about the availability and appropriateness of devices for their child and about suitable clothes shoes and adaptive cutlery equipment and adaptations refers to the need for equipment that is designed to support independence and participation in activities examples from this study demonstrate a need for equipment to support and facilitate independence while eating furthermore parents expressed a need for equipment that can be used in a normal car a need for easytomodify adaptations for a toilet or a shower and a safe bicycle seat for bigger children social and system support refers to the needs of parents for more expansive social networks to enable their childs participation in this study parents examples referred to extra support from grandparents and support assistants to bring their child to leisure activities assistance during physical education at school or during church services engagement in play activities at home or in the play garden and to do educational activities on a computer discussion the purpose of this study is to gain insight into parents own daily actions challenges and needs while supporting their child with a physical disability at home at school and in the community in one week on every single day all participating parents described several efforts to enhance the participation of their children with a physical disability by using enabling or changing the social and physical environment or by supporting their child to perform or engage in meaningful activities fascinatingly those actions were primarily a result of challenges caused by restrictions in social and physical environments needs described by parents notably spotlight environmental aspects like a need for environments designed for all people additionally this study intended to refine the existing preliminary thematic framework arising from a scoping review 17 two major themes all categories and subcategories except two of the preliminary thematic framework 17 were consistent with the actions challenges and needs mentioned by the parents in this study one challenge regarding financial burden and one need for service and information were not identified in the analysis however the analysis reveals two new actions two new challenges and three new needs the previously named challenge regarding financial burden and the need for service and information were not identified in the current study this might be related with socioeconomic status and level of education of our sample however at this point this is a speculation the previous scoping review 17 showed that parallels exist between the parents actions challenges and needs described in the preliminary framework for children with a physical disability and studies done with parents of children with down syndrome young people with epilepsy and young adults with a physical disability 36 37 38 studies and policy reports from the netherlands support the newly found actions challenges and needs related to environment for example free access to public buildings and places for all citizens in the netherlands was not taken into the equal opportunities act there is no obligation to guarantee access for persons with a disability 39 consequently only 29 of people with a severe physical disability in the netherlands can enter shops 40 parents in this study expressed a new need for accessible products and environments like playgrounds and showed their own initiatives to change the physical environment into a more suitable one to support their childs participation in the netherlands there are no specific regulations for leisure and sports clubs concerning children with a disability 41 the inclusion of children with disabilities in mainstream primary education has been arranged by law in august 2014 42 therefore it might be valuable to all educators to construct learning experiences that are meaningful for all young children including those with diverse abilities by applying universal design principles for learning 43 the 47 included diaries indicate that parents of children with a physical disability carry out many actions face numerous challenges and have several unmet needs while supporting their childs participation at home at school and in the community it is interesting that parents actions challenges and needs are mainly directed towards the social orand physical environment therefore paediatric rehabilitation using fcs may need to address the importance and the impact of the environment on the participation of a child with a physical disability rather than only focus on the childs abilities care professionals might need to ask themselves whether the real world of children with a physical disability and their parents is central in their approach and whether they involve the knowledge of parents in shareddecision making in order to effectively support parents while enabling the participation of their children in daily life tailored approaches are compulsory these approaches may also contribute to stress reduction and better health and wellbeing of parents raina et al 44 found that health and wellbeing of parents of children with cerebral palsy seem strongly influenced by child disability parkes et al 45 showed that a quarter of parents of children with cerebral palsy experience very high stress however any approach needs to be based on parents wishes for support the goal of most qualitative studies is not to generalize but rather to provide a rich contextualized understanding of some aspect of human experience 46 however the analysis showed that several actions challenges and needs of the dutch parents resemble with the actions challenges and needs from other studies in europe or outside 17 future research into the meaning parents ascribe to their experiences regarding actions challenges and needs while supporting participation of their child in different cultural contexts is warranted study limitations some possible limitations in this study are noteworthy to discuss selection bias may have occurred as we used the database of the dutch association of people with disabilities and their parents to draw our participants from and only 9 of eligible parents decided to participate the participating parents 92 mothers had a higher educational level than average in the netherlands and considering their membership in bosk may have been parents who are very involved and motivated in enhancing the participation of their child with a physical disability however the data set is rich in nature and there is a large variety among data some parents reported more actions challenges and needs at home and others at school or in the community further mothers are usually the respondents in other similar studies like almasri et al 47 they are known as caretakers of children with a disability and are therefore most involved in enhancing the participation of their child in a study about parents of children with intellectual disabilities rowbotham et al 48 found that mothers undertake more daily caregiving tasks than fathers but the range of tasks is similar however it is unclear how such differences influence actions challenges and needs of fathers and mothers additionally it can be argued whether data collection of just one week is sufficient as the optimal length for this type of study is one to two weeks 27 and the data received were rich in nature the period of time probably has not been a limitation conclusions actions challenges and needs of dutch parents of children with a physical disability are mainly directed towards the social orand physical environment the presented thematic framework can offer practitioners knowledge of how to support parents and promotes relevance for future research investigation with the intention of supporting parents further work is necessary to supply tailored approaches competing interest the authors declare that they have no competing interests the authors alone are responsible for writing this article and for its contents

background parents have a vital influence on the participation of their child with a physical disability the aim of this study is to gain insight into parents own daily actions challenges and needs while supporting their child with a physical disability at home at school and in the community an additional objective of this study is to refine the preliminary thematic framework previously identified in a scoping review methods a qualitative research inquiry was performed based on using a diary over a 7day period to gather data to systematically organise data into a structured format content analysis has been applied using both inductive and deductive reasoning guided by the existing preliminary thematic framework results analysis of the eligible diaries shows that the actions mentioned by the 47 parents describe several efforts to enhance participation of their children with a physical disability by using enabling or changing the social and physical environment or by supporting their child to perform or engage in meaningful activities those parents actions are primarily a result of challenges caused by restrictions in social and physical environments parental responses highlighted above all the need for environments designed for all people based on the findings a redefined thematic framework is presented conclusions parents actions challenges and needs are mainly directed towards the social orand physical environment the presented thematic framework can offer practitioners knowledge to support parents more work is necessary to provide tailored approaches paediatric rehabilitation may need to address the importance of the environment on the participation of a child with a physical disability

senior companion program the senior companion program seeks to improve lives strengthens communities and fosters civic engagement through service and volunteering exclusively as caregivers for other older adults in particular the senior companion program has been recognized as an important program that helps to bridge the gaps of geriatric care by meeting the nonmedical needs of older adults through assistance provided by other older adult volunteers the senior companion program engages adults aged 55 years and older who have incomes at or below 200 of the poverty level in national service the senior companion program is an intragenerational national service model designed to help older adults maintain independence and prevent feelings of loneliness and social isolation through instrumental activities of daily living companionship and caregiver respite previous studies have shown that the senior companion program is beneficial for clients and their families including a study by rabiner et al which demonstrated that the senior companion program improves quality of life among frail older adult clients companions are carefully screened and receive expert ongoing training to assure quality service and a rewarding volunteer experience each senior companion volunteer provides 1540 hr of service each week and they typically serve two to four clients the scheduled time spent with clients allows for oneonone care while building strong stabilizing bonds of friendship creating the opportunity for reciprocal benefits clients receive inhome friendly visits with planned daily activities including emotional support engaging in mental and physical stimulation meal preparation light housekeeping and escort to doctors appointments caregivers receive senior companion respite care providing time to run errands take care of personal needs while aiding their frail loved one to age in place the lowincome senior companion volunteer is compensated with a small stipend for their time spent with their client to cover any expenses incurred our local senior companion program serves marion county central indianas most populated urban county marion county has the largest number of persons aged 65 years and older in the state 110700 or 11 of the population of those 12 are living in poverty 35 are living with some kind of a disability thus needing supportive services over 50 of volunteers in our local senior companion program have been identified as living below the poverty line our local senior companion volunteers are committed to and passionate about staying active and engaged in the community as well as serving elders in their community as noted by butler older adults are motivated to volunteer for a variety of reasons pertaining to our local senior companion volunteers many have primarily expressed that they were initially interested in volunteering with the senior companion program because it provides them with an opportunity to stay active get out the house and give back to others additionally several of our senior companions have shared that they were motivated to join the program after they learned about the positive experiences of their friends neighbors and church members who were existing senior companion volunteers one of our volunteers has also shared that she became interested in serving as an senior companion after her physician encouraged her to as a means for combating depression the current research was undertaken to identify the motivation for and the benefits of participating in the senior companion program by our volunteers beyond the anecdotal reports described above social isolation and loneliness among older adults decades of gerontological research has focused on the negative consequences of aging particularly for minority and lowincome older adults two primary concerns among older adults have been the issues of social isolation and loneliness social isolation among older adults has been defined as a state in which the individual lacks a sense of belonging socially lacks engagement with others has a minimal number of social contacts and is deficient in fulfilling and quality relationships social isolation has been linked to adverse health outcomes among older adults including reduced quality of life and depression social isolation has also been found to be a significant predictor of mortality in both men and women over the age of 65 consequently gerontology researchers suggest that social isolation be included as part of clinical assessments of older adults whereas social isolation largely pertains to lack of interaction with or availability of social contacts loneliness relates to individuals state of mind and is a subjective feeling of emotional isolation thus it is possible to be lonely even in the presence of others older adults may experience various types of loneliness including episodic transient loneliness related to acute and shortlived feelings that arise when doing something alone that previously involved another person and chronic loneliness longlived feelings of emotional isolation for two or more years estimates indicate that for 15 30 of the general population loneliness is a chronic state a recent study by pikhartova bowling and victor found that the prevalence of experiencing loneliness was 24 among older adults both situational and chronic loneliness has been associated with increased mortality among older adults a variety of efforts have been put forth to reduce social isolation and loneliness among older adults programs designed to maintain or increase social interaction and social position have been associated with increased life satisfaction among older adults in particular programs that incorporate peer support have been especially effective in with this population as they promote social engagement and close interpersonal connections according to findlay social support groups that empower older adults and encourage friendship are particularly useful in reducing social isolation peer support has also been demonstrated to reduce perceived loneliness among older adults volunteerism trends among older adults the volunteerism rate for older adults aged 65 years and over has risen steadily over the past three decades from 143 to 235 in 2015 older adults have been found to be more likely to participate in an organized volunteer effort if they have more social capital such as being highly educated having higher incomes working at least part time being married and have a spouse who also volunteers or if they are already involved in other social activities such as church clubs and organizations us volunteerism trends show that rates are increased among adults in their late 50s and 60s and begin to drop after age 80 racial and ethnic differences also exist in volunteerism with african american older adults having lower rates of participation than their white counterparts among african american older adults females are more likely to serve in volunteering roles than males benefits of volunteerism among older adults older adults personally benefit from the experience of serving as volunteers in a study by morrowhowell 50 of older adult volunteers indicated that they were better off as a result of the experience and 30 indicated that they were a great deal better off in particular older adult volunteers tend to have greater satisfaction in life and greater quality of life older adult volunteers also experience other benefits such as learning new skills and expanding their leadership ability consequently older adults have reported a greater personal sense of purpose and accomplishment as a result of their volunteering experiences health benefits several longitudinal studies have found that volunteerism is associated with better overall selfrated health and lower disability among older adults there is strong evidence documenting the relationship between volunteering and positive physical outcomes among older adults in particular volunteering has been associated with better functional ability and lower incidence of cardiovascular disease closely related volunteering has been linked to longevity recent longitudinal and metaanalysis study findings have indicated that volunteering was associated with lower mortality rates among older adults volunteerism has also been found to improve older adults mental health one large crosssectional survey study conducted across 14 european countries found that older adults volunteers have significantly lower rates of depression than their nonvolunteer counterparts similarly some secondary data analysis studies have found that older adults who volunteer and who engage in more hours of volunteering were found to report higher levels of wellbeing and lower levels of functional dependency racial differences have been observed in the mental health benefits of volunteering among older adults in an early crosssectional study by tang choi and morrowhowell results showed that african american older adult volunteers had better selfreported health ratings and less depressive symptoms than their caucasian counterparts social benefits as noted by miller et al volunteering constitutes one of the most important prosocial activities recently a 5year longitudinal study demonstrated that volunteering offers an opportunity to increase engagement ones social network and is especially beneficial to older adults who frequently experience loneliness due to loss and change in life roles for older adults volunteerism is an empowering experience as they become engaged in the community and active contributors to society in a previous survey of older adult volunteers by morrowhowell hong and tang most respondents agreed or strongly agreed that they experienced social benefits from volunteering including expanding their network of friends and acquaintances and having increased participation in social activities findings also indicated that volunteering enhanced older adults interpersonal skills by increasing their ability to interact with different kinds of people older adults expanded network and increased interpersonal relationships gained through volunteering is a form of social capital that provides informal support and consequently improves their mental health outcomes and acts as a stress buffer to reduce disease risk demographic differences in older adult volunteers perceived benefits stephens breheny and mansvelt caution that older people should not be treated as a homogenous group instead they vary greatly in terms of their health financial resources and social networks which may influence the benefits they perceive from volunteering the perceived benefits of volunteering has been found to increase with age in a study of differential benefits across the life course van willigen found that older volunteers experience greater increases in life satisfaction and greater positive changes in their health than younger volunteers a growing body of literature also suggests that older adults perceived benefits from volunteering experiences is influenced by volunteers socioeconomic status stephens et al note that volunteering is beneficial for older people particularly those with few resources in particular lowerincome and lowereducated older adult volunteers have reported more benefits than their higher income and higher educated peers race ethnicity has not been observed to be an independent predictor of perceived benefits of volunteering among older adults in a previous study by morrowhowell race only became a significant predictor of volunteer benefits after controlling for program characteristics such as stipends and trainings purpose the purpose of this study was to understand the perceived benefits of volunteering in the senior companion program specifically this paper will present findings of focus groups conducted with urbandwelling lowincome older adult women who are senior companion volunteers to date most senior companion program evaluation studies have focused on the programs impact on client and family outcomes and most have been quantitative the few studies that have qualitatively evaluated the experience of senior companion volunteers have been conducted with primarily white participant samples the impact of volunteering on urbandwelling lowincome senior companions is largely understudied given existing disparities in health outcomes and volunteerism rates it is imperative to assess the perceived benefits that urbandwelling lowincome senior companion volunteers experience through the senior companion program methods institutional review board approval for the study was granted by the indiana university human subjects office participants and recruitment senior companions were invited to participate in focus groups to provide insight about their experiences with the program all active senior companions were eligible to participate in the focus group study regardless of length of time as a senior companion volunteer prospective participants were recruited via a twostep process first a formal letter of invitation was mailed to each senior companion addressed from the study principal investigator and local senior companion program director the letter informed senior companions about the purpose of the focus groups and emphasized the voluntary nature of the study a copy of the study informed consent form was also included with the mailed letter as an additional recruitment strategy the study pi and the senior companion program director made an inperson announcement about the focus group opportunity at local senior companion inservice meetings and answered any questions that interested senior companions had about participating a total of 72 invitation letters were mailed to all current senior companions with a consent rate of 819 at the completion of each focus group each participant was given a 40 gift card to a local grocery store as a token of appreciation for their time procedures a total of nine focus groups were conducted between april and june 2016 each focus group lasted approximately 60 min the focus groups were held in a private conference room at a local faithbased organization all focus groups were facilitated by trained members of the research team who were experienced in qualitative data collection and were accompanied by trained observers all focus groups were audio recorded prior to the start of each focus group the facilitator reviewed the informed consent form with participants and participants were asked to complete a short written demographic survey which collected basic data including gender age race ethnicity education level and income the survey also collected information specific to participants experiences in the senior companion program including their length of time as a senior companion and their history of attending workshops on dementia and alzheimers disease following the completion of the demographic survey the facilitator provided each participant with a copy of the questions that would be asked during the focus group during the focus groups participants were asked a total of five openended questions which gathered information about a variety of qualitative domains specifically related to the experience of being a senior companion including perceived benefits perceived challenges suggestions for improving the senior companion program suggestions for improving client services and strategies for recruiting senior companions this paper will present our study findings pertaining to the perceived benefits interview domain which was assessed by asking participants the openended question what do you enjoy most about participating in the senior companion program a complete list of the focus group questions and the study recruitment materials can be obtained from the corresponding author data analysis focus group recordings were professionally transcribed and then coded using dedoose qualitative analysis software emergent themes were identified in the transcripts using inductive content analysis a systematic and objective approach to analyzing written information in our initial analysis phase open codes were applied to participants narrative statements that were determined to consist of similar content and then were compared across all focus groups to reveal primary themes next a nested coding approach was used to identify subthemes that were nested within each primary theme to reach coding consensus four research team members who were skilled and experienced in qualitative analysis independently reviewed and coded the focus group transcripts the team members discussed any discrepancies in coding of narrative text and discussed the selection of exemplary quotes for inclusion in the manuscript the few discrepancies were discussed until all members were in agreement results focus groups analysis of focus group data revealed that female senior companions view their volunteering experience as being mutually beneficial to their clients and themselves one participant in focus group 9 noted for me i enjoy the program because not only am i helping somebody else but im helping myself as well in particular participants overall focus group participants identified a wide variety of psychosocial benefits through their volunteering role a table of emergent primary themes and corresponding subthemes regarding senior companion benefits is presented in table 2 as shown in table 2 senior companions perceived benefits focused predominately on how volunteering afforded them the opportunity to stay socially connected engaged and active participants also perceived their senior companion volunteer roles to be beneficial regarding their awareness of their own aging process and increasing their knowledge about health issues related to aging emergent themes and illustrative quotes are presented below volunteering reduces social isolation among senior companions most participants expressed enjoyment for their senior companion volunteer role because it gives them an opportunity to leave their homes im at an age im just sitting there in the house and this way going to meet with them clients thats helping me get out of the house in particular participants describe getting out of the house to volunteer as a way to gain more social interaction especially among those who are socially isolated what i enjoy about the senior companion program is it helps me get out of the house and maintain a social relationship with the world … volunteering helps me because like i said i live alone i dont have any friends dont nobody come and see me so just like getting up at 900 am and dont have to be there until 100 pm im excited to get there closely related some participants expressed that their close interactions with their clients facilitates meaningful relationships in their lives for example one participant described her relationship with her client as a sisterly bond and another discussed how senior companion volunteering has helped her to develop friendships with her clients in fact many senior companions viewed their clients as companions for themselves my companion shes 90 years old she dont seem like a companion she seems more like a sister we do things together she gets dressed we go out to lunch we go to the beauty shop…it dont seem like im working it just seems like im enjoying a sister or relative…we just have a good time…it just makes me feel like im 37 …youre not just making clients youre making friends…i do some peoples laundry and take them to walmart or target to the doctor out to eat and we all enjoy that and we play cards together in the community room and we have a good time so we are not just clients and senior companions were also friends volunteering helps senior companions to have a good quality of life several participants discussed how senior companion volunteering has helped them to stay active for example one participant described how senior companion volunteering has helped to maintain her vitality as a senior i enjoy the senior companion program because otherwise i would be couch potato and i wouldnt be active at 87 like i am closely related participants frequently noted that senior companion volunteering gives them something to do …i think i see it volunteering as a double blessing i can be of a blessing to help someone else but its a blessing to me because it will get my lazy butt up out of the bed and out in front of the tv and give me something productive to do some participants also mentioned how senior companion volunteering has improved their emotional wellbeing specifically participants indicated that the social interaction afforded through the senior companion program helped to reduce depression volunteering facilitates a sense of purpose among senior companions sense of purpose was the most frequently expressed benefit of senior companion volunteering among focus group participants and consisted of four related subthemes including sense of accomplishment feeling needed daily motivation and feeling appreciated many participants described senior companion volunteering as giving them a sense of meaning and purpose in particular senior companions expressed that helping other seniors made them feel accomplished some families are still working and very busy and they dont get a chance to really spend the time you end up knowing more about the client than the family does and some of them are just very appreciative and that makes you feel good you feel like youve accomplished something… closely related several focus group participants noted that they enjoy senior companion volunteering because they feel needed by their clients participants expressed satisfaction over feeling needed in general volunteers also indicated that feeling needed by their clients gave them a sense of youthfulness and purpose as they themselves were also older adults well what i like most about participating in the program is that i just find myself that i feel like that im needed i like the idea of feeling needed even though at my age of 63…it makes me feel young…it makes me feel good… additionally some participants indicated that volunteering gives them a sense of meaning and purpose because serving their clients is a motivator for them to get up each day finally several participants noted that they enjoy being a senior companion volunteer because their clients make them feel appreciated and recognized for their efforts i enjoy getting up every morning putting my makeup on jumping in my car and going to work its a blessing we are living longer and its a blessing to just be able to still drive and go and be able to do for someone that they really appreciate it im just having a good time i have one client whos a kidney transplant…sometimes he stays pretty sick so a lot of times i go and kind of talk him through his misery and prepare meals for him he swears im the best cook in the world but what makes me most happy about him is how appreciative he is he said i see you come in and i just brighten up that really makes me feel good volunteering increases senior companions awareness and understanding of aging another benefit expressed by senior companions is an enhanced understanding of aging based on their clients experiences several participants discussed that volunteering has given them a glimpse of what to expect for themselves in the future and has better prepared them for the journey of aging moreover they frequently expressed their awareness of the fact that they will one day need assistance and also expressed a desire to be treated and cared for in the manner that they serve their clients i have two clients with alzheimers disease and i enjoy working with both of them it teaches me that what maybe i can expect when im older and i can expect it more its showing me the steps that i might be taking one day just getting that age and hopefully that the love that i give them that i will get it back…so thats what im seeing that one day thats going to be me and im going to be needing that and i hope i get the love that im giving out discussion and implications this study contributed to a growing body of literature that promotes the importance of social engagement among older adults and in particular highlights the benefits that urbandwelling lowincome older adult women experience from volunteer activities it is also important to note that our sample of senior companion program volunteers primarily consisted of african american women affording the opportunity to gather insight from an underrepresented group in the extant literature on volunteering to date most studies on the benefits of volunteerism for older adults have been conducted with primarily white participant samples a systematic review by cattan et al found that few studies have included sufficient representation by racial and ethnic minority groups consequently findings of previous studies of older adult volunteers have lacked generalizability to racial and ethnic minority groups such as african americans previous senior companion program studies have also been largely focused on understanding the benefits that senior companion program clients and their families receive but very few qualitative studies have been conducted to assess the perceived benefits of the experience from the perspective of senior companion volunteers authors have suggested that more highquality qualitative studies are needed to explain why and how volunteering impact older adults quality of life as findings would be valuable for informing policy and practice our qualitative study findings expands the older adult volunteer literature and senior companion program evidencebased by providing insight about the reciprocal benefits that are experienced by urbandwelling lowincome older women senior companion volunteers our sample of lowincome older adult women focus group participants expressed a wide variety of personal benefits that they experience as a result of being an senior companion volunteer and they enthusiastically endorsed the senior companion program this observation expands our understanding of the individual characteristics associated with volunteerism as previous studies have associated social capital such as high education and high income with increased likelihood of volunteerism among older adults in this regard our results mirror similar findings in a new zealand study by dulin gavala stephens kostick and mcdonald where older adults with low economic living standards had a stronger relationship between volunteering and happiness than those with high els similar results were also found in a study by tang choi and morrowhowell where low socioeconomic status older adult volunteers were found to have more personal benefits volunteering than their high ses counterparts more so than discussing the physical benefits of senior companion volunteering our participants emphasized the positive impact that senior companion volunteering had on their emotional wellbeing in particular several participants described how senior companion volunteering reduced their feelings of depression our participants emphasis on the psychological benefits of volunteering is an especially important finding as mental health has historically been a stigmatized topic among older adults and especially among racial and ethnic minorities moreover our participants discussion about their reduced feelings of depression resulting from senior companion volunteering strengthens the existing literature on the relationship between depression and volunteerism as formal volunteering has been associated with reduced depression among older adults to date many formal senior volunteer programs have involved older adults working with youth studies on experience corps a schoolbased volunteer program for older adults have found that volunteering with youth is associated with a perceived increase in confidence and social connectedness among older adults a reduction in depressive symptoms feeling more active in general as well as being more physically active our study shows that similar benefits are experienced when older adults volunteer to help other older adults in addition these benefits may be more personal due to the fact that the senior companion program allows senior companion volunteers to work with other older adults who are commonly viewed as peers analysis of our focus group data revealed that senior companion volunteers statements largely reflected a perceived personal relevance of working with other seniors as participants often referred to their own identity as seniors for example several focus group participants discussed how volunteering with older adults has increased their own understanding and awareness of aging such that they are better prepared for what to expect in the future as they age these findings support the literature on the relationship between future planning and volunteerism among older adults for example a recent study by shen and khosla found that the likelihood of having advance care planning and a durable power of attorney was higher among older adults who had volunteering experience in the past 10 years than those who did not have such experience our findings that the senior companion volunteering experience facilitates meaningful relationships supports existing literature on the benefits of peer support among older adults while senior companions function in a volunteer capacity the experience affords them the opportunity to interact with other older adult clients who they view as their peers thus several of our participants discussed having close connections with their clients and described them as having a familylike relationship or being close friends similar to our findings that senior companion volunteering facilitates meaning and purpose a recent quantitative study by klinedinst resnick found that volunteering is directly associated with feelings of usefulness among older adult residents of a continuing care retirement community our findings are also consistent with recent work by withall et al conducted with a caucasian british sample showing that older adults are motivated to engage in volunteer activities because they experience personal benefits such as it gives them something to do prevents social isolation and fulfills their desire to feel needed similarly several of our participants discussed how they were grateful for the opportunity to serve as senior companion volunteers because it gave them something to do in particular many women in our study mentioned their adjustment to life after retirement and emphasized how they were used to working and being active even to the extent that they called their senior companion volunteering role work this observation suggests that women are eager to stay active and socially engaged after retirement additionally it underscores the importance of developing programs and policies to support volunteerism among older adults as civic engagement has been recognized as a retirement role for aging adults in the united states a variety of theories have sought to explain individuals motivation to volunteer first given our participants emphasis on feeling needed our study findings closely align with role theory which posits that a set of responsibilities expectations and ones identity is associated with specific roles such as a volunteer as noted by gammonley older adult lay volunteers play an important role in the lives of the people they serve by making use of their life experiences problemsolving skills and social skills… role theory also posits that holding specific roles or positions can enhance individuals sense of selfworth as well as afford them to have social interactions where they receive positive feedback about their performance thus our emergent theme that volunteering facilitates purpose among female senior companion volunteers was supported by the subthemes associated with their role as volunteers such as them feeling a sense of accomplishment feeling needed and feeling appreciated our focus group participants expressed a strong commitment to their postretirement senior companion volunteer role like many other older adults the role of volunteer was especially important to our participants because it helps them to stay engaged as active contributors to society our study findings also closely align with the principles of selfdetermination theory the theoretical constructs of selfdetermination theory provide guidance for understanding and explaining factors related to human motivation for behaviors such as volunteering selfdetermination theory posits that individuals motivation to engage in behaviors is increased through the fulfillment of three basic psychological needs autonomy competence and relatedness of the three basic psychological needs autonomy is considered to be the master need as it is a critical determinant of motivation the theory posits that individuals positive outcomes are primarily achieved through behavior that is autonomous the act of volunteering is highly motivated by intrinsic rewards a previous study by bidee et al observed that autonomous motivation was positively associated with volunteer effort where the more autonomously motivated the volunteer the more effort he or she put into his or her volunteer work the literature cites several intrinsic rewards that motivate individuals to volunteer the experience of volunteering increases individuals feelings of utility due to the benefits that others receive as a result of the volunteers service they enjoy seeing the benefits of their work in others lives closely related individuals are motivated to volunteer because the act of helping others gives others enjoyment which in turn makes the volunteer feel good volunteer opportunities help to fulfill individuals needs for personal enjoyment as they volunteer for activities that they enjoy doing and find personally interesting our sample of urbandwelling lowincome women senior companion volunteers discussed a variety of intrinsic rewards received via their client interactions such as feeling needed appreciated and accomplished moreover participants comments suggested that the interpersonal interactions that senior companion volunteers have with clients facilitates fulfillment of the volunteers basic psychological need of relatedness as they frequently discussed the close connection they had with their clients overall our qualitative study on the perceived psychosocial benefits of senior companion volunteering in a sample of urbandwelling lowincome older adult women produced emergent themes that were similar to other qualitative senior companion program studies as with our study ulsperger and colleagues observed that their qualitative interview study participants emphasized the reciprocal benefits of the volunteerclient experience where several of their participants discussed senior companion volunteering as helping themselves and others and noted that they senior companion volunteering helped to alleviate their loneliness similar to our study participants in butlers study perceived their senior companion volunteering experience to be beneficial because it afforded them the opportunity to interact with others and develop meaningful relationships with their clients an emergent theme she called companionship also similar to our study butlers participants described senior companion volunteering as being beneficial because it keeps me active they also expressed their satisfaction with feeling needed while our qualitative findings on the reciprocal benefits of senior companion volunteering closely mirrored previous similar studies we are able to contribute two additional distinct perceived benefits discussed by our participants including that senior companion volunteering improves emotional wellbeing namely by reducing feelings of depression and senior companion volunteering increases older adults understanding of aging such that they are better prepared for what to expect in the future as they age strengths and limitations a notable strength of our study is the use of qualitative methodology to gain indepth contextual information about the perceived benefits of senior companion volunteering additionally our sample size of 59 participants across 9 focus groups is a considerably large thus affording the opportunity to collect sufficient data and achieve saturation of emergent themes and subthemes as previously noted our study filled an important gap in the senior companion program evaluation literature by gaining insight into the perceived benefits in a sample of urbandwelling senior companion volunteers primarily consisting of african american women an underrepresented perspective in the extant literature a few limitations to our findings also merit consideration as our study sample consisted of urbandwelling lowincome women our findings may not be generalizable to other older adult female populations additionally demographic data such as age race or ethnicity was not linked to each speaker during transcription thus we were unable to include participant demographics with our exemplary quotes however careful consideration was taken to gain the perspectives of a diverse variety of participants such that exemplary quotes were selected from all focus groups conclusions our study findings suggest that urbandwelling lowincome older adult women view senior companion volunteering as being mutually beneficial for both themselves and their clients reciprocal benefits discussed by our participants highlight the positive psychosocial impact that volunteerism has on older adults including reducing social isolation and feelings of depression our findings show that urbandwelling lowincome older adult women volunteers experience a variety of intrinsic rewards through their experiences as senior companions such as increasing their perceived sense of meaning and purpose through them feeling needed and appreciated by their clients additionally several of our senior companion volunteers perceived that the experience has increased their understanding of the aging process causing them to reflect upon and prepare for changes occurring as they themselves are aging the various reciprocal benefits of volunteering presented in our study results underscores the importance of social involvement as a form of positive gerontology moreover our qualitative results on the perceived psychosocial benefits of volunteerism among our sample of urbandwelling lowincome older adult women underscores the need for increased advocacy and policies to support and extend senior volunteer program opportunities to individuals from a diverse variety of sociodemographic backgrounds thereby enhancing the potential to promote productive aging in a larger segment of the older adult population predictors of participation aging mental health 14 917927 doi10108013607861003801045 pikhartova j bowling a victor c conflict of interest none reported

background as the older adult population increases it is imperative to increase older adults opportunities for social involvement thus maintaining their important roles and contributions to society while there are known healthrelated benefits of volunteerism among older adults a dearth of information exists on the perceived benefits of volunteerism among lowincome and ethnic minority older adults purpose to understand the perceived psychosocial benefits of volunteering in the senior companion program and to present findings of focus groups conducted with urbandwelling lowincome older adult women volunteers design and methods inductive content analysis and the dedoose qualitative data analysis software were used for analyzing data obtained from 59 older adult women senior companions who participated in nine focus groups results content analyses of the focus group transcripts identified four major themes 1 reducing social isolation 2 improving quality of life 3 finding purpose and meaning and 4 increasing understanding of aging the majority of our participants 81 were african american women with a mean age of 70 years approximately 831 had completed high school and 627 lived below the poverty line discussion and implications findings provided data rich in descriptions of positive psychosocial outcomes finding meaning and purpose and a better understanding of aging in urbandwelling lowincome older women volunteers the findings also provide support for the need for policies and programs that promote civic engagement in this population translational significance while this population is largely underrepresented in the volunteering literature our results indicate that urbandwelling lowincome older adult women experience many benefits from volunteering our findings underscore the need for increased advocacy and policies to support and extend senior volunteer program opportunities to individuals from a diverse variety of sociodemographic backgrounds thereby enhancing the potential to promote productive aging in a larger segment of the older adult population

introduction pregnancy and the postpartum period can be joyful times as well as times of stress and difficulties since delivery and childcare bring several physiological and psychosocial changes for mothers 12 consequently they are the periods of increased vulnerability for the onset or relapse of a mental illness 3 the untreated depression during pregnancy persists to the postpartum period 4 the perinatal depression further results in obstetric outcomes and birth complications 56 and poor physical health and cognition of the infant 7 8 9 perinatal depression is thus a considerable public health problem affecting the mother her baby and her family 810 the prevalence of antenatal and postnatal depression is highly variable between populations and across cultures 11 12 13 14 the prevalence of maternal mental disorders is reported to be greater in lowand middleincome countries than in highincome countries 515 a recent metaanalysis in lmics showed that about 253 and about 190 of women experienced ad and pd respectively 16 despite this mothers at risk during pregnancy or delivery often go undetected and underdiagnosed in lmics 61718 since the maternal depression is given less priority for intervention due to the belief that it does not immediately cause fatalities the association of southeast asian nations is a regional intergovernmental organization that promotes economic political and security cooperation among its 11 countries in southeast asia 8 including timorleste which joined in 2019 in line with the united nations sustainable development goals 19 mental health is identified as one of the health priorities under the asean post2015 health development agenda for 20162020 20 nonetheless according to the mental health report of 2016 many of the member states are faced with several challenges such as a lack of resources to fund mental health services and communitybased interventions and a mental health workforce shortage consequently maternal depression during pregnancy or the postpartum period still remain neglected in many of the asean member states with no standard specific guidelines for maternal mental healthcare services although some studies of the asean member countries were included in previous international and regional reviews 6121416 to our knowledge there is a lack of information specific to the region moreover the asean countries have a great diversity in terms of socioeconomic conditions ranging from lowermiddleincome to highincome countries as well as culture and religion which may contribute to differences in the prevalence of perinatal depression this highlighted the need to identify recent epidemiological evidence of the prevalence of ad and pd among the asean countries the identification of the scope of existing studies and comprehensive understanding of the phenomena of interest may increase awareness of the need for timely and appropriate mental health interventions and programs among the vulnerable population in asean countries 20 which has so far been neglected and offer insights into how wellprepared asean countries are for achieving the sdgs methods and materials the primary focus of the review is on prevalence of maternal depression during pregnancy to the postpartum period descriptive research methodology was used to review peerreviewed literature a literature review was conducted to gather data from various sources and to ensure proper understanding of the research subject the preferred reporting items for systematic reviews and metaanalysis chart shows the phases of paper identification and selection the main inclusion factor was peerreview scientific journals indexed in selected electronic databases such as scopus pubmed and the asian citation index databases articles were searched using several combinations of search words and their synonyms with the boolean operators and or or searching titles keywords and abstracts the language selected was english studies published during the last 10 years were included because they were more likely to reflect the current state of knowledge on maternal depression from pregnancy to the postpartum period the main inclusion factor was peerreview scientific journals indexed in selected electronic databases such as scopus pubmed and the asian citation index databases articles were searched using several combinations of search words and their synonyms with the boolean operators and or or searching titles keywords and abstracts the language selected was english studies published during the last 10 years were included because they were more likely to reflect the current state of knowledge on maternal depression from pregnancy to the postpartum period antenatal or postnatal or postpartum or perinatal 3 thailand or vietnam or cambodia or laos pdr or malaysia or philippines or singapore or myanmar or indonesia or brunei or timorleste combined terms 1 and 2 and 3 inclusion criteria peerreviewed articles published from jan 2010jan 2021 studies that report prevalence of antenatal and postpartum depression following childbirth and english publications exclusion criteria the following studies were excluded because they were not the focus of the study furthermore articles were selected based on the inclusion and exclusion criteria the exclusion criteria were as follows editorials letters intervention studies interviews no access to full text since the methodological quality of the papers could not be assessed and no assessment of prevalence a primary focus of the study studies on highrisk populations were excluded because the risks of these populations developing ad and pd are high furthermore studies conducted outside asean member countries were excluded since the findings of these studies recruiting asian minorities as part of their samples might be different from the general population in each country because they were possibly influenced and complicated by other cultural and environmental factors results literature search studies were identified using scopus pubmed and aci the database search with our selected keywords returned a total of 280 records of those 100 records titles and abstracts were reviewed after review 45 articles were eligible for fulltext review methodological issues such as study design primary focus of study and target population were assessed by the authors and discussions were conducted to resolve any discrepancies in decisions about excluding or including articles after the stepwise elimination 37 records were included in the final review the total number of included studies for the literature review by country are shown in table 2 a total of 37 peerreviewed articles conducted in 8 out of 11 asean member countries were included in this review namely indonesia lao pdr malaysia philippines singapore thailand timorleste and vietnam the edinburgh postnatal depression scale was the most common instrument used to identify ad and pd other screening tools included were the center for epidemiological studiesdepression the hospital anxiety and depression scale the mini international neuropsychiatric interview the selfreported questionnaire the structured clinical interview for diagnostic and statistical manual of mental disorders axis i disorders and whooley questions the new country income classifications for the world banks 2020 fiscal year when there are two studies determining factors within a different framework but reporting the same prevalence using the same cohort data we included both studies but counted as one study for the studies reporting prevalence characteristics measurement and prevalence of ad the number of studies on prevalence of ad was 18 namely studies in malaysia singapore thailand timorleste and vietnam as shown in tables 3 and4 of the 18 studies the majority of the studies collected data longitudinally and in hospitals or health clinics and during the third trimester of pregnancy the most common instrument used to identify ad was the epds and the most used cutoff scores of the epds to screen for ad were varied between countries and among studies of each country for example the most used cutoff scores of the epds were 12 for malaysia 15 for singapore 13 for timorleste and 10 for vietnam the prevalence of ad ranged from 49 in vietnam to 468 in thailand eight studies reported a prevalence of 50149 while eight studies reported a prevalence of 150250 one study reported a prevalence of less than 5 and one study reported a prevalence greater than 250 by country the prevalence ranged from 103 to 200 in malaysia 71 to 170 in singapore 193 to 197 in timorleste and 49 to 245 in vietnam characteristics measurement and prevalence of pd the number of studies reporting the prevalence of pd was 24 in eight member countries the studies were conducted in indonesia lao pdr malaysia philippines singapore thailand timorleste and vietnam as shown in tables 4 and5 the majority of the studies collected data crosssectionally up to 4 months postpartum and at hospitals although the assessment tools used were different between studies the most common instrument used to identify pd was epds the different cutoff scores used between countries made the direct comparison difficult between studies the prevalence ranged from 44 in malaysia to 417 in thailand one study reported less than 5 and five studies more than 250 prevalence eleven studies reported prevalence of 50149 while seven studies reported prevalence of 150250 by country the prevalence ranged from 199 to 262 in indonesia 318 in lao pdr 44 to 143 in malaysia 164 in philippines 90 to 233 in singapore 53 to 417 in thailand 126 in timorleste and 82 to 276 in vietnam discussion to identify the needs for maternal mental healthcare evidence on the prevalence of maternal perinatal depression is important this scoping review represents the first attempt to identify the burden of perinatal depression in the 11 asean member countries this study showed substantial variation in prevalence of ad and pd between countries with very few studies conducted in lowermiddleincome countries and between studies due in part to variations in study design and methods of assessment further research should be conducted to provide the best information on mothers at risk of perinatal depression aimed at addressing maternal mental problems at national and regional levels particularly in resourcepoor settings our study revealed substantial difference in number of studies on prevalence of perinatal depression among the asean countries the included 37 peerreviewed articles for ad andor pd were from 8 out of 11 countries many of the studies included were from vietnam followed by malaysia singapore and thailand on the other hand few studies were available in the remaining member states specifically lao pdr philippines and timorleste and no studies in brunei cambodia and myanmar met the inclusion criteria the very limited number of studies in those countries except brunei can be associated with the high burden of maternal mortality maternal and child health is given top priority in policy and strategy development among several asean members with high maternal mortality rate 121 deaths per 100000 livebirths for philippines and 142 for timorleste 160 for cambodia 177 for indonesia 185 for lao pdr and 250 for myanmar 20 it appears that most health policies in these countries focus on issues causing high mortalities and thus minimal attention is paid to the maternal depression during pregnancy and postpartum periods it should be highlighted that the neglected issue of maternal mental health during the periods may consequently contribute to failure in the great reductions of maternal and child mortality and morbidity 58 since untreated symptoms of maternal depression can have negative consequences for the health of women and their neonates and infants 3359 this study showed that ad and pd were prevalent but ranged widely across the studies in the asean countries regarding ad 18 studies in five countries were included in this review the majority ranged from 50 to 250 eight studies reported a prevalence of 50149 while eight studies reported 150250 meanwhile more studies on pd were conducted and the prevalence seems wider one study reported less than 5 and 11 studies reported prevalence of 50149 while seven studies reported prevalence of 150250 and five studies reported more than 250 prevalence more attention has been drawn to the presence of depression among women during the postpartum period compared to antenatal period this may be explained by many new challenges such as caring for a new infant and also the serious negative impact on the mother and their family as well as child developmental outcome childcare with insufficient family and social support can lead to poor sleep 6061 and anxiety and stress due to the mothers need to take care of herself and baby including feeding practices 39404953 62 63 64 which further lead to pd furthermore the wider range of prevalence of pd compared to ad may be associated with negative obstetricpediatric factors such as history of caesarean section abnormal signs of the fetus and infant pregnancy complications and maternal ill health poor obstetricpediatric outcomes prevalent in many lmics may result in higher prevalence of pd in line with previous studies 515 this indicates that healthcare services should introduce psychological support in the treatment plan for women who have obstetric complications from pregnancy particularly in lmics however due to the limited number of studies in lowermiddleincome countries such as cambodia lao pdr myanmar the philippines and timorleste we cannot say that the prevalence of pd is high in lowermiddleincome countries rather a pattern of decreased prevalence rates was found in studies using either longitudinal study design or crosssectional study design with a nationally representative sample the substantial difference in the prevalence of ad and pd in our study may be due in part to the study design used and methods of assessment the included studies on ad andor pd were either crosssectional or longitudinal studies which are useful for reporting prevalence while about 60 of the included studies on ad used a longitudinal approach the majority of the studies on pd used crosssectional study design with small sample sizes among crosssectional studies only two studies estimated the prevalence using a nationwide representative sample in thailand 50 and malaysia 43 this may suggest that more efforts are required to identify the accurate estimation of the burden using a nationwide representative sample among pregnant and postnatal mothers and there is a clear need for rigorously designed longitudinal studies to improve our understanding of perinatal depression in asean countries in addition although the epds was identified as the most frequently used measurement tool in the asean region the cutoff points used to define the perinatal depression and timing in the assessment of the problem resulted in the wide disparities in the reported prevalence estimates across the included studies for example the cutoff scores of epds used were varied either ≥10 or ≥11 for ad and ranging from ≥11 to ≥13 for pd in thailand and ≥10 to ≥13 for ad and pd in vietnam therefore further study on validation of the epds using a larger sample representing the overall population of perinatal women particularly in lowermiddleincome countries where no or few validation studies have been conducted should be followed nonetheless given the substantial prevalence of maternal depression during pregnancy and after birth this review provides valuable insights into the importance of timely detection of maternal depression during pregnancy and after birth and the development of policy and programs aimed at addressing issues which have so far been neglected in the asean countries the who 65 recommends integrating mental health services into primary care and this has also been applied to lmics as there are no evidencebased guidelines for lmics skilled healthcare professionals including midwives nurses and physicians under strong supervision monitoring and supportive structures would also be necessary to identify the occurrence and severity of maternal perinatal depression through timely detection and to deliver essential psychosocial care and mental health support to pregnant and postpartum mothers at the primary care level in resourcelimited settings 155866 however mental health services in most of the asean member countries have not been integrated into the primary healthcare system due to human resource shortage while some countries such as singapore brunei darussalam and thailand have implemented integrated mental health services into primary care levels as well as hospitals 67 furthermore there is little evidence available on how to integrate evidencebased interventions into nonspecialized care settings such as primary care maternal and child healthcare and community care settings in lmics the recommended antenatal care visits varied considerably but were relatively low in most countries in the asean region 68 postnatal care visits are much less frequent than those of antenatal care across the countries due to the majority of women in the lowermiddleincome countries delivering at home despite the existence of a mental health policy plan in the asean region most of the asean member countries had no plans including maternal mental health as warranting special attention or focus findings must be interpreted with caution due to some weaknesses of this review first the review includes studies written in english for international comparison and indexed in the three chosen databases although additional literature searches were conducted in google and google scholar to determine whether articles were missing from the three chosen databases we may have missed some original articles for asean member countries in addition most of the studies are subject to selection and measurement bias which occur by use of a crosssectional study design small nonrepresentative samples convenience sampling and variability in the instrument measures and scale which contribute to heterogeneity in results and hinder the generalization of the results next we did not perform a metaanalysis of the prevalence however the findings drawn from the review may be useful to understanding the burden of perinatal depression of mothers and to developing planned maternal mental healthcare in the asean countries by providing an overview of maternal perinatal depression across the countries conclusions the findings of this review showed that published research is still not sufficient particularly in lowermiddleincome countries of the asean members the substantial variation in prevalence of ad and pd between countries and between studies is due in part to variations in study design and methods of assessment further research should be conducted to provide the best information on mothers at risk of perinatal depression aimed at addressing maternal mental problems at national and regional levels in the asean member countries data availability statement not applicable

identification of mothers with depression is important because untreated perinatal depression can have both shortand longterm consequences for the mother the child and the family this review attempts to identify the prevalence of antenatal and postnatal depression ad and pd respectively of mothers among the asean member countries a literature review was conducted using pubmed scopus and the asian citation index the reviews covered publications in peerreviewed journals written in the english language between january 2010 and december 2020 of the 280 articles identified a total of 37 peerreviewed articles conducted in 8 out of 11 asean member countries were included the edinburgh postnatal depression scale epds was the most common instrument used to identify depression this study showed the number of studies reporting the prevalence of ad was 18 in five countries for pd 24 studies in eight countries were included the prevalence of ad ranged from 49 to 468 and that of pd ranged from 44 to 577 this first review among asean countries showed very few studies conducted in lowermiddleincome and substantial heterogeneity in prevalence among studies reviewed further research should be conducted to estimate the prevalence using a large representative sample with a validated assessment tool among the asean countries

introduction in most highincome countries approximately two thirds of socioeconomic inequalities in mortality are attributable to cardiovascular disease and cancer with less than 5 attributable to injuries and communicable diseases this pattern may be markedly different in lowand middleincome countries where noncommunicable diseases have become a leading cause of death but mortality from both communicable diseases and injuries remains relatively high while lower socioeconomic status is often associated with higher mortality from povertyrelated diseases such as preventable infections it is less clear how socioeconomic status might relate to conditions associated with modern lifestyles such as cardiovascular disease the contribution of different causes to socioeconomic inequalities in mortality has been documented in wealthy nations while few studies have focused on lowand middleincome countries colombia faces relatively high mortality from communicable diseases and injuries as well as high mortality from noncommunicable diseases rates of premature mortality from noncommunicable diseases are comparable to those in highincome countries while mortality from infections and injuries are four times higher this pattern has resulted in a double burden with injuries and communicable diseases accounting for approximately half of all deaths and noncommunicable diseases for another half a potential hypothesis is that the increasing burden of noncommunicable disease mortality has disproportionately affected the lower socioeconomic groups which also have higher mortality from infectious diseases and injuries classified as a middlehigh income country colombia has experienced improvements in socioeconomic and healthcare indicators over the last decades between 1998 and 2007 constant gdp per capita grew on average by 19 per year the percentage of population living in poverty declined from 141 in 1998to 75 in 2007 and healthcare insurance coverage increased from 598 to 925 educational attainment has also risen with noticeable increases in the proportion of population with secondary and tertiary education despite these improvements inequalities in colombia remain high by international standards in 19992003 the gini coefficient of income inequality was 55 9 in this study we examine trends in socioeconomic inequalities in mortality and estimate the contribution of specific causes of death to these differentials between 1998 and 2007 in colombia we hypothesized that mortality from noncommunicable diseases infections and injuries contribute each to socioeconomic differences in mortality however we expected an increasing concentration of noncommunicable diseases in the lower socioeconomic groups leading to widening socioeconomic inequalities in total mortality methods data data were obtained from official registries of the national administrative department of statistics which collects and harmonizes data on deaths based on international guidelines for all deceased individuals data were collected on sex age of death and educational level causes of death were coded according to the international classification of diseases and aggregated into 10 major causes of death grouped into four broad categories noncommunicable diseases injuries infections and other causes table appendix 1 shows specific icd10 codes for each cause of death data on population counts were obtained based on the following procedure first we estimated the distribution of education by 5year age group sex and year based on data from census and national surveys harmonized by the international institute of applied system analysis and the vienna institute of demography as part of the iiasavid database we then combined this information with data on national population counts from the national statistics office to obtain the number of population by educational attainment iiasavid data were only available per quinquennium therefore we performed demographic projections to obtain population counts for inbetween years using the demographic software pasex data on educational level was missing for approximately a third of deceased cases we used multiple imputation methods implemented in sas through the impute procedure to impute educational level for these cases this was done to avoid bias due to the potentially higher rates of missing education for lower educated individuals and to minimize the potential for numeratordenominator bias this procedure fits a sequence of regression models and draws values from the corresponding predictive distributions the sequential regression procedure was applied based on a model that included sex region age and marital status as covariates imputation was not possible in 68 of cases full details on the procedure are available elsewhere we distinguished three groups based on highest educational level attained completed primary school completed secondary school and completed tertiary education we excluded individuals below age 25 because many would not have completed their education before this age in addition we focused on adult premature mortality an indicator of population health believed to be strongly influenced by social economic and environmental factors and a common indicator of health system performance while some premature deaths are unavoidable a substantial part of premature mortality is avoidable through public health programmes and policies that address the social determinants of health methods of analysis we first calculated agestandardized mortality rates by educational level sex and year rates were standardized using the direct method based on the who standard population of 1997 which better reflects the age structure of the world population than the segi standard population subsequently we implemented separate poisson regression models with deaths as dependent variable and the natural log of personyears as offset variable incorporating age and educational level as independent variables to assess mortality trends by educational level we estimated the annual percent change in mortality based on a poisson model that incorporated an interaction between educational level and year the apc measures the average rate of change in the mortality rate per year at a second stage we estimated rate ratios of mortality by educational level to assess changes in inequalities controlling for changes in the educational distribution we estimated the slope index of inequality and the relative index of inequality to construct these measures educational groups are first ordered from lowest to highest the population in each educational level covers a rage in the cumulative distribution of the population mortality is then regressed on the midpoint of the cumulative distribution of education for each group the rii can be interpreted as the ratio of mortality between a hypothetical person whose relative rank in the distribution of education is zero and a person whose relative rank in the cumulative distribution of education is 100 the sii corresponds to the equivalent absolute rate difference between these two points further details on the rii and sii are available elsewhere regression analyses were conducted in each of the five multiple databases generated by the multiple imputation process since results were nearly identical for all imputations we used the proc mianalyze procedure in sas to combine estimates from all databases and adjust standard errors accounting for the uncertainty in the imputation this procedure reads the parameter estimates and associated covariance matrix for each imputed dataset and then derives valid multivariate inferences for these parameters this allows for valid statistical inference that appropriately reflects uncertainty due to missing values all analyses were conducted in sas® version 92 results table 1 shows mortality rates at ages 2564 years between 1998 and 2007 in colombia 633905 deaths occurred from 1998 to 2007 with male deaths accounting for two thirds of overall deaths mainly owing to exceptionally high rates of homicide mortality noncommunicable diseases accounted for half of all female mortality while 46•3 of mortality among men were due to injuries infections accounted for around 7 of deaths figure 1 shows premature mortality rates by educational level men and women with lower levels of education had higher premature mortality from any cause of death than their highereducated counterparts rate ratios summarising differences in mortality across educational groups are presented in table 2 lesseducated men and women had higher rates of mortality for all causes than their highereducated counterparts inequalities were largest for injuries among men while among women they were largest for infections particularly for tuberculosis and hiv aids appendixfigure 3 shows that premature mortality declined among both men and women over the study period however mortality rates for those with primary and secondary education remained relatively constant or grew for deaths from infectious disease and other causes while rates for higher educated men steadily declined for all causes while mortality from injuries declined steadily among men with middle and higher education it increased during the first years for lowereducated men and only started to decline in 2002 figure 2 summarizes trends in mortality differences by education on the basis of the rii for both men and women inequalities in total and causespecific mortality widened over the first half of the period but remained stable over the second half apc estimates in figure 3 show that the initial increase in inequalities by educational level is due to more favourable trends among the highereducated groups among men mortality declined by 4•5 per year in men with tertiary education as compared to 2•3 in men with secondary education and 1•5 in men with primary education or less similar results were observed among women although differences in the apc were not significant the largest difference in trends was for injuries among men and women similar trends were observed for noncommunicable disease mortality among men while declines were similar for women from all educational groups although confidence intervals were wide results suggest that those with primary education experienced an increase in infectious disease mortality while those with tertiary education experienced no change figure 4 shows the contribution of each cause of death to absolute differences in premature mortality by education measured with the sii absolute differences in mortality were nearly twice larger for men than for women this difference was almost entirely due to the large contribution of injuries particularly homicide to inequalities in mortality among men which overall explained 55•1 of male inequalities noncommunicable disease mortality was the second largest contributor among men accounting for 27•1 of inequalities in total mortality among women noncommunicable diseases were by far the largest contributor to inequalities explaining 62•5 of inequalities in total mortality infections explained only 5•9 of differences in mortality by education among men and 8•0 among women discussion inequalities in premature mortality by education in colombia widened over the first half of the study period and remained constant over the second half mortality from injuries particularly homicide explains more than half of inequalities among men while noncommunicable diseases are the most important contributor to female inequalities and the second contributor among men infections explain a relatively small proportion of inequalities in premature mortality our results highlight the need for a shift in focus towards policies addressing the increasing contribution of noncommunicable disease and injuries to socioeconomic inequalities in premature mortality explanation of results our study suggests that lowereducated men and women have benefited significantly less from declining premature mortality than their highereducated counterparts several explanations could account for this pattern including inequalities by educational level in social economic and working conditions access to health care and risk factor prevalence our decomposition by cause of death sheds some light on the role of some of these mechanisms the most striking finding from our study is the large contribution of homicide to socioeconomic inequalities in premature mortality among men homicide rates in colombia have declined but remain among the highest worldwide we found that homicide is primarily concentrated among lowereducated men and it is disproportionately high for young men lowereducated men face high levels of poverty unemployment social disruption and risky behaviours and are more likely to live in deprived areas colombia has one of the highest levels of income inequality in latin america which may contribute to high youth homicide rates our findings underscore the significance of homicide as a major contributor to male mortality inequalities our study also suggests that traffic accidents have large socioeconomic gradients and contribute importantly to socioeconomic differences in mortality in colombia lower education has been linked to higher reliance on unsafe forms of transportation vehicle safety infrastructure is less welldeveloped in socially deprived areas where individuals may be less likely to comply with safety regulations on seat belt use driving while drinking and speed limit enforcement mirroring findings for highincome countries we found that noncommunicable diseases are a leading contributor to inequalities in mortality by educational level in colombia socioeconomic inequalities in noncommunicable diseases have been associated with the unequal distribution of behavioural risk factors particularly smoking alcohol consumption an unhealthy diet and a sedentary lifestyle existing evidence suggests that as in high income countries lower education is associated with a worse risk factor profile in colombia data from 2007 suggests that the prevalence of smoking was 41 among colombians with primary education or less as opposed to 26 among those with a college education similarly 26 of lowereducated colombians aged 2550 years have at least a risk factor for cardiovascular disease as opposed to only 5•9 in those with a university degree trends in infections on the other hand might reflect socioeconomic differences in both preventive and curative care which may remain despite large increases in health insurance coverage noticeably there are large inequalities in the availability of running water sewage systems and adequate housing in colombia which may be more important in generating inequalities in communicable diseases limitations of the study despite several strengths some limitations should be considered data on mortality were obtained from mortality registries while data on population counts came from censuses this may have led to the socalled numeratordenominator bias which generally results in an overestimation of inequalities for some years data on population size were obtained from demographic projections as census were conducted in 1985 1993and 2005 we focused on premature mortality given the public health relevance of this measure and strong association with social determinants and health system performance further research is required to examine mortality patterns for older ages as in other middleincome countries underregistration of deaths remains a problem in colombia particularly in the poorest regions for example the estimated proportion of registered deaths in the choco region one of the poorest in the country was only 25 compared to 90 or higher in most other regions our estimates of inequalities are likely an underestimation because those with lower education are more likely to live in areas with higher underregistration we may also have underestimated the increase in inequalities because underregistration has decreased over the study period our results therefore are indicative of potentially larger inequalities in mortality by education it is likely that part of the differences in mortality by education observed in our study reflects regional differences in mortality unfortunately no data are available on mortality by educational level separately by region to partly address this question however maps in appendix figure 4 show agestandardized mortality rates and average years of schooling for each region in 2002 based on these aggregate data we find only a weak correlation between regional average years of schooling and mortality nevertheless more detailed data is required to fully examine to what extent regional variations explain differences in mortality by education information on education was missing for 34•2 of death records this may have led to an underestimation of inequalities as missing values are likely to be more common for the least educated we imputed missing values on education based on a rich set of variables available for most deceased individuals partly minimizing potential bias conclusion mortality from both injuries and noncommunicable diseases contribute considerably to disparities in premature mortality in colombia the striking contribution of homicide to socioeconomic differences in mortality among men highlights the need for public policies that address the profound social and economic factors that underlie interpersonal violence in colombia at the same time the increasing contribution of noncommunicable diseases calls for urgent prevention policies for curbing the increasing prevalence of noncommunicable disease risk factors in the lower socioeconomic groups research highlights both injuries and noncommunicable diseases contribute to mortality inequalities homicide contributed more than half of inequalities in male premature mortality policies on violence and chronic disease risk factors are key to curb disparities agestandardized premature mortality rates per 100000 population by educational level ages 2564 19982564 2007 colombia colombia trends of the relative index of inequality of age agestandardized premature mortality rates by educational level ages 25 rates by educational level ages 2564 19982564 2007 colombia colombia annual percentage change of agestandardized premature mortality rates by educational level ages 25 educational level ages 2564 19982564 2007 colombia colombia slope index of inequality of age agestandardized premature mortality rates per 100000 personyears by educational level ages 25 years by educational level ages 2564 19982564 2007 colombia colombia table 1 premature mortality rates per 100000 personyears by educational level ages 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 supplementary material refer to web version on pubmed central for supplementary material

objectivesnoncommunicable diseases have become the leading cause of death in middleincome countries but mortality from injuries and infections remains high we examined the contribution of specific causes to disparities in adult premature mortality ages 2564 by educational level from 1998 to 2007 in colombia methodsdata from mortality registries were linked to population censuses to obtain mortality rates by educational attainment we used poisson regression to model trends in mortality by educational attainment and estimated the contribution of specific causes to the slope index of inequality resultsmen and women with only primary education had higher premature mortality than men and women with postsecondary education rr men 2•60 95 confidence interval ci 2•56 2•64 rrwomen2•36 ci2•31 2•42 mortality declined in all educational groups but declines

introduction the advent of online social platforms and their usage in the last decade with exponential increasing trend made possible the analysis of human behavior with an unprecedented volume of data to a certain extent online interactions represent a good proxy for social interactions and as a consequence the possibility to track the activity of individuals in online social networks allows one to investigate human social dynamics 1 more specifically in the last years an increasing number of researchers focused on individuals activity in twitter a popular microblogging social platform with about 302 millions active users posting daily more than 500 millions messages in 33 languages 1 in traditional social science research the size of the population under investigation is very small with increasing costs in terms of human resources and funding conversely monitoring twitter activity as well as other online social platforms as facebook and foursquare to cite just some of them dramatically reduces such costs and allows to study a larger population sample ranging from hundreds to millions of individuals 2 within the emerging framework of computational social science 3 the analysis of twitter revealed that online social networks exhibit many features typical of social systems with strongly clustered individuals within a scalefree topology 4 twitter data 5 has been used to validate dunbars theory about the theoretical cognitive limit on the number of stable social relationships 67 it has been shown that individuals tend to share ties within the same metropolitan region and that nonlocal ties distance borders and language differences affect their relationships 8 many studies were devoted to determine which and how information flows through the network 9 10 11 12 as well as to understand the mechanisms of information spreadingeg as in the case of viral contentto identify influential spreaders and comprehend their role 13 14 15 16 17 attention has also been given to investigate social dynamics during emergence of protests 18 with evidences of social influence and complex contagion providing an empirical test to the recruitment mechanisms theorized in formal models of collective action 19 twitter allows users to communicate through small messages using three different actions namely mentioning replying and retweeting while some evidences have shown that users tend to exploit in different ways the actions made available by the twitter platform 20 such differences have not been quantified so far in this work we analyze the activities of users from a new perspective and focus our attention on how individuals interact during exceptional events in our framework an exceptional event is a circumstance not likely in everyday news limited to a short amount of timetypically ranging from hours to a few daysthat causes an exceptional volume of tweets allowing to perform a significant statistical analysis of social dynamics it is worth mentioning that fluctuations in the number of tweets mentions retweets and replies among users may vary from tens up to thousands in a few minutes depending on the event a typical example of exceptional event is provided by the discovery of the higgs boson in july 2012 21 one of the greatest events in modern physics we use empirical data collected during six exceptional events of different type to shed light on individual dynamics in the online social network we use social network analysis to quantify the differences between mentioning replying and retweeting in twitter and intriguingly our findings reveal universal features of such activities during exceptional events materials and methods material it has been recently shown that the choice of how to gather twitter data may significantly affect the results in fact data obtained from a simple backward search tend to overrepresents more central users not offering an accurate picture of peripheral activity with more relevant bias for the network of mentions 14 therefore we used the streaming application programming interface made available by twitter to collect all messages posted on the social network satisfying a set of temporal and semantic constraints more specifically we made use of the public streaming api2 subjected to filters if the flow of tweets corresponding to the filter is smaller than 1 of the total flow on twitter then all tweets satisfying the filters are obtained otherwise a warning reporting the number of missed tweets is received we consider different exceptional events because of their importance in different subjects from politics to sport more specifically we focus on the cannes film festival in 20133 the discovery of the higgs boson in 2012 4 21 the 50th anniversary of martin luther kings famous public speech i have a dream in 2013 5 the 14th iaaf world championships in athletics held in moscow in 2013 6 the peoples climate marcha largescale activist event to advocate global action against climate changeheld in new york in 2014 7 and the official visit of us president barack obama in israel in 20138 for each event we collected tweets sent between a starting time t i and a final time t f containing at least one keyword or hashtag as specified in table 1 for almost all events we have chosen keywords and hashtag that are very specific reducing the amount of noise in the case of the visit of barack obama in israel in 2013 we have included the more generic keyword peace because in this specific context it was relevant for gathering data however it is worth anticipating here that our results show that the amount of noise in this dataset did not alter the salient statistical features of the dataset finally we report that in a few cases we complemented a dataset by including tweets obtained from the search api and that in the worst cases the flow of streaming api was limited causing a loss of less than 05 of tweets methods to understand the dynamics of twitter user interactions during these exceptional events we reconstruct for each event a network connecting users on the basis of the retweets mentions and replies they have been the subject or object of in the literature on twitter data what is usually built is the network based on the followerfollowee relationships between users 489 however this kind of network only captures users declared relations and it does not provide a good proxy for the actual interactions between them users in fact usually follow hundreds of accounts whose tweets appear in their news feed even if there is no real interaction with the majority of those individuals therefore to capture the social structure emerging from these interactions we build instead a network based on the exchanges between users which can be deduced from the tweets that they produce in particular there are three kinds of interactions that can take place on twitter and that we will focus on • a user can retweet another users tweet this means that the user is endorsing a piece of information shared by the other user and is rebroadcasting it to herhis own followers • a user can reply to another users tweet this represents an exchange from a user to another as a reaction of the information contained in a users tweet • a user can mention another user in a tweet this represents an explicit share of a piece of information with the mentioned user a fourth kind of possible interaction is to favourite a users tweet which represents a simple endorsement of the information contained in the tweet without rebroadcasting however we do not have this kind of information for this dataset and therefore we do not consider this kind of interaction as just discussed each kind of activity on twitter represents a particular kind of interaction between two users therefore an appropriate framework to capture the overall structure of these interactions without loss of information about the different types is the framework of multilayer networks 22 23 24 25 26 27 more specifically in the case under investigation the more appropriate model is given by edgecolored graphs particular multilayer networks the second column reports the total number of nodes and edges corresponding to a network in which information is aggregated the last three columns report the number of active nodes and edges per layer a node is considered active on a given layer if the corresponding user is the subject or the object of the corresponding kind of interaction where a color is assigned to different relationshipsie the edgesamong individuals defining as many layers as the number of colors we refer to kivelä et al 28 and boccaletti et al 29 for thorough reviews about multilayer networks here for each event we build a multilayer network composed by l 3 layers rtrpmt corresponding to the three actions that users can perform in twitter and n nodes being n the number of twitter users interacting in the context of the given event a directed edge between user i and user j on the rt layer is assigned if i retweeted j similarly an edge exists on rp layer if user i replied to user j and on mt layer if i mentioned j an illustrative example is shown in figure 1 details about the number of nodes and edges characterizing each event are reported in table 2 we can observe that the number of nodes and edges can vary importantly across events and across layers but for each event and each interaction type the size of the corresponding networks is sufficient to allow a statistically significant analysis of the data results in the following we present an analysis of the networks introduced in the previous section which is oriented at exploring two different but complementary questions firstly we want to know if within one same event the three kinds of interactions produce different network topologies to this aim we consider basic multilayer and singlelayer network descriptors relevant to characterize social relationships and we study how they vary when considering different layers secondly we want to unveil if different exceptional events present any common pattern regarding users interactions as shown in figure 2 the temporal pattern of the different events a b c d e f figure 2 volume of tweets in units of number of messages posted per hour over time for the six exceptional events considered in our study in panels we show the volume corresponding to each exceptional event reported in table 1 respectively considered in our study presents highly heterogeneous profiles some events are in fact limited to one day or only to a few hours whereas others span over a week or more and the profile of tweets volume varies accordingly however despite of these differences do the user interactions that take place during these events present any common feature edge overlap across layers to understand if the kinds of interaction produce similar networks or not we analyze if users interact similarly with each other regardless of the type of activity or not this information can be obtained by calculating the edge overlap 2630 between each pair of layers however when the number of edges is very heterogeneous across layers a more suitable descriptor of edge overlap is given by o αβ e α ∩ e β min where e α is the set of edges belonging to layer α and • indicates the cardinality of the set this measure quantifies the proportion of pairwise interactionsrepresented by the edgesthat are common to two different layers because as shown in table 2 the number of edges can vary largely on the different layers the normalization is given by the cardinality of the smallest set of edges to avoid biases resulting from the size difference the results are reported in figure 3 each value is obtained by averaging over the different events the standard deviations are not shown in the figure for the sake of clarity but are reported in table 3 we see that for every couple of layers o αβ ≪ 1 this result indicates that different layers contain different pairwise interactions ie the users that we retweet are not necessarily the same that we mention or we reply to for example this result suggests that considering the different activities separately might be very relevant in order to understand human interaction dynamics on twitter degreedegree correlations across layers in this section we study the degree connectivity of users the most widely studied descriptor of the structure of a network we focus in particular on the indegree k iα which quantifies the number of users who interacted with user i on layer α this is the simplest measure of the importance of the user in the network first we explore if users have the same connectivity on the different layers or not ie if the users consistently have the same degree of importance on all the layers or not to this aim we compute the spearmans rank correlation coefficient 31 between the indegree of users on one layer and their indegree on a different layer for each pair of layers the results averaged across the different events are reported in figure 4 with statistical details reported in table 3 the value of two degreedegree correlations out of three is about 035 and the thirdand highestcorrelation is 05 this means that users tend to have different indegree values on the different layers ie a highly retweeted user is most likely not to be mentioned or replied to by as many users this result suggests that the different types of interaction might produce different networks and should be considered separately in realistic modeling of individual dynamics degree distribution per layer building on the result discussed in the previous section we also explore for each event the distribution of the indegree on the different layers separately intriguingly for each layer we find that the empirical distributions corresponding to all the exceptional events present very similar shape as shown in figure 5 this result suggests that individuals communications on twitter present some universal characteristics across very different types of events the indegree shown in figure 5 exhibits a powerlaw distribution for about three order of magnitudes to validate our observation we fit a power law to each distribution following a methodology similar to the one introduced in clauset et al 32 by noticing that the indegree is a discrete variable we estimate the scaling exponent of a discrete power law for each empirical distribution the goodness of fit is estimated by using the chi square test 33 we find that the null hypothesis that the data is described by a discrete power law is accepted for all empirical distributions with a confidence level of 99 we have tested other hypotheses by considering other distributions with fat tails such as lognormal exponential gumbels extreme values and poisson in the cases where the null hypothesis is accepted with the same confidence level we used the akaike information criterion 3435 to select the best model it is worth remarking that in all cases we find that the power law provides the best description of the data powerlaw distributions of the degree have been found in a large variety of empirical social networks 36 here the main finding of our results is that each kind of interaction presents a different scaling exponent to show this in figure 6 we report three notched box plots each corresponding to a different layer and including the information about the different events notched box plots present a contraction around the median whose height is statistically important if the notches of two boxes do not overlap this offers evidence of a statistically significant difference between the two medians this is indeed the case in figure 6 meaning that the median scaling exponent of the indegree distribution of each of the three layer is different from the exponent characterizing the indegree distribution of the other layers the fact that the indegree distributions corresponding to the different types of interaction are characterized by different scaling exponents indicates that the dynamics of each type of interaction in twitter should be modeled as a distinct process and that existing models of twitter activity that do not take into account this fact should be carefully rethought average clustering per layer lastly for each layer separately we calculate the average clustering coefficient of the corresponding network this is a measure of the transitivity of the observed interactions and constitutes an important metric to characterize social networks notched box plots present a contraction around the median whose height is statistically important if the notches of two boxes do not overlap this offers evidence of a statistically significant difference between the two medians this is the case here meaning that the median scaling exponent of the indegree distribution of each of the three layer is different from the exponent characterizing the indegree distribution of the other layers 37 in particular for each event and each layer we compute the average local clustering coefficient defined by c 1 n n i 1 c i where c i 2 e jk v j v k ∈ n i e jk ∈ e k i where e jk indicates the edge between users j and k we show in figure 7 the values of the clustering coefficient using three notched box plots each corresponding to a different layer and including the information about the different events the mention network has the highest clustering level whereas the reply network has the lowest one the clustering level of the retweet network is the most variable across events however the three medians are again different because the notches do not overlap this result is a further confirmation that the three layers and therefore the three types of interaction that they represent form different network topologies and that the dynamical processes producing them are thus distinct discussion in this paper we analyze six datasets consisting of twitter conversations surrounding distinct exceptional events the considered events span over very different topics entertainment science commemorations sports activism and politics our results show that despite the different fluctuations in time and in volume there are some statistical regularities across the different events in particular we find that the indegree distribution of users and the clustering coefficient in each of the three layers are the same across the six different events our first conclusion is therefore that users behavior on twitterduring exceptional eventspresents some universal patterns secondly we show that different types of interactions between users on twitter generate networks presenting different topological characteristics these differences were captured making use of the multilayer network framework instead of discarding the information contained in the tweets regarding how users interact we use this information to build a more complete representation of the system by means of three layers each representing a different type of interaction the fact that networks corresponding to different layer present different statistical properties is an important hint for models aiming at reproducing human behavior in online social networks our results indicate that to faithfully represent how users interact these models cannot be based on an aggregated view of the network and should account for all the different processes taking place in the system separately conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest copyright © 2015 omodei de domenico and arenas this is an openaccess article distributed under the terms of the creative commons attribution license the use distribution or reproduction in other forums is permitted provided the original author or licensor are credited and that the original publication in this journal is cited in accordance with accepted academic practice no use distribution or reproduction is permitted which does not comply with these terms

nowadays millions of people interact on a daily basis on online social media like facebook and twitter where they share and discuss information about a wide variety of topics in this paper we focus on a specific online social network twitter and we analyze multiple datasets each one consisting of individuals online activity before during and after an exceptional event in terms of volume of the communications registered we consider important events that occurred in different arenas that range from policy to culture or science for each dataset the users online activities are modeled by a multilayer network in which each layer conveys a different kind of interaction specifically retweeting mentioning and replying this representation allows us to unveil that these distinct types of interaction produce networks with different statistical properties in particular concerning the degree distribution and the clustering structure these results suggests that models of online activity cannot discard the information carried by this multilayer representation of the system and should account for the different processes generated by the different kinds of interactions secondly our analysis unveils the presence of statistical regularities among the different events suggesting that the nontrivial topological patterns that we observe may represent universal features of the social dynamics on online social networks during exceptional events

introduction lesbian gay bisexual transgender and queer youth spend most of their lives in schools navigating through the difficult and threatening space 5480 schools can be a threatening space for lgbtq youth as they experience increased victimization and a lack of safety 59 this fact is alarming since students spend most of their time in schools approximately 175 to 220 days per year with an average of 5 to 85 h per school day 81 schools then can be thought of as youths second home particularly concerning for lgbtq youth due to the lack of safety in their school environment many studies have indicated that lgbtq youth experience numerous socioemotional educational and health risks at school due to lgbtqspecific prejudice and victimization this includes isolation from peers low social support low school engagement low academic success school dropout stress anxiety depressive symptoms and suicidal ideation and attempts 414760 however rather than problematizing youth as atrisk emerging research is shifting the focus understanding social support for lgbtq youth through ecological systems theory lgbtq youth experiences have been increasingly explored in a variety of settings family community and school settings one approach to organize the lgbtq youth literature is through a broader systemic lens bronfenbrenners 14 15 16 ecological systems theory can provide the systemic lens needed that allows a way of thinking for the study of interconnections among systems the model views the individuals development as a complex system of interactions and relationships across multiple systems surrounding the individual the systems suggested by bronfenbrenner 14 15 16 include microsystem mesosystem exosystem macrosystem and chronosystem briefly the microsystem consists of the immediate stakeholders that are directly in contact with the individual the mesosystem includes the interactions between the individuals microsystems the exosystem consists of stakeholders or environments which do not contain the individual and that indirectly influence the individual via their microsystems the macrosystem consists of the cultural components that influence an individuals development the chronosystem consists of normative andor nonnormative environmental changes that occur over the lifespan that can influence an individuals development an understanding of the various systems surrounding the individual allows for the exploration of the relationships between the systems previous empirical research on youth and lgbtq studies have applied the ecological systems theory to understand effective ways lgbtq youth are accessing the necessary support to thrive in their environment for example watson and others 119 interviewed gaystraight alliance advisors addressing various topics including school climaterelated issues that influenced their ability to be advocates for their students the authors found that sociocultural factors schoolbased factors and individual factors were both barriers and facilitators of their ability to be advocates from the advisors perspective aligned with bronfenbrenners ecological systems theory they are required to navigate across systems to effectively support their lgbtq youth results were corroborated from other studies that consider the necessity of school counselors to navigate across ecological systems to support the lgbtq youth in their schools 7 other studies focusing more on the community surrounding lgbtq youth revealed similar navigations across systemic barriers in their identity exploration katzwise and others 57 interviewed tgnb youths experience in their gender identity exploration specifically in family and community settings eight themes were developed from this study that aligned with the ecological systems individual factors family factors community factors and societal factors broadly the ecological systems theory shifts the research focus to a more relational developmental systems view acknowledging the interconnectedness of the systems and its associations to the individual taken together this scoping review attempts to explore existing social support for lgbtq youth in schools through the ecological systems theory an ecological systems approach in understanding the existing literature on social support for lgbtq youth can provide an organizational framework necessary to consolidate the comprehensive literature of social support for lgbtq youth in schools as the scoping review attempts an initial exploration and organization of existing social support for lgbtq youth in schools a deeper exploration on the relationship between the systems will be explored in a separate review 1 3 schoolbased protective systems for lgbtq youth american psychological association 1 published an informational guide summarizing the various schoolbased protective systems present for lgbtq youth although not comprehensive the guide listed several support systems available in schools educators school policies gaystraight alliances inclusive curriculum and school climate briefly the guide implicated the importance of educators to help create a safe school climate for lgbtq youth the need to create and enforce antiharassment policies the creation of gaystraight alliances and the development of lgbtqinclusive curriculum each system were found to be critical to an establishment of a lgbtqaffirming school climate which in turn was shown to help minimize victimization rates and increase sense of safety for lgbtq youth 54122 other research similarly suggests the importance of lgbtqaffirming school climate as a support system to help minimize victimization rates and increase sense of safety for lgbtq youth 28 as literature in this field typically examine systems of social support in isolation this scoping review aims to provide a more comprehensive search strategy in consolidating the research on the available social support systems for lgbtq youth in schools this scoping review attempts to bring together the literature across multiple systems of social support for lgbtq youth to develop a systemic definition of social support for lgbtq youth identify current research across all systems of social support identify barriers and difficulties experienced by lgbtq youth in schools and identify areas for future research in understanding the social support systems for lgbtq youth schools as a key site of stress for lgbtq youth results from the 2015 youth risk behavior survey indicate that over 60 of lgb youth experienced prolonged feelings of hopelessness compared to only 25 of heterosexual youth in a national survey of lgbtq youth 59 67 heard homophobic comments in schools 58 perceived a lack of safety as a result of their sexual orientation identity and 43 perceived a lack of safety as a result of their gender identity and expression although there was a high percentage of lgbtqspecific concerns only 12 of lgbtq youth reported teacher intervention in gay lesbian straight education network s national survey 59 926 of lgbtq youth mentioned health concerns as the main reason for not graduating high school followed by academic and safety concerns therefore a further detailed systematic breakdown of existing social support systems in educational settings is required to better understand what can be done to offset negative experiences and risks this analysis will also clarify the barriers schools face in providing support and inform future inquiry for schools to move towards improved support for lgbtq youth present data highlights that lgbtq youth are at a heightened risk for numerous health and educational concerns such concerns can be attributed to a lack of connection with their teachers and school staff 58 a lack of acceptance from their family members 5774 and peers 122 a lack of school curricula and policies that value lgbtq diversity 105 and the existence of overall hostile and exclusionary school climates 59 the level of warmth and positivity in a school environment can positively impact lgbtq students experiences and their subsequent health and educational outcomes for example teacherstudent relationships are positively associated with increased academic engagement performance and socialemotional wellbeing for lgbtq youth 66 this review seeks to pull together literature on how lgbtq youth are supported in schools and examine the ways that different types of social support can affect outcomes to provide an organized framework to effectively support lgbtq youth research question and aims of the current study while efforts have been made to support lgbtq youth in schools literature is diffuse and show mixed results 54109 subsequently a systematic surveying of the literature on all existing support systems that provide the necessary social support for lgbtq youth is necessary social support includes numerous school professionals and community members such as school psychologists educators counsellors and principals to act as critical individuals holding the power to support and advocate for lgbtq youth the scoping review aims to synthesize current research on social support for lgbtq youth in schools recurring literature on social supports for lgbtq youth include gaystraight alliances school policies curriculum and parent and peer support 54 the review seeks to direct future research by providing clarity and illuminating gaps in literature to foster more nuanced research and interventions that ameliorate significant health and educational disparities for lgbtq youth as research is robust indicating the disproportionate stress that lgbtq youth experience 122 this review is imperative to systematically explore the systems of social support for lgbtq youth this study seeks to respond to the following question how does social support in elementary and secondary education relate to outcomes for lgbtq youth with the following objectives define what it means to have social support in schools identify and describe the current research on outcomes for lgbtq youth given the implementation of these social support systems identify barriers and difficulties to support lgbtq youth in an educational setting and identify areas for future research for lgbtq youth and social support in schools method search strategy this study follows the methodologically rigorous scoping review approach designed by arksey and omalley 5 and conducted a systemic search across the disciplines of education and psychology though the keywords and categories used to conduct the systemic search was allencompassing and should capture relevant stakeholders in schools specific domains of studies outside of the field of education and psychology was not explicitly considered due to the interdisciplinary nature of education therefore the search strategy may not have a wide reach for paraprofessionals that work with lgbtq youth in schools however based on the broad nature of the keywords paraprofessionals working in schools to support lgbtq youth should be included a scoping review was chosen to allow for the inclusion of multiple study designs and to allow for posthoc analysis of inclusion and exclusion criteria 86 in particular as a systematic review approach required study appraisals a scoping review was more appropriate due to the inclusion criteria of both empirical and nonempirical studies eligibility criteria a set of inclusion and exclusion criteria were established a priori to provide guidance for the systematic search strategy inclusion criteria included empirical articles that were published in peerreviewed journals between 2007 and 2021 nonempirical literature including books book chapters case reports reviews between 2007 and 2021 written in the english language lgbtq individuals school environmentspecific all geographical locations and social support outcomes for students exclusion criteria included nonlgbtq specific unrelated to school environment social support outcomes not for students information sources the search used the following databases psycinfo eric genderwatch proquest dissertation and thesis web of science cochrane database of systematic reviews and campbell systematic review a description of keywords can be seen in supplementary table 1 and a visual for the search and data collection process in supplementary figure 1 search a social science librarian was consulted to ensure the scoping review was conducted in a systematic procedure the five databases were crosschecked with an expert in the field of lgbtq studies to ensure a comprehensive collection of databases after databases were confirmed key concepts were brainstormed and crosschecked with the second and third author the expert in the field of lgbtq research and the librarian keywords were broken down into three sections the first column consists of lgbtq terms the second column consists of school terms the last column consists of social support terms refer to supplementary table 1 for a full list of search terms all phase four revised data collection a revised data collection was addended since the 2007 through 2017 phase another round of data collection abstract and fulltext screening was conducted from 2017 through 2021 the update in data collection was done in 2021 to account for the many changes happening in society related to lgbtq populations as the manuscript was in the process of writing and revisions along with the delays as a result of the covid19 pandemic an additional 198 articles were collected for initial screening following the same procedures of phase one title and abstract screening independent screening was conducted by the first and fourth author resulting in 56 articles retained with an interrater reliability of 8434 replicating phase two the first and fourth author conducted independent fulltext screening on the 56 articles resulting in 40 articles with an interrater reliability of 7500 following phase three the resulting 40 articles from the fulltext screening were broken into two blocks of 20 each author independently read one block of articles and extracted relevant data after independent data extraction the two authors checked and resolved any differences in the other block synthesis of results after data abstraction quantitative data was collected on the following categories research design participant sample size range lgbtq acronym school setting number of schools number of students and the types of social support initial irr of 94 articles was 7660 and discrepancies were discussed and resolved through an iterative process between the first through fourth authors subsequent thematic analysis 3132536117 was conducted this method of analysis is justified as a descriptive qualitative method to identify common themes found in the key findings of the 94 articles initial irr was 7872 above the acceptable level of reproducibility and discrepancies were discussed and resolved among the first four authors data analysis involved both quantitative and qualitative methods resulting in a multilayered synthesis process that allowed for the identification of existing gaps in the literature and revealed potential topics for conducting future systematic or novel reviews results study characteristics refer to supplementary table 2 for a tabulation of characteristics across the 94 articles research design out of the 94 articles there were 48 quantitative studies 43 qualitative studies and three mixedmethods studies lgbtq acronym as each article used several lgbtq acronyms interchangeably there are a total of 102 acronym frequencies across 94 articles acronyms include lgbtqglbtq lgbtglbt sexual minoritysmy lgbq lgbglb transgendertrans ssa gsmgsd lgbtqq gendervariant gm lgbtq2s lgbtq queer msmy bisexualpansexual tgd participant sample range across 94 articles 42 studies provided specific age or grade ranges of the participants participants ranged from students in grades nine through 13 grades seven through 12 grades eight through 12 grades 10 through 12 and grades six through 12 40 studies did not provide specific age or grade range of students and only included the educational institution broadly high school middle and high school high school and college middle school elementary school college elementary and high school the remaining 12 studies included adult staff or parent participants or did not specify school setting as each study recruited school settings that were different in type and in developmental age there was a total of 108 counts of school settings across the 94 articles school settings included high school middle and high school private schools elementary through high school elementary school catholic schools middle school college alternative schools community center democratic school and independent school six studies did not specify the type of school setting types of social support each study reported more than one type of social support related to lgbtq students resulting in a total of 188 counts of social support types social support was organized into four categories school support peer support parental support and community support school support was further broken to include gaystraight alliances supportive nonteaching staff supportive teachers positive school climate programs and policies schoolwide approaches and curriculum synthesis of results based on bronfenbrenners ecological systems theory the constructed themes that was developed across the 94 articles were organized into support systems that directly impact lgbtq youth outcomes as geographical information was not extracted findings are generalized and may not accurately represent specific geographically contextualized policies and environments the role of family systems and social support three distinct themes were constructed from the literature high actual or perceived familycaregiver support buffered many negative socioemotional or educational outcomes familycaregiver support was not consistently adequate to buffer the negative emotional behavioral and educational outcomes and sex differences within family experiences highlighted complexities of familycaregiver support high caregiver support buffering negative outcomes when family support was low lgbtq youths level of emotional and behavioural distress was high 48182440558590124 a lack of social support in the family system was positively associated with adverse social emotional and educational outcomes for lgbtq youth however studies have shown that family acceptance was a type of social support that fostered lgbtq youths critical thinking and advocacy for safe spaces in schools to support marginalized students 40124 family support was particularly associated with better school performance for lgbtq racialized youth for both white and racialized lgbtq youth perceptions of being close with parents and direct involvement with parents in activities moderated experiences of victimization at school and reduced substance use and suicidality educational risks and increased school belonging 188590 moreover lgbtqaffirming resources aimed at developing family support fostered lgbtq youth academic wellbeing physical and emotional safety and ability to be authentic in classrooms 233882 caregiver support inconsistent in buffering negative outcomes studies showed that family support did not consistently buffer the negative outcomes that happens at school 1790 though family support may be protective against victimization and selfharm among youth effects were less robust for gender minority youth 96 sex differences within family experiences three unique studies found differences present for boys and girls and mothers and fathers pearson and wilkinson 85 found that only sexual minority girls were less distressed when they reported a sense of strong family relationships however there was no association found between caregiver support and peer victimization for sexual minority girls 55 bos and others 11 found less distress among all lgbtq youth who established a strong relationship with their fathers a strong relationship with fathers resulted in increased positive social emotional and educational outcomes supporting lgbtq youth through the curricular education system four distinct themes were constructed from the literature lgbtqinclusive curriculum was most often taught in social sciences humanities and health classes fostering authenticity with students and creating an inclusive classroom lgbtqinclusive curriculum led to decreased victimization and negative socioemotional outcomes and increased sense of safety a hidden heteronormative curriculum exists behind the official academic curriculum that impedes lgbtq youth support and engagement and a need for teachers to feel supported to teach lgbtqinclusive curriculum effectively lgbtqinclusive curriculum fostering authenticity with students and creating an inclusive classroom lgbtqinclusive curriculum appeared to be taught only in specific classes specifically in social sciences humanities and health classes 10 103 104 105 124 making connections with lgbtqinclusive material allowed students to make authentic connections between their lives and the class content 73 which contributed to an increased psychological wellbeing and disrupted homophobia and other forms of oppression 10103118124 teachers who incorporated lgbtq material into their curriculum allowed youth to identify teachers as possible safe adults to discuss sensitive concerns teachers also agreed on the importance of weaving social justice topics in the curriculum to model critical literacy and to create an inclusive curriculum benefitting all students 84 lgbtqinclusive curriculum decreased negative outcomes and increased sense of safety lgbtqinclusive curricula had supportive elements at the individual and school level incorporating lgbtqinclusive curriculum and having access to lgbtqrelated information in schools was positively associated with perceptions of a safer school environment and negatively associated with perceptions of victimization 105110 therefore developing a curriculum that centers lgbtq issues can disrupt homophobia injustice and other forms of oppression which can provide safety and acceptance and validate lgbtq youths experiences at school 102118 hidden heteronormative curriculum impedes lgbtq youth support and engagement this theme expands on the hidden heteronormative curriculum that exists behind the official academic curriculum castro and sujak 19 mentioned the need for lgbtqinclusive curriculum to expand outside of academics such as the social and campus curriculum lgbtqinclusive curriculum is most effective when it can be generalized beyond formal learning spaces gaystraight alliances a supportive network outside of the classroom is one space that can supplement lgbtqinclusive curriculum outside formal education informal spaces of lgbtqinclusive curriculum can foster student engagement and provide further opportunities for students to engage in social advocacy and promote a positive school climate 6473123 teachers need to feel supported to teach effective lgbtqinclusive curriculum though lgbtqinclusive curricula can be a pillar of social support for lgbtq youth teachers often miss teachable moments conducive to inclusive curriculum 70103 teachers mentioned difficulty fostering an inclusive curriculum due to rigid curriculum high stakes testing and parental resistance 84 requiring the administration to provide the support needed for teachers to change the curriculum 69 note that the barriers may be contextual as highstakes testing does not occur in all school contexts and curricula may be externally constructed in relation to the geographical context of the school environment gaystraight alliances and other school programs six distinct themes were constructed from the literature gaystraight alliances fostered a space for empowerment and change creating a safe space and climate for lgbtq youth gsas created opportunities for connection for lgbtq youth in their community gsas allowed for engagement and youth involvement in schools gsas had varying functions gsas encountered challenges in delivering positive outcomes and schoolbased interventions were effective in supporting lgbtq youth note that most of the articles referred to gsas as gaystraight alliances one article referred to them as gendersexuality alliances gsas foster a space for empowerment and change creating a safe space and climate for lgbtq youth gsas help students provide a space to act together to create cultural and institutional change 3198123 and can be transformative for school culture these spaces provide a positive and safe physical and intellectual space where students can engage in knowledge transfer and discuss lgbtq issues otherwise silenced in the larger school community 31406364697172777898106107123 gsas give lgbtq youth a safe place to go where they can be accepted 69 gsas can be a space where mental health promotion programs can be incorporated to provide students with coping skills and resources 44 the presence and membership in gsas were positively associated with school belongingness school engagement school safety academic success wellbeing and negatively associated with substance use psychological distress and victimization incidents 64546536793111112 entering gsa classrooms offered visibility positive symbols of acceptance respect and affirmation providing lgbtq youth with a sense of safety 687 gsas create opportunities for connection for lgbtq students in their community gsas provide accountability support community increased academic success and decreased feelings of isolation by connecting youth with other lgbtq community members events and resources subsequently the connections lead to increased validation and normalization of identity sense of hope acceptance greater selfesteem greater appreciation for self and other peers adaptive social relationship skills and a sense of safety and empowerment for lgbtq youth 31 40 46 69 7173 75 98 106 111 gsas allowed for connections to community organizations providing a gateway to the wider lgbtq community supportive adults community resources fostering activism opportunities and increasing lgbtq visibility 687 gsas allow for engagement and youth involvement in schools participation in gsas were positively associated with perceptions of a safer space for lgbtq youth to engage in selfexpression and identity validation 62 their involvement in gsarelated activities and events increased their selfefficacy 20 academic success school engagement school belongingness 43111112 sense of hope and advocacy and awarenessraising efforts 8891 engaging with gsas enabled students to form their own identities grounded in empowerment rather than as victims 3198 lgbtq youth teachers and school administrators have reported that having and engaging in their gsa gave students space for emotional safety 7172 gsas vary in their function gsas had distinct purposes in assisting different aspects of lgbtq youth advocacy education and social support literature to reflect on the lives and experiences of lgbtq youth and developing skillsets to assist students in fostering inclusion and acceptance 114 advisors believed the primary role of gsas is to bring awareness and act in schools whereas students believed the purpose was to foster a sense of community and belongingness 637194 the varying functions of gsas depended on the internal provisions of support from visibility raising to collective social change 7192123 students who were more involved in accessing information and advocacy efforts discussed more healthrelated topics prepared more awarenessraising campaigns and had increased school engagement 89 on the other hand gsas with a stronger focus on socialization efforts focused less on mental health discussions 89 gsas encounter challenges in delivering positive outcomes although gsas were found to be effective in supporting lgbtq youth in schools only 191 of youth reported an existence of a gsa in their high school 8 program implementations within gsas also encountered common problems problems included a lack of staff training and safe staff a lack of student understanding towards lgbtq issues a lack of sensitivity towards lgbtq topics and challenges in facilitating a discussion on sexual or genderrelated topics 5069 gsas struggled to subvert the heteronormative school climate in schools where the greater community was unsafe particularly in rural environments 286371 for example high schools had concerns and restricted policies on gsa student behaviours limiting activities allowed by students 3135 in communities that were indifferent or hostile towards lgbtq populations gsa advisors were required to negotiate with school administrators to provide lgbtq youth a safe space in schools 6 in schools with high levels of victimization the benefits of gsarelated social justice involvement and presence dissipated 111112 in some schools the presence or participation in gsa activities did not predict student school engagement and was not associated with mental health outcomes or sense of safety 21289399100 rather the presence of a gsa led to emotional vulnerabilities to the wider school community 6 as such the impact of gsas on lgbtq youth safety and school climate may vary widely across schools and geographic context schoolbased interventions were effective to support lgbtq youth there is a need to employ a pragmatic approach and focus on student safety to gain administrative support to conduct interventions 656994 classroom intervention focused on accepting individual differences through open discussion and participation of emotional and sensitive issues were effective in framing uniqueness as a strength and fostered change towards an accepting classroom climate 7094 youthled theater and dialoguebased interventions were effective to address heterosexism and genderism in schools with increased reports of willingness and intention to advocate for social justice and equality for lgbtq people 121 hall and others 42 showed how a studentled community art gallery was effective to create a space for discussion on gender issues and act towards supporting lgbtq youth the role of peer systems in supporting lgbtq youth two distinct themes were constructed from the literature peer support and acceptance were related to lower levels of emotional and behavioural distress and fostered positive outcomes and inconsistencies in the effectiveness of peer support for diverse lgbtq youth fostering peer support and acceptance relates to lower levels of emotional distress and fosters positive social and educational outcomes lgbtq youth who had higher levels of peer acceptance and lower levels of strained peer relationships experienced lower levels of depression and suicidal behaviour higher levels of selfesteem increased academic success 115156 particularly for youth from rejecting families 23 on the other hand lower peer acceptance or connection predicted higher levels of depressive symptoms and lower levels of selfesteem and belongingness to the school 11 uniquely peer acceptance from straight allies played an important role to address antigay stereotypes 64 engaging in peer education and interventions led to increased levels of safety for lgbtq youth 2833102 older youth were found to have less homophobic attitudes and were more willing to remain friends with gl youth 110 schools where glb youth had opportunities to socialize reported increased belonging in their school and in their larger community 79 being out to more peers at school was generally associated with higher grades and less school harassment 120 similarly seeing peers who were out was positively associated with a sense of safety in schools 83 having thick friendships were shown to help encourage lgbtq youth to question their sexuality 37 the culmination of research on peer support reiterates the importance of peer support in schools for an increasingly safe and positive school environment inconsistencies in the effectiveness of peer support for diverse lgbtq youth though peer support was effective in fostering positive socioemotional outcomes and minimizing emotional distress inconsistencies were found within the lgbtq community subgroup identities had different conclusions regarding the effectiveness of peer support craig and smith 24 found that racialized lgbtq youth did not have a relationship between peer support and educational outcomes studies show that having supportive peers to discuss problems increased the risks of suicidal ideation and attempts for lgbtq youth particularly for lgbq youth who have had been victimized and gender minority youth 1796 generally social support did not buffer effects of victimization on selfesteem for lgbtq students 108 questioning the nuances in the efficacy of peer support as a social support system school professionals and teachers as a system of support for lgbtq youth four distinct themes were constructed from the literature high level of withinschool adult support resulted in positive benefits high level of withinschool adult support reduced negative outcomes teachers and school staff were ineffective and inconsistent in supporting lgbtq students and school staff perceived external support as key to ensure coordination of inclusivity for lgbtq students high level of withinschool adult support results in positive benefits lgbtq youth perceived more support in schools when they perceived that their school staff administrators and teachers showed more than verbal support lgbtq youth mentioned the need to observe school staff acting and having a presence explicitly taking a stance against bigotry emphasizing the importance of behavioural management to establish a safe classroom space 10 69 70 71 84 lgbtq youth who had natural mentors were three times as likely to graduate from high school had increased intentions to seek help for suicidal thoughts 21 and had positively impacted their engagement and connectedness to their school 23 compared to youth who did not have such mentors 30 when the number of safe adults increased at school lgbtq youth would become more engaged with their school and community through opportunities and access to resources from supportive staff members 697299100 supportive teachers had the power to foster a safe classroom climate and environment set clear expectations open inclusive dialogue with students implement lgbtqinclusive school and classroom procedures that positively impacted lgbtq youths safety and acceptance in schools 28102 educational achievement 34 and wellbeing 116 teachers having power to foster a safe classroom climate was similarly voiced by tgnc youth subsequently supporting their transition 38 likewise teachers and school staff understood the importance of developing skill sets to foster an inclusive and supportive classroom environment for lgbtq youth 113114 therefore supportive school staff are key stakeholders to foster a safer classroom environment and to create opportunities to foster awareness of lgbtq issues in their school environment high level of withinschool adult support reduces negative outcomes lgbtq youth perceptions of greater adult support at school was linked to lower levels of victimization school avoidance substance use suicidal behaviour and other mental health risks the identification of an adult ally predicted a decrease in fearbased truancy 7299100 principals agreed that there is a need to increase efforts to reduce discrimination towards lgbtq youth by setting a safe and positive climate in schools 12 an avenue that was effective in creating an inclusive and affirmative environment and reduce health risks among lgbtq youth are schoolbased health centers 125 teaching and nonteaching school staff were ineffective in supporting lgbtq students though there are benefits in having a supportive school staff there was a lack of communication between lgbtq youth and school staff 809 of lgbtq youth reported never talking to a teacher about lgbtq topics 708 of youth never talked to a school health counselor and 865 of youth never talked to a school administrator about lgbtq issues in school 8 the lack of action or silence teachers and school administrators take towards lgbtq topics or incidents is a reason for the lack of communication students reported that teachers are inconsistent in their intervention against victimization incidents often focused on stopping the harassment and providing reasoning for why such incidents can cause harm 48 there was a common perception of school administration silence surrounding lgbtq topic as normative in school environments 71 teachers reported feeling unprepared to support lgbtq youth and required more information for example through collaboration with gsas to improve pedagogy 7072 coulter and others 22 found that withinschool adult support was ineffective in protecting lgbtq youth against suicidality compared to outsideschool adult support therefore teachers and school staff need to increase their responsibility to support lgbtq youth 38 school staff perceived external support as necessary to foster staff support for lgbtq students school staff mentioned the importance of having a coordinator external to the school to provide support for curricular efforts and activities to students and staff and adapting to school needs reducing harassment for lgbtq youth 506970 schools with an external source of support showed significant improvements towards supporting lgbtq youth as reported by student observations 50 sexuality education workshops were another form of external support that led to significant positive effects on teachers beliefs and behaviours to support their lgbtq youth 61 the role of school policies and safer school spaces for lgbtq youth three distinct themes were constructed from the literature sociopolitical values of the wider community beyond the school impacted school policies and staff attitudes implementation of inclusive and antidiscriminatory policies were effective in fostering a safer school space for lgbtq students and school policy and community support showed challenges in fostering positive outcomes sociopolitical values of wider community impacting school policies and attitudes policies from the broader context can provide the support needed for schools to have inclusive school policies supportive government and school board policies allowed for organizations to be accepted subsequently fostering community connection and support for lgbtq youth 69106 however schools located in communities with more nonprogressive attitudes and beliefs about lgbtq individuals due to political or religious conservatism generated hesitation to support lgbtq students by school administrators 6571124 hesitations to support lgbtq youth include the ban of gsa creation sending a message regarding lgbtq invisibility in school environments 65 school staff were cautious and focused on minimizing external resistance and pressure from the larger community as a result this led to restrictions in gsa activities and spaces 6571 snapp and others 104 found that school policies were inequitably enforced as lgbtq youth were punished for public displays of affection and violation of dress code compared to heterosexual peers indicative of a lack of inclusive school policies reframing the support for lgbtq youth as systematic inclusion to meet the needs of all students may be a method to circumvent the restrictions and pressures from the larger community environment reframing support for lgbtq youth to general support for all students can reduce the hesitance school staff have to support lgbtq youth 6571106 most notably a schoolwide approach and communal investment is required to change and move towards inclusive school policies promoting the social psychological and physical safety for all students 33 the implementation of inclusive and antidiscriminatory policies to foster safe school spaces schools with higher reported implementation of inclusive and antidiscriminatory policies had lower levels of discrimination against lgbtq youth 12 fostering a safer school space effective bills such as bill 13 allowed lgbtq youth to create a space to transform their lives and offer opportunities of activism 52 inclusive policies allowed for inclusive events that provided a safer environment for lgbtq youth 107 therefore inclusive policies are important to set up a safe environment for students and challenge the heterocisnormative dynamic present in policy documents and classroom environment 113 introducing inclusive policies require collaboration across professionals to support legislation that acknowledges lgbtq issues in schools 61 inconsistencies in fostering positive outcomes from inclusive school policies and wider community support bullying policies did not consistently predict lgbtq safety and victimization 1228 rather higher proportions of students who reported inclusive school policies predicted lower perceptions of safety based on gender nonconformity 110 lastly community support was not related to decreased rates of harm for lgbtq youth 96 the role of a positive school climate on lgbtq youth outcomes in school three distinct themes were constructed from the literature a positive school climate reduced negative emotionalbehavioural outcomes a positive school climate fostered positive psychosocial and educational outcomes and a whole school effort is required to foster a positive school climate positive school climate reducing negative emotionalbehavioural outcomes for both lgbtq and heterosexual youth a positive school climate strong school connectedness and involvement in schoolbased activities predicted fewer physical victimization fewer depressive symptoms less suicidal ideation and attempts substance use and truancy 9212932 similarly teachers reported perceiving fewer depressive symptoms among their male sexual minority youth in positive and supportive school environments 29 positive school climate fostering positive psychosocial and educational outcomes a positive and safe school climate can promote tolerance respect and inclusion for lgbtq youth 6972121 lgbtq youth who were in less heteronormative schools had inclusive classroom environments and lgbtq affirming school climates allowed them to be more inclusive have increased opportunities to understand diversity and differences 102 fostered increased psychological wellbeing 116 and had more positive perceptions of safety in their schools 28 a positive school climate has also benefitted teachers by helping them feel comfortable to advocate for their lgbtq youth 7072 students parents and school staff mentioned the importance of having a safe space as a deciding factor to attend school for students to be recognized accepted and to participate in their school 49 subsequently those who were more involved in school activities and had stronger school connectedness felt safer in schools and had increased achievement 3234100 whole school effort is required to foster a positive school climate creating and maintaining a positive and safe school climate for lgbtq youth can foster positive outcomes for all students this effort requires constant vigilance from all relevant stakeholders students teachers administration and community members 94 effective interventions are all necessary to foster a positive school climate this in turn provides support for lgbtq youth and fosters wellbeing and educational and social success 3950568394121123124 a concerted effort provides lgbtq youth with access to resources and create more opportunities to carry out programs and training that can maximize the potential for lgbtq youth to feel supported in their wellbeing and safety additionally a wholeschool approach can support teachers and school administrators by providing them with more resources and external support all instrumental to attain a wholeschool system that is positive and inclusive 69 gsas may be an avenue whereby students can act to address antilgbtq bias to provide education and address the silences on lgbtq issues through whole school efforts 69121123 most importantly having a supportive principal can facilitate a positive wholeschool approach to promote lgbtq inclusivity in schools 70 discussion a systemic definition of social support for lgbtq youth the first objective of this review is to define what social support in schools mean for lgbtq youth prior to understanding how social support in elementary and high school education relate to outcomes for lgbtq youth the scope of social support needs to be defined to create a systemic framework that can map how different social support systems are associated with lgbtq youth outcomes in school organized through the ecological systems theory social support can be defined as support that is provided across various systems related to lgbtq youth this scoping review brought forth how social support in schools for lgbtq youth can span across systems family curriculum gsas peers school administrators and teachers school policies and school climate the seven systems that were constructed from the review indicated that they impact lgbtq youth and their experiences in school the parental system was constructed from the review as a form of social support that is associated with lgbtq youth outcomes in schools parents or caregivers who supported their lgbtq youth through advocacy open communication trust closeness and acceptance minimized many negative educational outcomes and promoted wellbeing academic success physical and emotional safety among other outcomes the curricular system was constructed to show how influential lgbtqinclusive curriculum can be for lgbtq youth lgbtqinclusive curriculum provided lgbtq youth the opportunity to explore their lgbtq identity make authentic connections challenge oppression and acquire knowledge inclusive of lgbtq people and issues when a lgbtqinclusive curriculum is introduced in classrooms lgbtq youth reported feeling safer more accepted in their classroom and lower victimization incidents gsas and other schoolbased programs were social support systems that were constructed based on the robust data related to how gsas can provide space for empowerment and change creating a safe space and climate for lgbtq youth this in turn can promote many positive outcomes in schools and decrease substance use victimization and psychological distress among other risks supportive and accepting peers were a system of social support that fostered higher levels of school belongingness school engagement academic success sense of safety and minimized levels of depression and school victimization for lgbtq youth school administrators and teachers were another system of support for lgbtq youth the higher the number of safe adults that were identified at school the greater the school engagement for lgbtq youth supportive adults at school through the knowledge resources and connections they have about lgbtq issues acted against bigotry and victimization incidents at school and fostered a positive studentteacher relationship for lgbtq youth subsequently they perceived a safer and accepting classroom environment increased sense of school belonging academic success and wellbeing school policies were constructed as a system influential to lgbtq youth outcomes in schools schools with lgbtqinclusive policies reported lower levels of victimization and increased sense of safety and opportunities for lgbtq youth to act towards an empowering climate school climate arose as an overarching system where the other systems interacted to foster a safer and accepting climate for lgbtq youth promoting tolerance respect academic success wellbeing and school connectedness based on the seven systems of social support for lgbtq youth in schools social support in schools can be defined as an understanding of systemic interactions amongst the seven systems and how each system uniquely and in overlap can both positively promote academic socioemotional and behavioural outcomes and moderate the health and psychological risks typically associated with lgbtq youth in schools studies that did not align through the lens of ecological systems focused on specific definitions of social support for example day and others 27 conceptualized social support as lgbtq youths perception of teachers as caring fostering supportive classroom environments and friendly and attentive classmates encouraging inclusivity in activities mcdonald 76 mentioned the difficulty in defining social support due to the multiple interpretations present in the literature in their review social support was defined as social school and family connectedness support from peers adults advisors and support groups 76 therefore grounded in the ecological systems approach social support cannot simply be understood in a single dimension but across multiple dimensions this study further enhances the importance of defining evaluating and measuring social support for lgbtq youth through multiple dimensions changing the narrative of social support from passive recipients of support to opportunities and spaces for activism skill learning and engagement the second objective of this review was to identify current research on outcomes for lgbtq youth given the implementation of the social support systems identifying current research shed light to understand how social support provided across the social support systems are associated with lgbtq youth outcomes the current research on social support outcomes for lgbtq youth sheds light on the multifaceted nature of social support systems shown to influence lgbtq youth outcomes in schools the current research on family systems focuses on fostering positive connections between parents and lgbtq youth more specifically current research expands beyond family acceptance and closeness as family support family support also entails the active support through advocacy allyship and communication this finding was replicated in other social support systems where providing social support for lgbtq youth entails the act of standing up advocating and challenging the lgbtqrelated issues present in schools and community current research on curriculum support highlights variance in the implementation of lgbtqinclusive curriculum lgbtqinclusive curriculum was most often incorporated in social sciences humanities and health classes where students were able to make authentic connections between their lives and lgbtqrelevant social events moving towards a systematic implementation of lgbtqinclusive curriculum that expands beyond social sciences humanities and health classes is an important step to provide safety for lgbtq youth in schools a heteronormative curriculum excludes lgbtq youth from making authentic connections with their own lives subsequently influencing their interest and engagement in classrooms increasingly incorporating lgbtqinclusive curriculum in education can move towards the vision for lgbtq youth to foster authentic connections between their identity and their curriculum this can result in improvements in their learning wellbeing identity exploration and foster a supportive school and classroom climate like the family system pushing for a lgbtqinclusive curriculum moves the system to actively challenge and disrupt the homophobia and injustice that is present in schools based on the findings from both systems it appears that activism advocacy and this shift towards criticality against an injustice educational system is common in the literature reviewed from 2017 through 2021 current research on gsas and other school programs were effective in creating a safe space for empowerment and change for lgbtq youth though gsas had different functions based on the schools needs and context two of gsas functions were to act as a space for advocacy and education and acquire coping skills and resources to support their mental health similar to the previous systems gsas are moving towards providing lgbtq youth the skills and opportunities necessary to be active participants in fostering a lgbtqinclusive school environment and make connections to the wider community for support current research on peer support similarly highlights the importance of peers as active participants in schools to foster a sense of safety and positive classroom environment for lgbtq youth beyond peers as allies the act of peer education and intervention where peers take an active role to support their lgbtq peers in schools led to increased sense of safety and positive classroom experiences for lgbtq youth positive friendships also known as thick friendships pushed lgbtq youth to question their sexualities reflect and consider how their lgbtq identity emerges in their lives this form of close relationship with friends helped lgbtq youth take an active role in selfreflection of their lgbtq identity and disruption against existing oppression in schools current research on school administrators and teachers focused on school staffs lgbtqinclusive knowledge relationships with students and opportunities for students to open the space for discussion on inclusion and diversity school administrators and teachers have the power to create opportunities for students to foster awareness of lgbtq issues in their schools through community events this shows the importance for school administrators and teachers to have the knowledge and skills to create opportunities for students to be active participants in critical dialogue and reflection subsequently promoting safety and acceptance in the classroom like the interaction between gsas and the community system surrounding the school school policies were also impacted by the sociopolitical values of the wider community inclusive school policies allowed students to have opportunities to create change in schools such as the creation of lgbtqinclusive events like pride prom and the day of silence to acknowledge and promote awareness of lgbtq issues and inclusivity recent research further emphasized the importance of a schoolwide approach to effect change in schools and incorporate inclusive policies the research on school policies as a social support system emphasizes social support as an interaction of systems where the larger context and values can impact both the inclusivity of school policies for lgbtq youth and the level of supportiveness from school administrators and teachers family and peers school climate the last social support system highlights the interrelatedness between all systems many articles indicated the robustness of a positive school climate and the academic socioemotional and behavioural benefits for lgbtq youth to achieve a positive school climate each social support system is relevant to provide social support for lgbtq youth each social support system can influence each other in their effectiveness to provide the necessary space and opportunity for lgbtq youth to act and challenge their school environment in sum the current research on social support for lgbtq youth has moved beyond understanding lgbtq youth as passive recipients of education to recognizing lgbtq youth as active cocreators of supportive spaces and opportunities that promote inclusive school climates that foster a sense of belongingness and safety other reviews exploring the impact of positive school climate on lgbtq youth similarly emphasized the importance of a positive school climate for lgbtq youth ancheta and others 2 found that a positive lgbtqspecific school climate as defined by supportive staff teachers and nurses decreased suicidality among lgbtq youth promoting student empowerment and visibility through gsas inclusive curricula and inclusive policies like previous reviews this review highlights the importance of social support for lgbtq youths experiences in schools however this research expands on the change in narrative that may be an indication that social support is more than providing support to lgbtq youth rather social support is changing the narrative from passive lgbtq youth towards active lgbtq youth taking initiative to create change and develop skillsets to be successful in their school aligned with more selfdetermined behaviours school administration and larger community environment as barriers to supporting lgbtq youth in educational settings the third objective of this review was to identify barriers and inconsistencies to support lgbtq youth in schools though seven social support systems were identified to foster positive socioemotional behavioural and educational outcomes barriers and inconsistencies to support lgbtq youth were identified in each system family support did not consistently buffer negative emotional behavioural and educational outcomes rather general parental support was associated with peer victimization selfharm and poorer academic success 179096 button 17 found that victimized lgbq youth performed worse academically when they reported general parental support indicating nuances between the buffer from parental support on lgbtq youth outcomes inconsistencies may be explained by the functionality of family support as lgbtq youth may perceive that their family support is ineffective to resolve harassment experienced at school several studies indicated the barriers of incorporating lgbtqinclusive curriculum in an effective manner in schools one aspect includes the need to understand the hidden curriculum that exists beyond the formal academic curriculum the social relationships and school spaces can convey heteronormativity adversely affecting lgbtq youth and their sense of safety and engagement in schools additionally there is a need for administration to provide support for teachers to effectively incorporate lgbtqinclusive curriculum oftentimes teachers miss teachable moments that is conducive to inclusive curriculum due to the rigid curriculum of high stakes testing and fear of parental backlash there is indication where gsas can be spaces used to insert lgbtqinclusive curriculum in an informal space to compensate the barriers that exist in classrooms therefore school administrators act as key members to ensure a lgbtqinclusive curriculum can be incorporated effectively in classrooms gsas also demonstrated barriers and difficulties in delivering positive outcomes for lgbtq youth schools restricted gsa activities and presence because of sociopolitical reasons limiting activism for lgbtq youth there is a need to negotiate between gsa advisors and administration for lgbtq spaces in schools beyond macrolevel barriers gsas also encountered difficulties in program implementation because of a lack of staff training to discuss sensitive topics in schools there were inconsistent results in the benefits of having a gsa in schools possible barriers may be due to the larger school and geographic context as being involved in gsas in more hostile or unsafe environments that place lgbtq youth at risk in schools and geographical areas that is more hostile the presence and involvement of gsarelated activities is associated with increased risks of safety and decreased positive outcomes peers were inconsistent in their support for lgbtq youth victimized lgbtq youth who had peers to confide to and discuss problems performed worse academically had lower selfesteem and had increased suicidal ideation for racialized lgbtq youth peer support did not moderate perceived discrimination in schools and had no association with school performance in addition the lack of association for racialized lgbtq youth suggests how peer support may be overshadowed by other lgbtq concerns school administrators and teachers were met with barriers to effectively support their lgbtq youth in schools many lgbtq youth reported not reaching out to school adults for support the barrier appears to lie on the onus of lgbtq youth to reach out to school staff for support this can be due to a lack of trust or belief that teachers or administrators can effectively help them lgbtq youth reported teachers not knowing how to intervene in situations of harassment or teachers not feeling prepared to teach inclusive content and answer lgbtqrelated questions lgbtq students reported the need for teachers to increase their responsibility in teaching and conveying lgbtqinclusive material as the burden lies on students to provide education to their peers from the perspective of school staff they perceived the need for external support to coordinate support for teachers for curricular efforts activities and actions to reduce harassment towards lgbtq youth and foster a greater sense of safety having an external coordinator as the point person to organize efforts to push the school for lgbtq inclusion can increase lgbtq acceptance in schools the wider sociopolitical context that surrounds the school has an influence on the availability of lgbtqinclusive school policies the sociopolitical context act as barriers limiting the schools abilities to have gsas and school staff to show support for their lgbtq youth however there has been mixed evidence showing an inverse relationship between an increase of inclusive school policies and a decrease in perceptions of safety though there may be inclusive policies put in place in schools such policies may not be consistently enforced by school staff lending to the ineffectiveness of inclusive policies consistent implementation of inclusive school policies will require dedicated school staff to monitor the progress of policy implementation in this review school administrators and teachers have mentioned the need to have an external staff coordinator to monitor consistent implementation of inclusive school policies due to the lack of time and energy school principals also played a major role in the implementation of inclusive school policies as topdown administrative support is needed to send a message to school staff that they are supported by administration should they receive family or community backlash compared to the findings in this review russell and others 97 similarly found that inclusive policies have been associated with improved school climates for lgbtq and all youth with lgbt students reporting feeling safer at school hearing less verbal harassment and experiencing less gender and sexualspecific victimization the review emphasized that mixed results were rather due to the lack of appropriate communication of policy implementation the findings in this review provided added evidence that it is insufficient just to simply have inclusive school policies rather the implementation of inclusive school policies throughout the environment and ensuring that the policy is communicated across all relevant stakeholders is key to providing effective support for lgbtq youth a whole school approach to support lgbtq youth with particular focus to subpopulations within the lgbtq acronym the fourth objective of this review was to identify areas for future research for the seven social support systems and their associations with lgbtq youth outcomes in schools the barriers and inconsistencies found to support lgbtq youth across each system merits further research to explore the nuances in each system and their relationships to lgbtq youth outcomes in school within family support there is a nuance that lie between fathers and mothers and lgbtq boys and girls indicating a need to understand the complex nature of family relationships and reasons why certain family members may provide more effective social support towards lgbtq boys or girls for gsas there needs to be further exploration to understand effective methods to overcome problems in discussing gender and sexuality in school settings due in part to the lack of school staff training and student sensitivity towards lgbtq issues different aspects of a gsa have shown different social support outcomes for lgbtq youth in schools that are hostile and unsafe positive outcomes from gsa presence and engagement dissipate highlighting the interaction between the school climate and gsas ability to be considered as an effective social support system mixed findings demonstrated an inverse relationship between gsa presence and lower sense of safety by lgbtq youth lastly though gsas were primarily conceptualized as gaystraight alliances an exploration of gendersexuality alliances can provide insight in the nuances between experiences of students from diverse sexualities and diverse genders for peer systems it is necessary to further explore reasons why peer support is either positively associated with more behavioural and emotional risks or have a lack of association this can be due to the nature of peer support as peer rumination can lead to further issues in schools rather than problemsolving discussions the nature in how peers support lgbtq peers in schools can shed light why there may be such an association another avenue of future research is the intersection of ethnicity among lgbtq youth the lack of association between peer support and positive social outcomes for racialized lgbtq youth may be a result of the interplay of other identities that require other forms of support for example lgbtq asian youth may have an increased emphasis on the importance of family and familial piety the need for racialized youth to bring pride to their family and minimize shame 68 perhaps for racialized lgbtq youth the lack of association between peer support and positive outcomes may be a result that lean towards family systems as increasingly important for such racialized youth an area of future research involves an exploration of methods to circumvent the larger sociopolitical context that limits the provision of lgbtq support via inclusive policies one possible avenue to provide lgbtq support can be under the guise of universal design for learning this framework suggests the need to support all students focusing lgbtq support under the need to support diverse students another avenue of research involves exploring an explanation for inclusive policies predicting lower perceptions of safety this may be due to the inclusive policies setting up motion to create change towards an inclusive school environment creating change however can still lead to decreased sense of safety and increased harassment issues for lgbtq youth one of the specific populations highlighted to be a key support system for lgbtq youths were educators one constructed theme involved the inconsistency in showing support through their actions several of the themes highlighted how students perceived their school staff members as being hesitant to discuss lgbtq issues by being hesitant and uncomfortable to teach lgbtq issues a norm of lgbtq silence exists in the school environment attitudes and beliefs where educators believed that homosexuality and other lgbtq topics should not be discussed in school can lead to students perceiving their school staff as uncaring and exclusive towards lgbtq youth therefore educators and other school staff members need to be comfortable and foster an inclusive attitude and belief that they are supportive of all students as shown through their actions effective actions students have mentioned include consistent intervention against lgbtqspecific harassment and opening dialogue on the importance of inclusion and acceptance when students heard lgbtqinclusive topics in their classes they felt an increased sense of safety it is therefore important to have teachers be comfortable and open to teach lgbtqinclusive curriculum to increase lgbtq youths sense of safety the findings of this scoping review indicate three primary implications for future research and application first a whole school approach was emphasized by the themes as one of the most effective ways to provide social support for lgbtq youths studies that focused on specific domains of support such as peer support or family support have similarly shown their effectiveness in supporting lgbtq youth however having all relevant stakeholders involved in the process of supporting lgbtq youth such as a whole school approach was evidently the most effective notwithstanding a collaborative whole school approach may be overly idealistic and an unrealistic approach for schools embedded in a larger more conservative environment a middle ground between realism and idealism could be attained by auctioning the gsa as a physical supportive space where students can feel safe this would be contrasted to having gsas be a space for education and activism towards an increasingly lgbtqinclusive environment in some cases the inclusion of gsa spaces within schools may mean that generally the larger school spaces are unsafe for lgbtq youth influencing the concrete actions that educational stakeholders can take to provide support and opportunities for their students second there were differences in perceived support and outcomes depending on the subpopulation of lgbtq youth highlighting the issues of generalizing the lgbtq youth population as a homogenous population for example there were different perceptions of safety and struggles between sexual orientation minority youth and gender identity minority youth for example there were unique issues of gender nonconformity for youth who did not conform to their assigned gender at birth whereas lgbq youth were faced with victimization due to their sexual orientation of note there have been a recent trend for studies reviewed between 2017 through 2021 to include trans and gender nonconforming youth as the focus beyond the lgbtq general identities as several key findings foregrounded sexual identities over gender identities future inquiries of lgbtq youth should take into consideration the specific lgbtq subgroups to be studied by researchers particularly intersectionality should be taken into consideration as issues of gender class and ability may influence how specific lgbtq students experience school supports by doing so researchers can be aware of the various intersecting sexual orientation and gender identities that lgbtq youth manage and to be inclusive of programs interventions and strategies that are intended to support lgbtq youth as a whole though the seven social support systems have been shown to effectively support lgbtq youth the inconsistencies that some articles brought up shed light with the interaction of these social support systems and their intersectional identities third there were differences in perceived support and outcomes depending on the ethnicity and race of the youths for example lgbtq eurocentric youths experienced increasing emotional and behavioral distress due to lgbtqspecific victimization whereas lgbtq racial and ethnic minority youths experienced less distress a hypothesis explaining the difference may be linked to the coping skills and resilience that the racial and ethnic minority lgbtq youths have already learned to cope in the face of racial and ethnicspecific victimization this results in more frequent use of their coping skills and a higher resilience and grit in the face of lgbtqspecific victimization and being in a school environment that is perceived to be less safe therefore future inquiry should consider the multiple intersecting minority identities lgbtq youths may have had to juggle and its effect on their perceived safety and support in their school environment particularly critically thinking through race and its impacts on the experience of school supports for lgbtq youth should be a priority for future research based on their intersectional identities and experiences in schools the seven social support systems found in this review may vary in effectiveness based on their other identities limitations this scoping review attempts to consolidate material from 2007 through early 2021 organize and respond to the four research questions of defining social support identifying the current social support outcomes for lgbtq youth the barriers and inconsistencies encountered by the social support systems and the areas for further research because of the barriers and inconsistencies found in the literature due to the scope of the review the literature search strategy was broad and resulted in a larger volume of articles though the search strategy was comprehensive consulting various experts to ensure rigidity and confidence of the search strategy a scoping review search strategy utilizes a less defined search compared to a full systematic review additionally difficulty in consolidating a comprehensive search term strategy can lead to an increasingly narrow understanding of lgbtq individuals for example no articles explored nonbinary parents or children the search strategy did not account for an intersectional understanding of lgbtq identities particularly twospirit identities as the initial search strategy was executed in 2017 twospirit identities were uncommon and subsequently not taken into consideration future reviews should include the search strategy to account for an intersectional approach to the 2slgbtq community further search strategies for lgbtq terms are difficult to standardize and capture comprehensively even though various experts were consulted to ensure confidence in the search strategy the rigidity of keywords and subheadings in article search engines can be barriers in capturing the nuances inherent to the 2slgbtq community particularly transgender and nonbinary terms were limited moving forward it would be important to implement the university of minnesotas search hedges for tgnc terms 115 as well this scoping review did not follow the required critical appraisals and risk of bias assessment found in systematic literature reviews however based on the purpose of this study a scoping review methodology was the best approach due to the wide body of literature that has not been comprehensively reviewed additionally scoping reviews are best used when the purpose is to clarify working definitions and conceptual boundaries of this topic and identify gaps in existing literature therefore though a scoping review utilizes a less defined broader search strategy resulting in a broader literature less systematic and confident compared to a full systematic review the purposes of this study and research questions align with the scoping review design conclusion there have been many studies replicating the risks that lgbtq youth experience in schools socioemotional behavioural and educational however literature exploring the positive or protective factors for lgbtq youth has been steadily increasing in the field of youth and lgbtq studies as it is still an emerging perspective to explore the protective factors for lgbtq youth through positive youth development lens this review consolidated literature and gave rise to an organizational framework to consolidate the various systems of social support for lgbtq youth in schools from the review social support consists of seven social support systems that both uniquely and in overlap are positively associated with the promotion of positive socioemotional behavioural and educational outcomes as well as the moderation of the risks typically associated with lgbtq youth in schools though the literature consistently revealed the benefits of ensuring that these seven systems are present to positively support lgbtq youths development inconsistencies and barriers in providing positive outcomes for lgbtq youth was a result of a lack of training and support for school administrators and teachers to enforce lgbtqinclusive policies and curriculum a larger sociopolitical context impeding or preventing lgbtq activism and support in schools and unique differences within the subgroups of lgbtq youth including ethnicity sex and gender identity and expression future research should explore the gaps present in this review to address the barriers and inconsistencies found to effectively provide social support for lgbtq youth across these seven systems this review highlights a positive outlook towards the available systems of social support to promote positive development for lgbtq youth though the literature has been clear surrounding the risks associated with lgbtq youth this scoping review endeavored to provide a positive outlook on lgbtq youths school experiences by highlighting how these systems of social support allow lgbtq youth to act as active participants in the promotion of a positive and safe school climate 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 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recent research has increasingly focused on positive factors and supports for lgbtq youth this scoping review explores existing social support for lgbtq youth in schools through the ecological systems theory to respond to the following four objectives 1 define social support systems in schools 2 identify current research on outcomes for lgbtq youth 3 identify barriers to support lgbtq youth in schools and 4 identify areas for future research for lgbtq youth and social support in schools a systematic search arksey and omalley in int j soc res methodol 8 1 19 20 21 22 23 24 25 26 27 28 29 30 31 32 2005 between 2007 through 2021 resulted in 94 articles this review gave rise to an organizational framework to consolidate various systems of social support for lgbtq youth in schools social support consisted of seven social support systems family curriculum family peers school policies gsas and programs and school climate that are positively associated with the promotion of positive socioemotional behavioural and educational outcomes for lgbtq youth though the literature has been clear surrounding the risks associated with lgbtq youth this scoping review provides a positive outlook on lgbtq youths school experiences and how these systems of social support allow for lgbtq youth to act as active participants to foster a positive school climate and sense of safety

introduction child malnutrition is a significant global health problem and it remains a major threat to the reduction of poverty and the achievement of sustainable development child malnutrition accounts for almost 31 million child deaths worldwide and is responsible for 45 of underfive child deaths 12 child malnutrition significantly affects early childhood cognitive development 34 it is also responsible for school absenteeism and hinders prospects of better earnings and productivity in adulthood 5 6 7 8 the consequences of malnutrition can also pass to the next generations as malnourished mothers give birth to infants who struggle to develop and thrive 9 10 11 despite the rapid improvement of social and health indicators poor maternal and child nutrition is highly prevalent in bangladesh according to recent estimates about 36 of children under five were to date some studies 222339 have documented socioeconomic inequalities in child malnutrition in bangladesh however no study has examined the extent to which the regional contexts in bangladesh may condition the ses gradient in child malnutrition to fill this gap in the literature we investigated regional variations in socioeconomic inequalities in the prevalence of stunting and underweight among children under five in bangladesh materials and methods data and samples we pooled data from two recent rounds of the bangladesh demographic and health survey conducted in 2011 and 2014 the bdhs is a nationally representative survey on maternal and child health mortality fertility family planning and nutrition it also has an extensive collection to date some studies 222339 have documented socioeconomic inequalities in child malnutrition in bangladesh however no study has examined the extent to which the regional contexts in bangladesh may condition the ses gradient in child malnutrition to fill this gap in the literature we investigated regional variations in socioeconomic inequalities in the prevalence of stunting and underweight among children under five in bangladesh materials and methods data and samples we pooled data from two recent rounds of the bangladesh demographic and health survey conducted in 2011 and 2014 the bdhs is a nationally representative survey on maternal and child health mortality fertility family planning and nutrition it also has an extensive collection to date some studies 222339 have documented socioeconomic inequalities in child malnutrition in bangladesh however no study has examined the extent to which the regional contexts in bangladesh may condition the ses gradient in child malnutrition to fill this gap in the literature we investigated regional variations in socioeconomic inequalities in the prevalence of stunting and underweight among children under five in bangladesh materials and methods data and samples we pooled data from two recent rounds of the bangladesh demographic and health survey conducted in 2011 and 2014 the bdhs is a nationally representative survey on maternal and child health mortality fertility family planning and nutrition it also has an extensive collection of sociodemographic and socioeconomic variables such as education household assets and occupation the bdhs used a multistage cluster sampling technique which allows estimations at both national and regional levels a detailed description of the survey methodology sampling design and primary finding of the bdhs is available in the national institute of population research and training report 37 we used data from the child module of all children aged 0 to 59 months the bdhs collected data from evermarried women aged 15 to 49 years and their children aged 059 months using pretested structured questionnaires the response rate in the bdhs survey was about 98 37 trained interviewers used lightweight seca digital scales and standard wooden boards to measure the weight and height of the mothers and their children 1737 recumbent length was measured for children aged 024 months and standing height was recorded for all other children the analysis excluded about 18 of the children who had incomplete or missing information on height weight and age the final analytical sample included 14602 children with complete information on anthropometric data and all other variables used in the analysis measures of child malnutrition child malnutrition is the outcome variable of this study in the bdhs child malnutrition is measured by standard anthropometric indicators of heightforage zscores and weightforage zscores as defined by the world health organization 40 stunting and underweight are the two anthropometric measures that are commonly used as a proxy for child malnutrition 41 however there is a difference between these two measures stunting is an indicator of low height by age while underweight measures low weight by age stunting is the longterm measure of child malnutrition a child is stunted or underweight if the childs haz zscore falls two standard deviations below the median of the who reference population 2240 the study used a binary indicator of stunting and underweight explanatory variables we followed previous studies to model the relationship between child malnutrition and its associated factors 4243 the explanatory variables included in this study are wealth index region of residence place of residence mothers education fathers education mothers age child characteristics and the number of living children in the household parental education was a continuous variable of completed years of schooling the bdhs does not collect data on income instead the bdhs collects a wide range of household assets and dwelling characteristics ranging from ownership of a radiotv a refrigerator farmland farming animals materials used for the construction of houses water and sanitation infrastructure and so on 4445 the bdhs constructs a wealth index variable based on the amount and type of such assets and household characteristics by applying a principal component analysis broadly pca produces a range of scores for each asset and dwelling characteristics and gives each household a summative wealth score based on its ownership of amount and type of assets the underlying assumption of the wealth index is that there is a continuum of the economic status of the households in a given country and a particular households cumulative wealth represents its relative position in such a continuum of the economic status finally the cumulative wealth scores are divided into five wealth quintiles the lowest 20 represents the lowest wealth quintile group and the highest 20 represents the highest wealth quintile group households were divided into five equal groups to produce sufficient samples and to ease the interpretation of the results the details of the methodology and statistical approach used for constructing the wealth index are described elsewhere 4445 data analysis we used multivariable logistic regression models to examine the associations of wealth index and education with two outcome variables we included interaction terms between wealth education and region in the adjusted models to assess whether associations of wealth and education with malnutrition outcomes differed by region we employed the concentration index as the summary measure of socioeconomic inequality to quantify the degree of wealthand educationrelated inequalities in stunting 46 the value of the ci ranges from 1 to 1 41 when the ci is negative it indicates a disproportionate concentration of stuntingunderweight among the children from households with low wealth and less educated mothers 43 a zero value of the ci shows no socioeconomic inequality in child malnutrition we applied wagstaffs normalization and erreygerss correction to take into account the binary nature of outcome variables in this study 4748 the analysis of regional variation in inequality was conducted using the erreygerss correction as it considers a change in the mean of the outcome variables across the studied regions 46 all the estimates were adjusted using the survey design of the bdhs which includes sampling weight strata and clusters all the statistical analyses were performed using stata software ethical approval the bangladesh demographic and health survey received ethical approval from the inner city fund macro institutional review board maryland usa and the national research ethics committee of bangladesh medical research council dhaka bangladesh each participant gave informed consent before participating in the survey the deidentified data for this study were obtained from the dhs online 49 institutional ethical approval was not necessary as the study was conducted on anonymous publicuse data which had no identifiable information on the survey respondents results table 1 presents the prevalence of stunting and underweight across the regions by household wealth quintiles and mothers education overall the proportion of stunted and underweight children was the highest in sylhet followed by barisal rates of child malnutrition were the lowest in khulna in all regions children from the poorest households had a higher prevalence of stunting and underweight for example the prevalence of stunting was about 63 in the poorest wealth quintile households while it was about 26 in the highest wealth quintile households in sylhet there was also a similar variation in the prevalence of stunting and underweight among children by mothers education for example the prevalence of underweight was 51 among the children of mothers with no education in barisal on the other hand the prevalence of underweight was about 35 among the children of mothers with no education in rangpur the prevalence of stunting was about 15 among the children of mothers with higher education while it was about 60 among children of mothers with no education in sylhet the multivariable logistic regression analysis shows a significant association between child undernutrition and wealth index children from households in higher wealth quintiles had a lower likelihood of being stunted and underweight for example the odds of being stunted was 60 lower 040 95 confidence interval 033049 among the children from the wealthiest quintile compared to the children from the poorest wealth quintile malnutrition was also significantly associated with region for example compared to khulna the odds of stunting were about 14 times as likely in barisal the likelihood of children underweight in sylhet was about 60 higher compared to khulna parental education had a negative relationship with the stunting and underweight status of children the likelihood of stunting and underweight decreased by about 15 and 9 respectively in 2014 compared to 2011 table 3 reports the estimated wealthand educationrelated inequalities in child malnutrition in bangladesh negative and statistically significant values of all the indices indicate that stunting and underweight were more concentrated among children from poorer households and lesseducated mothers figures 3 and4 present socioeconomic inequalities in child malnutrition across the seven regions of bangladesh the negative values of eis across all regions indicate a higher concentration of malnutrition among children of poor households and with lesseducated mothers the extent of inequality varied across the regions wealthrelated inequality in stunting was the highest in sylhet and the lowest in khulna wealthrelated inequality in underweight was the lowest in khulna educationrelated inequality in stunting was the highest in chittagong and the lowest in khulna similarly educationrelated inequality in underweight was the highest in chittagong and the lowest in rangpur figures 5 and6 show the eastwest divide in wealthand educationrelated child malnutrition in bangladesh figures 7 and8 depict the predicted probabilities of stunting and underweight by wealth and education across the regions nonparallel predicted probability suggests that the probability of stunting by household wealth was associated with region it shows that the probability of being a stunted child was the highest in the poorest quintile and lowest in the wealthiest quintile the predicted probability of being stunted was the highest in sylhet and the lowest in rajshahi among the children from the poorest households however this difference in the predicted probabilities almost disappeared in the wealthiest quintile in all regions the flatter predicted probability curve for khulna indicates lower wealthrelated inequality in stunting and underweight in this region compared to other regions concentration of malnutrition among children of poor households and with lesseducated mothers the extent of inequality varied across the regions wealthrelated inequality in stunting was the highest in sylhet and the lowest in khulna wealthrelated inequality in underweight was the lowest in khulna educationrelated inequality in stunting was the highest in chittagong and the lowest in khulna similarly educationrelated inequality in underweight was the highest in chittagong and the lowest in rangpur figures 5 and6 show the eastwest divide in wealthand educationrelated child malnutrition in bangladesh figures 7 and 8 depict the predicted probabilities of stunting and underweight by wealth and education across the regions nonparallel predicted probability suggests that the probability of stunting by household wealth was associated with region it shows that the probability of being a stunted child was the highest in the poorest quintile and lowest in the wealthiest quintile the predicted probability of being stunted was the highest in sylhet and the lowest in rajshahi among the children from the poorest households however this difference in the predicted probabilities almost disappeared in the wealthiest quintile in all regions the flatter predicted probability curve for khulna indicates lower wealthrelated inequality in stunting and underweight in this region compared to other regions the approximately flat predicted probability curves for the three western regions such as rangpur rajshahi and khulna show that the level of inequality was not responsive to the level of mothers education however the other eastern regions such as chittagong and sylhet the southern region barisal and the central region dhaka showed a negative association between education and child nutrition status educationrelated inequality in stunting was the highest in the sylhet region there was an inverse relationship between underweight and mothers education across the regions except for rangpur the downward predicted probabilities indicate a negative association of education with underweight sylhet had the highest level of inequality in underweight than khulna and rajshahi the approximately flat predicted probability curves for the three western regions such as rangpur rajshahi and khulna show that the level of inequality was not responsive to the level of mothers education however the other eastern regions such as chittagong and sylhet the southern region barisal and the central region dhaka showed a negative association between education and child nutrition status educationrelated inequality in stunting was the highest in the discussion this study examined socioeconomic inequalities in child malnutrition and whether these inequalities differ by subnational regions in bangladesh results suggested that stunting and underweight were more concentrated among children from poorer households and those born to lesseducated mothers in bangladesh we found significant wealthand educationrelated inequalities in child malnutrition in the northeastern and southern and eastern regions compared to other regions further there was a differential protective effect of mothers education and household wealth across the regions in bangladesh the regional differences in the effects of ses tend to diverge at the lower levels of ses and converge or attenuate at the highest levels our analysis found some notable trends in the prevalence of stunting and underweight and how they differ by the subnational regions the prevalence of stunting and underweight was disproportionately higher in southern and eastern regions including barisal chittagong and sylhet earlier studies in bangladesh also found similar regional patterns in the prevalence of stunting and underweight in particular prior studies noted that eastern and southeastern regions in bangladesh have the highest concentration of severe child wasting and stunting with the severity of wasting exceeding the who critical threshold level 34 regarding the socioeconomic inequalities in child nutritional outcomes we found a higher concentration of stunting and underweight outcomes among low ses children and these inequalities varied across the regions the highest extent of wealthbased inequality in stunting was found in sylhet for stunting and it was the higest in chittagong for underweight in contrast the lowest levels of wealthrelated inequalities in stunting and underweight were found in khulna educationrelated inequalities in stunting and underweight also varied across the regions the highest inequality in stunting was observed in sylhet and the lowest was observed in rajshahi educationrelated inequality in underweight was the highest in chittagong and the lowest in rangpur parental education and household wealth appeared to be the most robust determinants of child malnutrition outcomes in the regression analysis the findings imply that children born to parents with higher levels of education and wealth were the most advantaged in terms of having favourable nutritional status although parental ses measures are protective factors for child health in bangladesh and other developing countries 16225051 we observed considerable heterogeneity in the effects of these protective factors across the regions in bangladesh for instance the predictive probabilities computed from the adjusted models broadly demonstrated that both household wealth and mothers education are negatively associated with outcomes across the regions however regional differences in the predicted estimates of the associations of ses indicators with outcomes tend to be larger at the lowest levels of ses indicators and converge or attenuate at the highest levels these findings imply that most advantaged sections of the population had favourable child health outcomes irrespective of their region of residence the observed regional differences in our analysis fairly corroborate with a few recent studies in bangladesh and elsewhere studies in bangladesh have shown that wealthbased inequalities in health especially in maternal health and child mortality were relatively larger in the eastern and southeastern regions in comparison to the western regions in bangladesh 3852 these studies identified the spatial clustering of health disadvantages they concluded that higher inequalities in the southern and southeastern regions in bangladesh may reflect the regionspecific unique characteristics including physical remoteness lack of transportation poor road infrastructure wetland ecosystem and ethnic conflicts which have implications for access to food and healthenhancing resources 365354 similarly an analysis of five african countries has shown that although there is a strong individuallevel ses gradient in child malnutrition community ses sometimes has an independent effect 29 further community context or regional inequality in socioeconomic resources can modify the effects of individual and household ses such that community or regional context appears to be the distal precondition for the proximal individuallevel ses to render its protective effects on child health 29 5556 this study has some limitations first our findings do not allow us to infer any causal relationship between ses and child malnutrition outcomes due to the crosssectional study design second we could not control for other regional factors that could potentially shape the associations between ses and outcomes in our analysis future research may investigate the association of other structural and contextual factors such as communitylevel poverty physical and financial barriers to health facilities and an array of cultural and local contexts contributing to the regional differences in child health conclusions child malnutrition is a major public health issue in bangladesh reducing socioeconomic inequalities in child health has remained to be a critical challenge for policymakers subnational regional variation in socioeconomic inequalities in child malnutrition in bangladesh requires further public health attention understanding regional differences in socioeconomic inequalities could provide useful information to help formulate strategies to reduce social inequalities in malnutrition funding this research received no externalfunding

socioeconomic inequality in child malnutrition is wellevident in bangladesh however little is known about whether this inequality differs by regional contexts we used pooled data from the 2011 and 2014 bangladesh demographic and health survey to examine regional differences in socioeconomic inequalities in stunting and underweight among children under five the analysis included 14602 children aged 059 months we used logistic regression models and the concentration index to assess and quantify wealthand educationrelated inequalities in child malnutrition we found stunting and underweight to be more concentrated among children from poorer households and born to lesseducated mothers although the poverty level was low in the eastern regions socioeconomic inequalities were greater in these regions compared to the western regions the extent of socioeconomic inequality was the highest in sylhet and chittagong for stunting and underweight respectively while it was the lowest in khulna regression results demonstrated the protective effects of socioeconomic status ses on child malnutrition the regional differences in the effects of ses tend to diverge at the lower levels of ses while they converge or attenuate at the highest levels our findings have policy implications for developing programs and interventions targeted to reduce socioeconomic inequalities in child malnutrition in subnational regions of bangladesh

derived three replicable profiles of aspiring chapters 4 and 5 showed that profile membership predicted additional variance in wellbeing even in highly conservative tests that control for the aspirations that comprise the profiles the profiles also differed in the breadth of their care for others from profile 1 to profile 3 increasingly more others are central in the configurations of aspiring starting with the self then close others and then the world in general these studies make a unique contribution to the literature by synthesizing the available evidence and by identifying replicable latent profiles of aspiring that account for variance in wellbeing and otherorientedness over and above the constituent variables

of the royal society of new south wales various phd thesis abstracts suggests that they are not universally divergent indeed consistent unexplained heterogeneity in the results indicates there are unobserved sources of heterogeneity in the data suggesting there may be subgroups with distinct patterns of aspiring in chapter 2 of this thesis a metaanalysis of more than 1000 effect sizes showed support for the universality of goal contents theory across countries age groups and socioeconomic statuses in chapters 3 4 and 5 bifactor structural equation modelling besem was combined with latent profile analysis lpa in three large independent samples from hungary australia and the united states of america and the nigerian civil war

introduction the topic of women has been hotly debated around the world for example the rowe v wade case which has been maintained for nearly half a century was overturned by the us supreme court and trafficking and prostitution in the documentary the price of sex are all facing the danger of womens rights the miami herald website reported on september 21 2016 a 16yearold high school girl in georgia high school classroom was sexually assaulted but due to a complaint by the school classes many times the school even forced her into the process of investigation and the infringer head of the inquiry process and demonstrate suffer in the same room to suffer secondary psychological damage also in china in recent years the chinese peoples daily praised zhang guimei for setting up the first free girls school to educate girls in mountainous areas and help them take the college entrance exam to change their lives through the power of education in underdeveloped cities the proportion of educated girls will still be lower relative to the proportion of educated boys 1 the thought is still deeply rooted in the feudal there is no sense of education for children to provide more opportunities to help them improve the trajectory of life the author hopes this article will give them the strength and courage to take the first step now there is a successful representative who has achieved this daunting challenge and changed a completely different life path with practical actions it has proved that education can change peoples lives make them have the courage to believe and overcome and let more children see light and hope at the same time it can also help them provide more opportunities and platforms no longer will backward regions be treated unfairly because of ideological errors zhang guimei grew up in the environment first of all we can look at zhang guimeis growing environment she was born in mudanjiang city longjiang province since childhood the author has experienced a lot of separation my father and mother died one after another from then on the author left my hometown and started my new life journey to the death of her husband she did not dwell too much on her grief from her life experience she knew exactly what it was like to be poor and backward while still struggling with her thoughts she came up with the seemingly farfetched goal of building a free girls school that would prevent these things or tragedies from happening she didnt want something that happened to her to happen to another child there is a lot of determination and courage behind these decisions therefore a person in rather backward environmental conditions and measures of the place silently struggles to adhere to more than ten years she helped 1600 female students from poor families to get out of the mountainous areas and enter universities to experience a better life making contributions to society and the countryit seems that it is something that is not above zhang guimeis ability and she did it it is also the only free school for girls in china she serves not only as the principal but also as the mother of 172 orphans as such a woman with a disease she contributed all her energy and time 2 she is a role model for our time an icon for women through the background of zhang guimei let us better see that the power of women is very strong also when faced with a fork in the road the author hopes to choose the right side more often rather than give up the more suitable path due to setbacks or other pressures we can learn from zhang guimeis spirit of perseverance and never say die we can inspire more friends who are struggling with darkness through real cases to believe that justice will never be late there are efforts to pay and adhere to always seeing the rainbow after the rain even if the environment we grew up in is bad or not so good we should make changes believe in our own power dont give in to them easily the story of a girls school there were some serious feudal ideas in the region such as a preference for sons over daughters some families even let their children become child brides in order to lighten the burden on the family and get a fortune or food for it whether girls get good grades or not their lives seem to be set in their minds their son is the pillar of the family the hope of the family who can lead them to a better life from then on zhang guimei began to steal people with the mountain and after countless times over the mountains walking the 110000 kilometers of home textile road she once said saving one girl is equal to saving three generations the students in the mountains are too poor and bitter and so kind and sensible the author wants to help themafter a long time in august 2008 huaping girls high school was finally built she believes a girls life can be changed through education 3 in the summer of 2011 in the first college entrance examination of huaping girls high school the comprehensive online rate was 100 and the online rate of one book was 426 the result exceeded expectations among the first batch of girls to graduate many went on to work as doctors teachers traffic police trainee lawyers and so on many girls are grateful to zhang guimei teaching them selfreliance and selfrespect can change the course of their lives but zhang guimei does not want them to come back to visit her she wants them to remember how poor and difficult they came from living in and does not want them to look back after that a lot of people see that free tuition has been quite good more and more children are signing up also therefore attracted a lot of mainstream media to report causing a lot of waves on the internet zhang guimei and huaping girls school were also frequently searched more people know about her story and the existence of an unprecedented school for girls many people were worried about zhang guimeis health and the schools facilities when they found out also attracted many people to huaping girls school through media dissemination zhang guimei is at the center of public opinion in a report she also became a controversial female figure in one report she made it clear that she was disgusted at not having a job and being a housewife after graduation in her concept children who have left the mountains and come back to the family to take care of their children are likely to lose some ability and rely on their husbands for their economy its easy to get swept away by this era it was the exposure of the housewife remark that made many people question her one of them is li xinye of tsinghua university who is encouraged to disagree with these words believing that zhang guimeis own experience leads to such prejudice and opposition he thought that zhang guimei had no children of her own and did not know how to take care of them hence the heated discussion is it really a prejudice against housewives the answer is obvious no when the author understands zhang guimeis original intention to establish a girls school the author will not think like this she is facing the children in the mountainous area in the process of education and far more than the children in the city and popularization and access to things are backward therefore the concept of housewife proposed by zhang guimei is not the same as having a very good education level in a big city moreover she is strongly opposed to the idea that mountain children should lead a backward and humble life and is not willing to change their lives through education in her eyes and responsibility it is to call for more female students to study and take the college entrance examination to get more peoples attention many people will generate whether she can keep her original intention which will not change because of any wealth and honor obviously zhang guimeis action can be completed without worrying about this question every year the author personally escorted students to attend the college entrance examination accompanying them to important moments and the international conference on interdisciplinary humanities and communication studies doi 105425427537048520220440 twists in their lives she used her life to stick to the initial aspiration of the lide tree people practice the mission of educating people for the party educating people for the country the model of the times method through literature collection content comparison to find out the corresponding common ground and analysis points and the cctv interview we can learn about zhang guimei dribs and drabs mainly from the equality of men and women housewife disagreement regional education and cultural level from zhang guimeis personal experience and the founding of the girls school it is less about zhangs title and her seemingly glamorous side but more about the power of women and helping the poor teenagers views in the face of mainstream media reports many teenagers have different views and attitudes towards this issue they have their own unique views on zhang guimeis case it fits in with the new age of teenagers who are independent autonomous and aggressive the pursuit of individuality and freedom of course there are also a lot of doubts and confusion about the adherence to this allfemale school why only female students and no male students is it biased against male students and so on there are good and bad voices on the internet as well as arguments in the heated discussion the term stayathome wife brought a strong reaction and the proposal of tsinghua students also triggered a huge heated debate which lasted for some time in the social hot event maybe we will be confused and opposed by the words at the beginning maybe we will change our perspective and start to look at zhang guimeis words with different meanings for the cognition of things we need more holistic cognition and selfsubjective judgment instead of blindly following the trend join in the fun 4 so in the process of controversy is it the mainstream media intentionally or is everyones ego it can be seen that media is a doubleedged sword which can produce events in two extremes and different directions 5 therefore in this kind of environment we need more selfawareness and a certain amount of knowledge to have the ability to judge and analyze for a weak educational background most of the choices will be to go with the flow there is no free opinion and will only choose the majority of the party on the contrary some have an educational background on the basis of the development of facts and analysis combined with their own views it can be seen that in this era knowledge is extremely important and occupies a very important position and influence in society for everyone conclusion nowadays in the age of advanced science and technology openmindedness and internationalization there are still some feudal ideas about the equality of men and women think the man is to be able to compare the woman have the prospect of development more girls on the other hand do more for their families no matter where we are we should use the power of education to change some minds and teach them what gender equality is and how to achieve it not only on a biological level but also in the way we think about gender equality its about achieving gender equality in more ways than one on many levels because of some gender discrimination women suffer unfair treatment and situations we should all go lower at the same time through zhang guimeis personal experience and her spirit we should learn and carry forward therefore we can increase courses and related lectures or activities through schools to promote the development of ideas in this area especially in asia the ideology is relatively feudal because the international conference on interdisciplinary humanities and communication studies doi 105425427537048520220440 some religious beliefs and long cultural history have been left behind we should take the initiative to change this injustice so that the next generation of children because of gender inequality do not have to suffer all the blame let more women have more opportunities and platforms 6

the zhang guimei incident has had a significant social impact in recent years in 2008 the countrys first free girls school was established to guarantee education for female students later when the first female high school graduates returned to the female high school mainstream media reported on this and the controversy of housewife occurred which made zhang guimei into a controversy of public opinion and was also labeled as a rural feminist at the same time the author analyzed the survey and questionnaire methods which raised questions about why only female students were admitted to female schools and formed the concept of red education there have been two extreme reactions to the controversy some people are able to understand zhang guimei and support her while others are against her position most famously students from tsinghua university chinas top university raised objections what kind of reasons are hidden behind a controversial point which we should analyze and explore？ finally what is gender equality and whether it can be improved to increase gender awareness in education for example we can add a course and carry out related activities or speeches to promote childrens cognition and understanding and help them establish correct awareness and understanding changing the feudal ideology of son preference with the international transition the opening of the mind should end the mistakes of these old ideas

introduction migration is population movement from one country region or other place of residence to another location a substantial global literature suggests that migration is associated with increased risk for poor mental and physical health this increased risk may be related to contextual and psychosocial factors associated with the migration experience or migratory lifestyle such as adjusting to the new sociocultural environment changes in traditions and lifestyles economic transitions or barriers to access local community services including heath care previous research has also documented that the discrimination and perceived unfair treatment encountered by migrants in their new destination may cause anxiety which contributes to mental and physical illnesses the impact of actual or perceived discrimination on the health of those individuals who are the target of the discrimination and unfair treatment can be enormous discriminated individuals when compared to nondiscriminated individuals generally have an increased risk for both mental and physical health problems the cumulative effect of the stressresponse stands at the forefront when discussing discrimination and the longterm impact on a persons health the cognitive appraisal of the situation is essential to the way by which the discriminated individual reacts to the associated stress negative appraisal usually results in lower selfesteem social withdrawal depression anger frustration exclusion and feelings of inferiority however there are individuals who may actually succeed in a discriminating situation in this case individuals look upon being discriminated as a motivator to accomplish their task they use an empowering model of behavior to deal with the discrimination rather than a coping model it is living with an internal resiliency to channel energy toward the positive aspects of life and not succumb to the discrimination however the existing literature on the relationship between actual or perceived discrimination and mental health among migrants has largely been limited to migrants within north american and european countries and those seeking permanent resettlements such as transculture or transcountry immigrants and war refugees data are limited regarding the relationship between discrimination or perceived social inequity and its effect on mental health among temporary economydriven migrants in many developing countries including china which is home to onefifth of the worlds population migration from rural to urban areas was restricted in china through the official household registration system for almost a quarter century until economic reform took place in the late 1970s under the hukou system each individual is officially registered as either a rural or an urban resident rural residents were not permitted to freely move to or settle in urban areas with the introduction in 1979 of the rural household contract responsibility system a form of rural economic reform china experienced rapid growth in agricultural productivity and a subsequent surplus of rural labor concurrently rapid economic growth in urban china continuously widened the income gap between the urban and rural areas this increasing income gap has provided a strong incentive for rural residents to migrate to urban areas in search of employment opportunities and better lives consequently millions of chinese farmers have left their villages to cities forming the ruraltourban migration one of the largest internal migrations in chinas recent history according to the recent chinese governmental statistics there are approximately 2255 million ruraltourban migrants in china accounting for 31 of total rural labor and 17 of the total population in china ruraltourban migrants work or live in urban areas without official urban household registration most of these migrants come from the poor rural areas in interior provinces to form a general geographic pattern of migration from the middle and western parts of china to the eastern and costal regions where economic development was more advanced because of existing legal restrictions on employment and housing in urban areas approximately 80 of the migrants do not permanently relocate while the current magnitude of the ruraltourban migration is already substantial china is facing an anticipated increase of ruraltourban migration in the coming years because of several salient socioeconomic factors both the ruralurban income disparity and the rural labor surplus have continued to rise in china in recent years in addition the chinese government has gradually been relaxing its control on rural to urban populationmovement both central and local governments have started to relax some regulations on ruraltourban migration for example the beijing government abolished the employment restriction in 2001 and waived some mandatory fees for rural migrants in 2002 given the size of this mobile population movement and the likelihood that this process will accelerate as modernization and industrialization proceeds the mental health status of this migratory population has become a significant public health issue in china in moving from the rural to the urban context migrants also encounter a rapid change of working and living conditions a weakening of family supports and a fragmentation of their social support network that may negatively impact their wellbeing and health status even though the proportion of the ruraltourban migrants is substantial and it is well recognized that these migrants are experiencing substantial statusbased discrimination in their daily lives in cities little data are available regarding the association of their discrimination experience and perceived social inequity with mental health status among these chinese migrants therefore the current study utilizing data from 1006 rural migrants in beijing was designed to examine the discrimination and perceived social inequity and their relationship with mental health problems among rural migrants in china method participants and sampling procedures the data used in this analysis were derived from a larger comparative study on mental health among the chinese population the ruraltourban migrant sample was recruited in beijing in 20042005 beijing is the capital city of china with a permanent population of 13 million according to governmental statistics there were more than 3 million ruraltourban migrants in beijing in 2003 and the majority of them were between 18 and 40 years of age the ruraltourban migrant sample was recruited in beijing using the occupational clusterbased quota sampling scheme to ensure the representative nature of the migrant sample according to 2003 beijing government statistics of migrant employment five occupational clusters employed 82 of the ruraltourban migrants in beijing these five occupational clusters were selected as the sampling frame for ruraltourban migrants in the current study the number of participants recruited in each occupational cluster was approximately proportionate to the overall estimated distribution of migrants in the cluster in addition the sampling was also stratified by gender to match the overall gender distribution of the migrant population in beijing the eligibility criteria for participation in the study included between 18 and 40 years of age born in a rural area and registered as a permanent rural resident worked in beijing without a permanent beijing residence had been physically present in beijing for at least 1 month the local research teams used workplaces as the sampling units streets were used as the sampling units for migrants who did not have fixed workplaces once a sampling unit was identified and selected according to the preestablished sampling scheme employers at the sampling unit were contacted for permission to conduct the survey on their premises a total of 38 sampling units were approached and 34 agreed to participate upon receiving permission the interviewers randomly approached eligible ruraltourban migrants in the sampling unit this process was repeated until target numbers of sampling units or numbers of participants in each sampling stratum were reached to prevent oversampling of migrants from any single sampling unit the number of migrants recruited from any unit was limited to 50 this sampling process yielded a final sample of 1006 ruraltourban migrant workers from the 34 sampling units these sampling units stratified by occupational cluster spread across 10 large geographic locations in two central urban districts two near suburban districts and two outer suburban districtscounties in beijing survey procedures once an eligible individual was identified in a sampling unit trained interviewers provided the individual with a detailed description of the study design and the consenting procedure and invited herhim to participate in the survey a total of 1020 individuals were approached and 14 of them refused to participate eligible individuals who agreed to participate and provided written informed consents were asked to complete a selfadministered anonymous questionnaire questionnaires were pilottested for comprehension and appropriateness of language prior to administration it typically took about 45 min to complete the survey participants completed the survey individually or in a small group at workplaces homes or other locations preferred by the participants for a few participants with limited literacy interviewers read questions to them and the participants gave oral responses to the interviewers who recorded the responses in questionnaires during the survey necessary clarification or instruction was provided promptly to the participants when needed no identifiable personal information was collected from the participants each participant was provided with a small monetary incentive as a token of appreciation for their participation the study protocol was approved by the institutional review boards at wayne state university in the united states and beijing normal university in china measures demographic characteristicsparticipants age gender ethnicity education level and marital status were collected because of small frequencies in some categories of education and marital status measures responses were grouped into three categories for education and two categories for marital status in bivariate or multivariate analysis because only 3 of participants were nonhan ethnicities these ethnic groups were collapsed into a single category participants were also asked to selfrate their overall health status on a 5point scale due to the low frequency in very poor category the response was grouped into four categories poor fair good and very good with a higher score indicating a better health status all participants were asked about their average monthly income discrimination experiencethe questionnaire contains 20 items assessing discriminatory acts or unfair treatment experienced or perceived by participants during their work and life all items were presented on a 4point scale the internal consistency estimate of the scale was 88 for the current study sample perceived social inequity the questionnaire contains 18 items to measure psi among participants in areas such as social prejudice and exclusion these items were culturally adapted from a published scale all items were presented on a 4point scale the internal consistency estimate was 78 for the current study sample mental health symptomsthe participants mental health symptoms during the most recent 7 days were measured with the symptom checklist90 the scl90 is a selfreport multidimensional inventory designed to screen for a broad range of psychological problems and symptoms of psychopathology the scl90 has nine primary symptom dimensions and a subscale of seven additional items the scale originally developed for assessment of symptomatic behavior of psychiatric outpatients has been used with a variety of populations from nonpatient normal population to medical patients or individual with psychiatric disorders and has been translated into numerous languages including chinese within the chinese population the scl90 has been used to assess mental health symptoms or trauma symptoms among community sample nurses women undergoing an early abortion adolescents patients of functional dyspepsia unemployed workers and migrant workers the internal consistency estimates of the 10 subscales ranged from 70 to 87 for the current study sample statistical analysis descriptive statistics were employed to examine the pattern of missing data and distributional property of the main study variables because of the relatively small amount of missing data no imputation procedures were employed to treat the missing data the calculation of the composite scores and various statistical procedures were performed based on available data the mean scores were employed as composite scores for main study variables to minimize the potential effect of missing data while most of the main study variables were negatively skewed their deviation from the normal distribution remain mild therefore no attempts were made to improve the distributional properties given that all the statistical procedures employed in the current study were robust when mild violation of distributional normality is present the following analytic approaches were further employed to achieve the research objective in the current study first analysis of variance was employed to assess the association between demographic characteristics and discrimination and psi measures second pearson product moment correlation coefficient was employed to assess the association between discrimination and psi and mental health symptoms third multivariate analysis using general linear model was employed to assess the association of mental health symptoms with discrimination and psi measures controlling for potential confounders because of the conceptual differences between discrimination and psi and also the high positive correlation between the two scales we conducted two glm analyses separately for the discrimination and psi to use discrimination and psi measures as betweensubjects factors in anova analysis both measures were categorized into three groups using the 25th and 75th percentile of the responses as cutoffs age gender and other demographic characteristics that were significantly associated with discrimination or psi were included in the glm as either additional betweensubjects factor variables or covariates all covariates were entered into the glm analyses as continuous variables in their original measurement metrics results sociodemographic characteristics the sociodemographic characteristics of 1006 rural migrants are shown in table 1 nearly twothirds of the participants were male the mean age of the sample was about 2539 years the average monthly income was 980 yuan equivalent to us 120 at the time of survey the majority was han ethnicity seventytwo percent of the participants had received no more than middle school education about 61 had never been married more than twothirds of the sample reported very good or good health male and female migrants significantly differed on most of the demographic characteristics with male migrants being older and making more money than females in addition more male migrants were of han ethnicity and being married at least once more male migrants than female migrants reported having very good health demographic correlates of discrimination and psi as shown in table 2 male migrants reported a higher level of discrimination and psi than female migrants although only the difference in discrimination reached statistical significance discrimination was increased with age and younger migrants and older migrants reported a higher level of psi than the middle age group albeit neither of the trends was statistically significant migrants who married at least once reported a significantly higher level of discrimination than single migrants although both groups reported similar levels of psi health status was negatively associated with both discrimination and psi in a linear fashion with poorer health status being associated with high discrimination and psi education attainment was negatively associated with psi with lower education being associated with higher psi but not with discrimination length of migration was positively associated with discrimination but not with psi monthly income was significantly associated with discrimination and psi but only the association with psi showed a negatively linear trend further test using anova revealed a significant quadratic relationship between discrimination and income migrants whose incomes were in the middle range of the sample reported the highest level of discrimination mental health symptoms and discrimination and psi the pearson correlation coefficients between scl90 subscales and discrimination and psi are shown in table 3 the pearson r with scl90 subscales ranged from 24 to 33 for discrimination and from 17 to 25 for psi and all correlation coefficients were statistically significant table 4 depicts the glm results for association between mental health and discrimination controlling for age gender marital status health status length of migration and personal income discrimination was a significant factor in multivariate test and univariate tests for all scl90 subscales in addition gender was a significant factor in multivariate test and univariate tests for depression anxiety and phobic anxiety marital status was a significant factor in univariate tests for interpersonal sensitivity depression anxiety psychoticism and additional items there were no multivariate or univariate significant 2way or 3way interaction terms except genderbymarital status interaction that was significant for additional items subscale among the covariates age was significant in multivariate test and univariate tests for hostility and phobic anxiety selfreported health status showed significance in multivariate test and univariate tests for all scl90 subscales personal income was only significant in univariate test for depression length of migration was not a significant covariate in either multivariate test or any of the univariate tests the glm results for psi are shown in table 5 after controlling for gender age health status education attainment and personal income psi was a significant factor in multivariate test and univariate tests for all scl90 subscales gender was a significant factor in multivariate test and univariate tests for phobic anxiety paranoid ideation and psychoticism the 2way interaction between psi and gender did not show significance in multivariate test but was significant in univariate tests for all scl90 subscales except somatization among the covariates age was significant in multivariate test and univeriate tests for all scl90 subscales except somatization selfreported health status was a significant covariate for multivariate test and univariate tests for all scl90 subscales education attainment was a significant covariate for multivariate test and all scl90 subscales except the hostility personal income was only a significant covariate in univariate test for depression discussion data in the present study confirm and expand the findings from earlier studies consistent with previous research our study found a high level discrimination experience and psi among rural migrants in urban china migrants might be stigmatized in cities because of their attributes the common images of rural migrants created by the media were poor dirty ignorant and prone to violence in addition rural migrants were frequently blamed for the increasing crime rates and social instability in the cities consistent with the existing literature our results provide strong evidence that experience of discrimination in daily life and perceived social inequity are negatively associated with mental health experience of discrimination in daily life may create and enhance the perception of social inequity both discriminatory experience and psi may lower migrants selfesteem and self efficacy cause migrants feelings of inferiority depression frustration and social exclusion which in turn result in psychological problems among ruraltourban migrants inconsistent with prevailing findings in the literature we found that male migrants on average perceived a higher level of discrimination and social inequity in the urban areas than female migrants one reason for this gender difference in discrimination and social inequity among chinese migrants might be due to the fact that men usually take major responsibility for all aspects of their family life in china and are more likely to be discriminated against by urban dwellers and communities through their experiences in search for jobs and other social activities therefore compared with women there are more chances for men to be discriminated or unfairly treated in addition selfreport health status was negatively associated with both discrimination and psi migrants with a better selfreport health status perceived lower social inequity and discrimination one possible reason is that the healthier migrants might be more empowered to deal with the difficulties and stress and to adjust themselves to urban environment alternatively discrimination and psi might also have some negative impact on migrants physical health there are some potential limitations in this study first despite the efforts to ensure the representativeness of the samples our study sample remains a convenience sample of ruraltourban migrants from a single metropolis in china which limits our ability to generalize our findings to migrants from other areas of china second crosssectional data in the current study prevent causal interpretation of the findings a longitudinal research is needed to explore the causal relationship between discrimination and psi and mental health third because discrimination psi and mental health were assessed with a selfadministered questionnaire and therefore the data might be subject to socially desirable response and selfreporting bias regardless of these potential limitations this study represents one of the first efforts to examine the relationship between discriminationpsi and mental health status among ruraltourban migrants using validated scales among communitybased samples in china the results from this study have significant implications for health promotion programs to improve the mental health status of ruraltourban migrants first migrants make a major contribution to chinas industrial development and economic growth in the past decades however their contributions are not well recognized by the public they are frequently marginalized in urban areas and are targets of discrimination future interventions should seek to improve public attitudes toward ruraltourban migrants and generate actions to eliminate discrimination and social inequity second the government and legislature should eliminate structural barriers for migrants to fully benefit from the urban economic development third migrants poor workingliving conditions and insufficient social support may affect their psychological wellbeing thus the government and concerned organizations should seek to improve living conditions and social support for young migrant workers fourth the present study has shown that migrants with low socioeconomic status perceived higher levels of social inequity this might be the result of limited job opportunities for these migrants in urban areas future stigmareduction efforts need to help these migrants to learn or improve necessary occupational skills before or during migration finally the future health promotion efforts need to help migrants in urban areas to actively cope with various unsatisfactory or even stressful life experiences to alleviate the negative effect of these experiences on their mental health and other aspects of their migratory life

statusbased discrimination and inequity have been associated with the process of migration especially with economicsdriven internal migration however their association with mental health among economydriven internal migrants in developing countries is rarely assessed this study examines discriminatory experiences and perceived social inequity in relation to mental health status among ruraltourban migrants in china crosssectional data were collected from 1006 ruraltourban migrants in 20042005 in beijing china participants reported their perceptions and experiences of being discriminated in daily life in urban destination and perceived social inequity mental health was measured using the symptom checklist90 scl90 multivariate analyses using general linear model were performed to test the effect of discriminatory experience and perceived social inequity on mental health experience of discrimination was positively associated with male gender being married at least once poorer health status shorter duration of migration and middle range of personal income likewise perceived social inequity was associated with poorer health status higher education attainment and lower personal income multivariate analyses indicate that both experience of discrimination and perceived social inequity were strongly associated with mental health problems of ruralto

introduction social determinants that contribute to health inequality such as educational background economic status and occupational class have received a lot of attention housing tenure is also considered one of the important factors in determining health 1 2 3 the association between ht and health has been studied in many countries and many previous studies have reported that owneroccupiers have better health than people who live in privately rented or publically subsidized housing 4 5 6 7 8 9 10 11 12 although ht can be taken as a surrogate indicator of social class and wealth 6 whether or not the association between ht and health is independent of socioeconomic indicators may vary across countries 51011 first htrelated factors such as home ownership rate household preferences and housing administration policies vary depending on the country 101113 according to a report by the oecd 14 in 2016 on average 69 of households across the oecd owned a dwelling compared to 26 of households who rented a dwelling although owning a home is the most common form of housing switzerland and germany have a majority of renters regarding housing policies most oecd countries have a system of social rental housing but the size of the social housing stock differs from country to country the netherlands austria denmark france and the united kingdom have a high rate of social housing stock accounting for 15 or more of the total housing stock in japan 80 of households own their dwelling placing japan fifth highest in the oecd ranking of ownership rates however japan has a low rate of social housing stock comprising about 5 of the total housing stock inadequate housing policies may increase the proportion of economically vulnerable people living in lowrent and poorlymaintained accommodation in the private rental sector this could have adverse health effects due to financial stress and difficulties affording health care 3 second japan has among the highest proportion of older adults aged 65 and older in the world 15 because older people tend to spend most of their time at home and are vulnerable to barriers and problems of the home environment 16 japanese people may be more exposed to health risks associated with their own home furthermore previous studies suggest that the housinghealth association can be partly explained by neighborhood environments 1718 a crossnational research study in china japan and south korea has reported that the association between neighborhood social environment and selfrated health is strongest in japan 17 japanese culture is greatly influenced by confucian ideals where harmony among people is to be valued japanese people may tend to place emphasis on neighborly ties and therefore their health may be more affected by their neighborhood social environment based on these assumptions the hthealth association may be stronger in japan than in other countries therefore we hypothesize that ht is significantly related to the health status of japanese people independent of other socioeconomic factors such as education expenditure and occupation selfrated health is a subjective indicator of current general health which contains diverse aspects of health including physical and mental health wellbeing and life satisfaction to use the anonymous data in accordance with article 36 of the statistics law of japan 19 additionally srh which is frequently used in international comparative statistics 20 and epidemiological studies has been established as an independent predictor not only of mortality in general populations 21 and young adulthood 22 but also of functional decline in communitydwelling older adults 23 therefore srh is a crucial health outcome in nationally representative health surveys previous studies on ht and srh mostly focus on two categories of ht such as home ownership and rental 4710 or owneroccupiers and social renters 5 to the best of our knowledge no studies have examined the association between detailed types of ht and srh in japan therefore in this study we used anonymized data from a nationwide crosssectional survey targeted at households and household members throughout the country and investigated the following study questions 1 whether ht classified into five small groups is associated with srh among the general japanese population 2 whether this association is independent of demographic characteristics and socioeconomic status factors and 3 whether the relationship with ht and srh varies depending on social demographic attributes materials and methods data the data source in this study is based on the 2010 comprehensive survey of living conditions conducted by the ministry of health labour and welfare of japan the details of the 2010 cslc are explained elsewhere 24 briefly the cslc covers households and their membership throughout japan and has been carried out annually for the purpose of collecting basic data for the promotion of national health and social welfare a largescale survey is implemented every 3 years in other years smallerscale surveys are conducted with simplified questionnaires leaving out healthrelated questions such as srh in january 2018 when we received the cslc data from the ministry of health labour and welfare the 2010 data was the latest information provided for the 2010 cslc survey slips were distributed to all households in 5510 stratified random sampling districts on june 3 and collected from 229785 households we got permission to use this data for academic research in accordance with the statistics act article 36 and accepted an offer of anonymized data anonymized data were scrubbed of information that had the possibility of revealing personal identity not only personal information such as name and birthdates but also regional information such as prefectural names in addition anonymized data eliminated rare households such as singlemaleparent households and families who had a large age difference between husband and wife because including these households might lead to identification of individuals after rare households were excluded individuals from the anonymized data were randomly selected we were provided finally with anonymized data from 93730 people in 36387 households the reduced size equivalent to that of smallerscale surveys people with adl disability were excluded from our analyses because they have high potential for reverse causation adl disability may be a cause of some renters requiring publically subsidized housing 5 additionally people in a hospitalfacility and minors under twenty years of age were not required respond to questions about health status and lifestyle factors such as smoking and drinking therefore we excluded 33946 persons from our analyses because of being aged 20 being in a hospitalfacility having received longterm care needing certification having a selfreported adl disability and missing data on age hospital admission adl ht household crowding andor srh eventually we restricted our analyses to the data of 59784 persons of 20 years or older without adl disability whose ht household crowding and srh were available individuals excluded from this study due to missing information were older than those included in our analyses but there was no gender difference between the two groups study participants measurements housing tenure the cslc included the following question which type of housing do you live in participants were asked to select 1 of 5 choices ones own house privately rented housing provided housing publically subsidized housing and rented rooms and other according to the explanation of the terms used in the cslc 25 provided housing is defined as company housing and housing for national public employees and local government officers while rented rooms are defined as rented accommodation which is part of a dwelling where other households live based on this definition ht was classified into five groups owneroccupied privately rented provided housing publically subsidized and rented rooms selfrated health srh has been used as an effective indicator of overall health status not only in japan 23 26 27 28 but also worldwide 102930 this study assessed srh by a single item how is your health in general is it very good good fair poor very poor the oecd health statistics 15 has recommended this as a standard form of question about perceived health status and showed that the rate of people who report their health as good or better is very low in japan about 30 in 2011 compared to about 70 on average in the oecd and about 90 in the united states new zealand and canada one reason why japan has a low rate of people reporting to be in good health is that japanese people have a tendency to avoid giving a direct answer and like moderation with the result that in responses to questionnaires there is a marked tendency to concentrate on a midpoint 31 therefore although the oecd health statistics has considered people rating their health to good or very good as those who are in good health japanese epidemiological surveys have commonly adopted the definition of good health as including the middle scale of srh 26 27 28 in this study persons whose responses were very good good and fair were defined as having good srh and poor and very poor as having poor srh other housing information the questionnaire asked all participants about the number of rooms in their dwelling excluding entrance halls and bathrooms with reference to previous studies 410 household crowding is defined by the number of people in a family divided by the number of rooms using the median of household crowding participants were dichotomized into low and high covariates with reference to previous studies on housing and health 4 5 6 7 8 9 10 11 12 13 the following variables were adopted as essential andor potential covariates demographic factors and ses factors age was classified into 2034 years 3549 years 5064 years 6574 years and �75 years chronic medical conditions were defined as persons with at least one disease under treatment for hypertension diabetes mellitus cerebrovascular disease heart disease or cancer educational attainment was categorized into university high school and junior high school the cslc asked all households about their monthly household expenditures with the following accompanying explanation household expenditures are defined as the total amount of money spent by all members of the household during may 2010 which includes costs of food and drink housing utilities clothing healthcare education entertainment and family occasions such as marriages etc but exclude taxes social insurance premiums savings debtmortgage repayment and lifenonlife insurance premiums other than insurance with no refund payment 25 equivalent household expenditures were calculated as monthly household expenditures divided by the square root of the number of people per household 26 using ehe tertiles respondents were divided into high moderate and low regarding occupation respondents were asked about their working status in the last month additionally persons with a job were asked about their occupation based on the japan standard occupational classification 32 which is compatible with the international standard classification of occupations according to these two questions participants were grouped into four classes upper nonmanual lower nonmanual manual and nonworking 33 in considering missing values in response to questions we used missing category of covariates in the multivariable statistical models 34 characteristics of study participants including the number of missing values are provided in s2 table statistical analysis multiple logistic regression analysis was carried out using poor srh or good srh as a dependent variable independent variables were the five types of ht with owneroccupied housing as the reference group the results were shown as an odds ratio with a 95 confidence interval for poor srh model 1 was adjusted for age and gender model 2 was adjusted for all demographic factors model 3 was adjusted for ses factors in addition to adjustment for the variables in model 2 there was a high correlation between ht and household crowding to avoid the issue of multicollinearity we abandoned the use of household crowding as a covariate and considered the association between household crowding and poor srh according to type of ht all statistical analyses were performed using ibm spss statistics version 240 and the significance threshold was set at p 005 ethics in this study we received approval of use for academic purposes from the japanese ministry of health labour and welfare and were provided data without any information that would identify individuals results participant characteristics of the 59784 participants 241 were older adults aged 65 years or older 479 were men 759 were owner occupiers and 146 reported poor srh table 1 shows the characteristics of study participants by ht status owneroccupiers were more likely to be aged 65 years and older and have chronic medical conditions and less likely to be current smokers and live in crowded houses and private renters had the second highest tobacco use because a large number of people living in provided housing live apart from their family at the new workplace they had the highest percentage of the married males and upper nonmanual workers the second highest percentage of persons living alone and the lowest percentage of persons aged 65 or older and those who had a low level of education publically subsidized renters tended to have junior high school education live in crowded homes and report poor srh and those living in rented rooms were more likely to be current smokers and have a low ehe crosssectional association between ht and srh the ors for poor srh associated with ht are presented in table 2 publically subsidized renters had a significantly higher prevalence of poor srh this significant relationship persisted after adjustment for demographic factors and ses factors persons living in provided housing were less likely to have poor shr than owneroccupiers however after adjustment for age and gender this association did not remain significant adjusted or was 111 in model 1 and 112 in model 3 in contrast in the crude model private renters and persons inhabiting rented rooms showed no association with poor srh relative to owneroccupiers after adjustment for age and gender private renters and residents in rented rooms were more likely to have poor srh than owneroccupiers these significant associations were unchanged after adjustment for ses factors as well as demographic factors adjusted or was 136 in private renters and 141 in residents in rented rooms given that nine out of every ten people in this study had more than one member in their household there was a possibility that we had the violation of the independence assumption in the association between ht and srh to address this concern we conducted subset analyses limited to the head of the household the results did not change significantly with the subset analyses in model 3 adjusted or was 146 in private renters 143 in publically subsidized renters and 135 in residents in rented rooms compared to owneroccupiers consideration of household crowding the association between household crowding and srh by ht is shown in table 3 in the crude model a significantly lower or for household crowding of having poor srh compared with noncrowded homes was found in owneroccupiers private renters and publically subsidized renters after adjustment for age and gender significant associations in private renters and publically subsidized renters disappeared after adjustment for all demographic factors owneroccupiers had no association between household crowding and srh in contrast for those living in rented rooms household crowding was not associated additional stratified analyses we conducted further stratified analyses by age gender chronic medical conditions and ses factors because these variables can affect the association between ht and srh 4 5 6 7 262835 ht had a greater impact on shr for persons aged 45 or older than for those aged 2044 and for women than for men chronic medical conditions did not affect the association between ht and srh regarding education the lower level the participants had the more their srh was affected by ht ehe had only a slight influence on the association between ht and srh for occupation among upper nonmanual workers ht had no effect on srh the association between ht and poor srh was the strongest in nonworking people generally these results indicated that the htsrh association was stronger in the socially disadvantaged than in the higher socioeconomic group discussion our study found that publically subsidized renters tended to have significantly poorer srh than owneroccupiers independent of demographic and ses factors this result supports our hypothesis as well as agrees with the results of previous studies on ht and health in nonjapanese countries 4 5 6 7 1012 additionally we have revealed that not only residents in publically subsidized housing but also those in other types of ht had a significantly worse srh than owneroccupiers our results based on stratified analyses showed that ht status had a greater association with poor srh among people with weaker social positions than those with a higher level of sociodemographic status our findings are consistent with those of previous studies 11135 which suggest that housing environment exerts a greater impact on the health of vulnerable groups such as ethnic minorities older adults and the unemployed than the socially advantaged the association between ht and srh may be explained by three mechanisms housing circumstances health behaviors and the neighborhood first previous studies suggest that the housing environment of vulnerable groups tends to be crowded due to a large number of people living in a limited area unsanitary living conditions due to inadequate garbage and sewage treatment bad air with harmful chemical substances and poor ventilation and poor hygrothermal conditions such as warmth and humidity 336 crowding and poor air quality can cause respiratory disease and communicable diseases a polluted water supply can spread waterborne diseases and cold homes can elevate the risk for cardiovascular diseases and poor mental health 3637 in japan because universal access to a clean water supply and an effective sanitation system has improved the level of public hygiene unsanitary living conditions may not be an issue nowadays however because japan has a high death toll during the winter months 38 excess cold in the home is an ongoing problem in japan people with financial difficulties may not be able to afford adequate heating with consequent negative impact on their health in this study among persons living in rented rooms household crowding was associated with srh our results suggest that people living in rented rooms may be exposed to more hazards in the home environment than people living in other types of ht for example persons inhabiting crowded rented rooms seem likely to face the risk of intruders and excess noise these conditions together with crowding in housing are considered as psychological hazards relating to housing and could lead to increased risk of illness 37 second previous studies have reported that the social housing group tend to have a lower level of physical activity and a higher prevalence of obesity than those in other housing sectors 39 and that house owners are more likely to have regular medical checkups 40 and to be nonsmokers 11 than persons without house ownership they indicate that the positive health effect of house ownership may be the result of healthy lifestyle and active healthy behaviors among owneroccupiers these findings from previous studies agree with our results showing that among the five types of ht house owners have the lowest rate of current smokers third the neighborhood environment of dwellings in the publically rented sector is often characterized by poor access to recreational facilities shops public transport social support networks and health services 639 a neighborhood environment that discourages physical activity and health care may affect health behaviors and the health of residents 3 on the other hand research has shown that people living in a neighborhood with more sportsrecreational facilities more walkable green spaces and more people who practice healthy lifestyles such as choosing healthy foods and doing active physical exercise are more likely to report being in good health 41 42 43 44 the communities with a high homeownership rate are considered to have a healthy neighborhood 11 which promotes the health of house owners our study has several strengths first this study is based on nationally representative data therefore we have the advantage of generalization and have been able to examine the srhassociation based on five categories of ht second the cslc collects a large number of sociodemographic indicators such as marital status chronic medical conditions education and occupation the use of many covariates in this study makes the validity of the results a strong point our study has several limitations first we cannot omit the effect of reverse causation due to crosssectional design in particular we should consider the fact that health problems can trigger unemployment and loss of stable employment 545 as a result people may end up in poverty and need to sell their houses in this case poor health status is not attributed to housing environment however it is highly likely that residents in privately rented residences publically subsidized housing and rented rooms who relocate due to health issues will have poor srh second our results are based on selfassessment therefore we have the possibility of problems with common method variance and an overestimation between ht and srh 46 future studies are needed to confirm the association between ht and health using an objective assessment of health based on a prospective study design third anonymized data eliminated the rare households in order to prevent identification of individuals and our study failed to include persons with missing data the former ruled out social minorities and the latter resulted in selective loss of older people that is persons omitted from our study are vulnerable groups and potentially have poor health and poor housing this bias might lead to an underestimation of the association between ht and srh in this study conclusions this study has revealed a significant association between ht and srh in japan independent of ses factors and demographic characteristics the japanese government has adopted reduction of health disparities as one of the main target objectives for the national health promotion plan health japan 21 47 for a better understanding of disparities in health status among the japanese our findings suggest that ht is an important factor that deserves notice from a policy perspective policymakers need to pay more attention to ht as a social determinant that contributes to health inequality in japan supporting information s1

many studies have reported that housing tenure ht is associated with health but little is known about its association in japan we investigated the crosssectional association between ht and selfrated health srh among japanese adults taking demographic characteristics and socioeconomic status ses into considerationwe used data from a nationally representative survey conducted by the japanese ministry of health labour and welfare 28641 men and 31143 women aged �20 years ht was divided into five categories owneroccupied privately rented provided housing publically subsidized and rented rooms srh was evaluated using a singleitem inventory and dichotomized into poor very poorpoor and good very goodgoodfair we calculated adjusted odds ratios or and their 95 confidence intervals ci for poor srh with logistic regression models covariates included demographic factors ie age gender marital status family size smoking status and chronic medical conditions and ses factors ie education equivalent household expenditures and occupation among analyzed participants 759 were owneroccupiers and 146 reported poor srh after adjustment for all covariates compared with owneroccupiers private renters or 136 95 ci 126147 publically subsidized renters or 133 95 ci 119148 and residents in rented rooms or 141 95 ci 122162 were more likely to report poor srh stratified analyses by ses factors showed that the association between ht and poor srh was stronger in the socially disadvantaged than in the higher socioeconomic group

introduction locationbased social networks are massively used these days and some of the data generated by users on those systems represent relevant characteristics of urban environments thus lbsns can be seen as a source of social sensing and their data enables new research opportunities 1234 for example foursquare1 one of the most popular examples of lbsns allows users to share visited locations providing unprecedented opportunities for the large scale study of urban societies 4 the tourism activity not only contributes to creating more businesses but also generates more revenues employment and development 5 with that its development is a strategic action for a sustainable development tourists while in a different city may have different desires from those in their typical routines besides various factors such as distance and personal preferences play an important role in the activities tourists chose to perform thus to understand the behavioral patterns of tourists is a fundamental step to enable improvements in the tourism activity 5 one particular behavior that is underexplored in previous studies is the mobility 67 understanding how tourists move through time and space and the factors that influence their movements have important implications in several segments ranging from transport development to destination planning despite some efforts in the area very few studies have attempted to model the actual movement patterns of tourists on a large scale 89 in this work we study how we can use data shared by lbsn users the socalled checkins to better understand the mobility of tourists that would be difficult using traditional methods such as surveys checkin is an action performed by a user to register and share hisher location at any given time it is a voluntary contribution provided by the user that allows the study of human behavior at different granularities leading to a better understanding of urban areas such as the identification of popular places we consider the spatiotemporal aspects of the behavior of tourists and residents spatial aspects refer to the distinct types of places available in urban areas it is essential to analyze this dimension because for example the number of checkins at a given location may vary according to its popularity and category temporal patterns are related to events that occur at specific time intervals this is also another important dimension since users behavior may vary for example during different periods of the day the joint treatment of these two dimensions is essential for a better understanding of users behavior and the dynamics of the city where a given person is located the main objective of this work is to investigate if and how lbsn checkins specifically from foursquare can be used to study the mobility behavior of tourists to that end a fundamental step is to evaluate the potential of using foursquare data to extract useful properties of the behavior of tourists and residents in a city we show that we can have the opportunity to go one step forward in the understanding of tourists mobility identifying where and when places are more important to users in different cities based on data from foursquare we characterize the behavior of tourists and residents showing for instance their preferences and routines in four popular cities around the world london new york rio de janeiro and tokyo besides that we perform a largescale study of tourists mobility considering several aspects for example we use a spatiotemporal graph model to study the urban mobility of tourists of the studied cities we show that it is possible to find popular transitions among tourists and typical times that tourists visit certain places this model also allows the identification of central places regarding tourist mobility and how they could be explored to evolve the urban computing area in addition we propose a new approach based on a topic model that enables the automatic identification of mobility pattern themes which ultimately lead to a better understanding of the profile of users the remainder of this work is organized as follows section 2 presents and discusses the related work section 3 presents our dataset and the approach we used to identify tourists section 4 presents the behavioral properties of residents and tourists in distinct cities worldwide section 5 studies the mobility of tourists section 6 studies the behavior of tourists by looking at centrality metrics of spatiotemporal urban mobility graphs section 7 uncovers profiles of tourists based on mobility patterns section 8 discusses some of the potential applicabilities of our results and some of their main limitations finally section 9 concludes this study and discusses some future directions related work we divided the related studies into four groups mobility studies with traditional data such as gps traces proposals that study mobility with social data such as data from lbsn studies that focus specifically on the understanding of the mobility of tourists and applications based on tourist mobility studying mobility through traditional data human mobility is a fundamental aspect of cities and is the object of study of several areas such as anthropology geography and biology one possible approach to perform this type of study is to explore digital traces from users such as gps traces in the literature we can find studies about users routines and habits in urban areas using digital traces some of them analyzed gps data and cell phone signals of users to understand for instance their typical trajectories 1011 as an example an et al 12 developed a method for measuring urban recurrent congestion evolution based on mobility data of gpsequipped vehicles other examples include 1113141516 however only the spatial dimension may not be enough to understand the user context at that time karamshuk et al 13 point out that human movements are highly predictable but it is crucial to take into account regular spatial and temporal patterns gathering traditional mobility data such as gps traces is difficult for this reason the investigation and exploration of alternative sources are important studying mobility through social data by using gps records and cell phone signals it is possible to understand with reasonable accuracy the path often performed by users however there is evidence that this type of study is also possible using data from social media 171819 several studies used social media data such as checkins from foursquare to understand various aspects of urban social behavior including mobility 1192181732021 in this direction machado et al 20 observed an impact of mobility of users seen through foursquare checkins according to distinct weather conditions wang et al 21 studied the correlation between the social relationship among users observed in the social network and the spatial mobility patterns they explored data from gowalla and brightkite 2 cheng et al 1 used 22 million checkins shared on twitter 3 to study mobility patterns showing that users adopt periodic behavior and are influenced by their social geographical and economic status in the same direction pianese et al 19 were able to identify patterns in days and times regarding the activities performed by users and explored this information to discover communities and places of interest also preo and cohn 18 showed a possible approach to identify profiles of user behaviors nevertheless finding useful patterns from social media data brings nontrivial challenges since there is an irregularity in the distribution of data over time among users 19 mobility of tourists and residents tourism is one of the main economic activities that promote regional development 5 for instance the people displacement of their place of residence to a different one where there might be a meeting of new cultures and the search for 2 gowalla and brightkite are out of operation but there are public data from these systems on the web despite the efforts in understanding urban mobility mentioned in sections 21 and 22 few studies investigated urban tourist mobility in large scale 67 zheng et al 8 analyzed 107 gps logs of users over one year they concluded that the movement of tourists and residents is different and tourists behavior is influenced by their traveling experience and their relationships some proposals consider data from social media data for example silva et al 22 showed how to extract touristic sights by using the mobility of users observed in photos shared on instagram besides that hallot et al 23 used checkins performed at the art institute of chicago to show evidence that it is possible to use this source of data to infer the behavior of tourists in the same direction long et al 2 investigated travelers mobility patterns by mining the latent topics of users checkins performed in one city in the united states zheng et al 24 studied how to predict the tourists next movement within summer palace a tourist attraction in beijing china the authors obtained movement information from tourists using gps tracking technology in the area under study using a dataset of foursquare from 2012 ferreira et al 25 studied spatiotemporal properties of tourists and residents both identified by the city of residence informed in the user profile and among other results presented a graph model that can be useful for identifying central places in tourist mobility the present study significantly builds upon our previous work 26 in several directions differently from all the previous works in this study we propose an approach to identify mobility patterns which help to better understand the profile of tourists in particular properties of their mobility we also explore a graph model for identifying central places in tourist mobility relying on the model described in 25 in addition we present essential characteristics regarding the behavior of tourists including a discussion of the implications of such results these findings show the importance of the spatial and temporal dimensions helping to identify and understand mobility patterns besides it could be useful in decision making regarding the proposition of new services and applications as it is now discussed applications based on tourist mobility the study of spatiotemporal tourist mobility in the city and the factors that influence their movements have essential implications in several segments such as in smarter destination planning and help city planners to better support tourists hsieh et al 27 developed an application to recommend tourist itineraries based on users checkins in the same direction of personalized itineraries yoon et al 9 proposed an architecture to recommend itineraries for tourists considering the length of the stay and their interest also diplaris et al 28 created a framework that integrates the users interests and the corresponding realtime search context choudhury et al 29 and majid et al 30 used photos from flickr4 to automatically generate tourist itineraries shi et al 31 used the same approach but focused on recommendations of landmarks adding data from wikipedia5 to enrich the recommendation exploring user preferences basu rody et al 32 developed an application where users give feedbacks and iteratively construct their itineraries based on personal interests and time budgets yerva et al 33 proposed an itinerary recommendation system based on user preferences using data from lonely planet foursquare and facebook baraglia et al 34 presented a prediction model for the next point of interest of the tourist based on their history dataset in this section we describe our dataset and the procedure to identify tourists dataset description we collected checkins from foursquare using the twitter service where they are publicly available this was possible for foursquare users who shared their checkins on twitter which provides an api to obtain tweets in realtime we collected data spanning four months apriljuly of 2014 shared in london new york rio de janeiro and tokyo each checkin has the following attributes checkin id user id time and geographic coordinate we also performed an extra collection using the foursquare api to complement our dataset by retrieving information about the type of the venue in in our approach travel transport was divided into two categories travel to group subcategories related to that and transport to group subcategories related to urban transportation identifying tourists and residents in possession of our dataset we need to separate data shared by tourists and residents for this task we identify the city where the user spent the most time with at least 21 days of stay based on checkins intervals 6 from the checkins sequence performed in each city we check how many days were spent on them for example if a user gave a checkin in city a on may 5 2018 and another checkin at the same city on may 30 2018 we assume that heshe stayed 25 days in city a eventually a user may have been in different cities for more than 21 days in this case we consider the city where heshe spent the most time if a user gives a checkin in a city different from hisher home heshe is regarded as a tourist in that city we decided to apply this tourist identification process because it was successfully implemented by previous studies 3529 after the application of this process for each city we have 737 tourists and 2584 residents for new york 498 tourists and 3550 residents for rio de janeiro 584 tourists and 514 residents for london and 629 tourists and 4260 residents for tokyo users that we could not identify hisher residence due to a lack of data were excluded from the analysis to minimize misinformation to evaluate the assertiveness of the proposed approach to identify tourists and residents we randomly selected ten profiles for each city and class we evaluated all the 80 profiles manually and in all cases our approach correctly separated tourists and residents behavior of tourists in different cities worldwide tourists can behave differently in different cities depending on the purpose of their visit to try to capture that the cities considered in this study are located in distinct parts of the world and have different customs and cultures in this section we study the behavior of tourists and residents from several perspectives frequency and time interval of checkins by studying the number of checkins performed by tourists and residents we find that tourists perform more checkins than residents for all the cities analyzed although the volume varies between cities the pattern observed is similar for most of them we believe that this behavior might be directly related to the peoples motivation obtained from the new experiences and places they are discovering while traveling 36 for these cities tourists and residents tend to perform fewer checkins by hour compared to tokyo and new york however in london and rio de janeiro tourists share data more frequently than residents and this happens in a shorter time interval these differences can be seen as characteristics of the behavior of tourists while they are in those cities visited places the study of visited places also helps us to better understand the behavioral characteristics of tourists and residents in this direction figure 2 presents the places where residents and tourists performed checkins in the studied cities as we can see certain areas are more visited by tourists than others as expected for example in rio de janeiro most of the tourist activity happens by the sea in a specific part of the city where many tourist attractions are available in contrast in new york manhattan is the most popular destination for tourists although the visualization on a map gives us a good sense of where tourists are concentrated in cities it is interesting to further investigate where these two types of users tend to go tables 1 and2 show the ranking of most popular places according to the number of checkins for tourists and residents in the four studied cities some places are expected such as times square and the empire state building in new york and oxford street and the buckingham palace in london nevertheless other places are not traditional sights such as fifa 7fan fest in rio de janeiro which is a special place created for parties related to the 2014 fifa world cup event that rio de janeiro hosted attracting many tourists this example illustrates another potential of our study identify automatically dynamic changes in the popularity of places for tourists in the city including new places and the ones that may exist only for a short period with such a tool that could be leveraged by our study policymakers could for example know more precisely what places should receive more investment to improve tourism in the city looking at the ranking for residents we can identify places that are also frequented by tourists such as airports shopping malls and parks by performing this analysis we note that the most popular places according to the number of visits provide valuable information for understanding the behavior and motivation of tourists in the city however other factors such as time could provide an additional perspective on this understanding routines tourists and residents perform similar activities in the city such as eating however differences may exist in the pattern of performing those activities 38 to investigate this point figure 3 shows the number of checkins shared throughout the hours of the day for weekdays and figure 4 shows this information for weekends observing the behavior of residents in all cities during weekdays we can see peaks around the beginning of business hours lunchtime and at the end of business hours these results clearly show routines following traditional business hours which are performed by residents in their daily lives however we observe a different pattern among the tourists not very aligned with traditional daily routines this could be explained by the freedom that tourists have to perform various activities during their trip perhaps tokyo is the city where the behavior of tourists is more similar to the behaviors of residents because of the three peaks of activity in common note however that the activity of tourists tends to be more intense during the day this might mean that tokyo attracts a different kind of tourist that tends to perform activities in a more regular way for example having lunch at the same time as residents of tokyo the pattern observed for tourists and residents in each city for weekends is not very different in most cases we can also note that these patterns are very different from those observed during weekdays this could be explained by the fact that during weekends typically residents do not have routines being able to act somehow as tourists in the city which usually do not have to follow fixed schedules preferences of tourists the categorization of places helps us to better understand the preferences of tourists because as we showed above it is expected that cities have certain places that attract more tourists than residents to evaluate that point figure 5 shows a radar chart representing the popularity of the category of places for tourists and residents to measure the popularity of a category c of place we consider the number of checkins given in all places that are categorized by c some categories are expected to be visited by tourists such as airports hotels and monuments in contrast others such as houses markets colleges and universities are expected to be more popular among residents depending on the city the number and popularity of specific categories may vary for example in tokyo it is not popular for residents to perform checkins in places such as residence unlike other cities where residents typically perform checkins in places that belong to that category this is the case for rio de janeiro where residents make several checkins in the category home suggesting a smaller concern about their privacy cultural differences could explain these results tourists in new york tend to visit several places to drink while in london tourists tend to attend places related to sports in rio de janeiro tourists tend to visit places in the category entertainment such as concert halls and in the category outdoor such as beaches the category outdoor is quite popular in rio de janeiro among tourists not being the case for tourists in tokyo however the same category is popular among residents of tokyo demonstrating their habits in attending monuments and outdoor sites residents in new york visited considerably baseball stadiums a very popular sport in that city in rio de janeiro the subcategory related to barbecue restaurants received several visits reflecting a typical habit of local culture london is known for its pubs and nightlife beyond the great historical sites and behavior related to that is reflected in the category of visited places by tourists and residents besides showing differences among residents and tourists these results are also impressive because they reflect common cultural differences among the studied cities a fact that could be explored for instance in new recommendation systems implications information like the ones presented in this section might help define marketing strategies focused on each type of tourist as well as to understand what tourismrelated products might be relevant for each of them by considering the applied metrics our analysis help to understand useful properties on the behavior of tourists looking at when and the frequency tourists and residents performed checkins was valuable to gather evidence that tourists have more free time in contrast residents have tied behavior to daily routines as one would expect beyond the time aspect the spatial dimension ie visited places is also essential to understand the purpose of the trip performing a spatial analysis of visited places we can see which regions tourists tend to visit information that could help to provide better conditionsinfrastructure for a visit besides by a spatial analysis we can also understand the preferences of tourists in each city this is possible by looking at the types of places information available by foursquare and other sources this could be useful to define a profile of each city the properties presented in this section could also be helpful in the modeling of the behavior of tourists according to a specific city as well as in the exploration of new services for the recommendation of activities for tourists understanding mobility of tourists the study of user mobility within cities can bring rich information about the dynamics of the urban environment as well as the routines of users in the city using spatial data that implicitly express the preferences of users by specific locations in the city such as checkins we have the possibility to know where people come from and where they go user displacement we start the analysis of mobility with a study of the mean user displacement inside the city the mean user displacement is the mean of the cumulative distance traveled by a user to discover that we calculate the total distancebased displacement of consecutive checkins v n made by users and divide this value by the total number of checkins n the user has performed the checkins were ordered by chronological order performed by the users equation 1 defines the mean user displacement d u distance distance n where v i ∈ v and v is the set of visited locations and n is the total number of checkins figure 6 shows the cumulative distribution of mean tourists and residents displacement by studying the distance traveled by tourists we note that tourists tend to travel shorter distances than residents analyzing the behavior of tourists in each city it is possible to see some variations in rio de janeiro for example tourists move more compared to the other cities while in london ≈90 of the tourists move short distances up to 5 km considering residents we observe a tendency for higher distances travels in the city this could be explained because in big cities as those studied it is not uncommon to find residents residing far from their jobs besides they also may explore the city in more diverse ways including hidden places and further from central areas in the city a possible cause for the smaller displacement observed for tourists is the tendency to concentrate in some regions which may be a consequence of the limitation of time and knowledge of the city radius of gyration the radius of gyration is the typical distance traveled by an individual 11 while the displacement gives the cumulative distance traveled between all places the radius of gyration indicates the area where the user was concentrated according to the locations she visited with this metric we can understand the differences between the area of concentration of tourists and residents in the four studied cities this is relevant information for instance for urban planning we can calculate the radius of gyration using equation 2 r g 1 n i∈l n i 2 2 where n is the total number of checkins l is the set of visited sites n i is the number of checkins at a place i r i represents the geographical coordinates and r cm is the center of mass of the individual for this analysis were considered users that performed at least five checkins with this disregarding users that use the system sporadically figure 7 shows a cumulative distribution function of the radius of gyration for tourists and residents in the four cities we observe a smaller radius of gyration for tourists compared to residents this means that the area of concentration of tourists tends to be smaller among the cities there are some differences which can be explained by geographic features and available transportation infrastructure tokyo for example has a similar behavior among tourists and residents while rio de janeiro presents a more significant difference in the area of concentration of tourists and residents figure 8 shows a representative movement of users tourists and residents this metric is useful for understanding how tourists move in a city and also helps improve recommendation systems for places where tourists can visit if tourists have an explorer profile who ventures for more distant places we can suggest places in a larger area following the same idea if a tourist is more conservative regarding the distances heshe usually travels in the city the suggestion of places should stay within a smaller radius centrality metrics on spatiotemporal urban mobility graphs linked to spatial data another important factor to understand the mobility of users is the time the movement of users might change according to the day of the week and time for this reason in this section we perform the mobility analysis considering the time dimension spatiotemporal urban mobility graphs graph theory is an important tool for representing relationships between entities in this study we explore a directed weighted graph g where the nodes v i ∈ v are specific venues in the city at a particular time and a directed edge exists from node v i to v j if at some point in time a user performed a checkin at a venue v j after performing a checkin in v i in our graph we consider a 24hour time interval starting at 500 am our goal was to capture nightlife activities utilizing this strategy the labeling of vertices follows a simple pattern the locations name concatenated with the integer hour of the checkin for example a checkin at times square at 1000 am would be times square 10 when another user has performed the same trajectory the weight of the edge is incremented by one ie the weight w of an edge is the total number of transitions that happened from node v i to node v j isolated vertices were removed from the graph since there is no movement associated with that particular vertex the weight of the edge represents the number of users that performed this same tuple of checkins for instance in the figure the edge that links the nodes corcovado 10 and maracanã 14 illustrates consecutive checkins performed at corcovado at 1000 am and then at maracanã stadium at 1400 ten different times note that in the graphs the time is in 24hours format the socalled military format ie 1400 hours is 200 pm in a city there may be thousands of different combinations of movements between places some of which tend to be more popular than others our graph model enables us to study users movement along time and can also be used to find important places in the cities the importance of these places can be seen from different perspectives such as popularity in terms of the number of visits or best places to disseminate information in the city for those perspectives there are centrality metrics of complex networks that help us to understand the importance of the places in the cities popular venues in the city the reasons that motivate one person to travel from one place to another might be diverse for instance leisure business shopping and gastronomy the behavior of tourists inside the cities tends to reflect these reasons in several ways nevertheless we know that certain needs and places are common to all kinds of tourists such as food accommodation and transportation in our study we show that we can have the opportunity to improve the understanding of the behavior of tourists identifying where and when places are more important to users in different cities first we evaluate the degree centrality in our considered graph model to determine the most important locations in the cities according to this metric in a graph g the degree centrality of a node v is the number of incident edges on v normalized by the maximum degree in the graph verticesnodes with a higher degree centrality have a higher number of connections to other nodes of the graph in the urban mobility graphs of tourists and residents the higher the degree of vertices the greater their popularity in the graph historic site table 3 ranking of degree centrality of new york table 3 shows the top five places with the highest degree centrality of the residents graph of new york we can see that such places are typically visited by people who live in the city ie places related to their daily activities table 3 shows the ranking of degree centrality of the tourists graph of new york as expected we have the presence of key sights among the most popular places to tourists besides there is also the brooklyn beer soda located in brooklyn note that there is an indication that tourists might go to brooklyn to enjoy the nightlife in bars and restaurants table 4 shows the most important places in the graph of residents and tourists of rio de janeiro likewise we found for new york we have evidence that the most popular places among residents are typical visited places for this class of users while performing daily routines note for instance that we also found a university among the most popular places popular at 1800 many students in brazil attend night courses at universities helping to explain this result airport universidade uva 18 university aeroporto santos dumont 11 airport companhia do garfo 7 brazilian restaurant aeroporto santos dumont 7 airport jr mini pizza 18 pizza place praia de copacabana 17 beach table 4 ranking of degree centrality of rio de janeiro spreading information closeness centrality 39 of a node v is the reciprocal of the sum of the shortest path distances from v to all the other n1 nodes it measures how close a vertex v is of all others in a graph g for that it is taken into consideration the number of edges separating a node from others the shorter the distance to all other nodes the higher its closeness centrality with this measure we can estimate for example how fast it is possible to reach all vertices in g from v in the urban mobility graphs of tourists and residents a node with high closeness centrality signals an influential place at a certain time in the context we are studying locations with a high value of closeness centrality indicate for instance strategic locations for the dissemination of information for these two classes of users the insights that could be extracted using closeness centrality are interesting because they help in the decision making about choosing places to fast information dissemination such insights can be used by the government to promote more effective public campaigns among residents and offer better support and information for tourists emergency alerts also could be fast disseminated by authorities considering this type of approach bridge places betweenness centrality of a node v is the sum of the fraction of all pairs of shortest paths that pass through v 40 studying these centrality metrics in the mobility graph of tourists and residents we can see which places can make a connection between distinct components within the graph bringing this to the context of our research we can look at this metric as an indication of the places that could act as bridges between different groups the higher the betweenness the greater the chance that a user goes through that particular location 41 table 6 shows the ranking of the top five places according to the betweenness centrality in the residents and tourists graphs of rio de janeiro among them we have places that are related to different types of locations such as subway bus station and restaurants popular at the end of the night the fifa world cup 2014 happened in brazil and rio de janeiro was one of the host cities an interesting fact to note is the presence of the fifa fan fest the official place of celebration organized by fifa to gather supporters for all the world cup games this party was a central location in the routine of people in this city concentrating more residents at night note that these types of locations are likely to be a good place to connect different tribes in the city a fact that could help to justify the result we now turn our attention to tourists in rio de janeiro we can see in for example to improve user interactions among them in the city profiles of tourists based on mobility patterns there are some specific purposes of tourism such as gastronomic tourism religious tourism and tourism for business these particular types of tourism exist because we have a distinct profile of tourists based on different interests such as sports business and cooking by exploring social sensing specifically with foursquare checkins we can get an idea of how tourists behave in cities and therefore have the opportunity to identify tourists profiles according to the interests of each tourist we find users profiles based on mobility patterns identifying the set of most visited places by a specific group of people this is interesting in several cases in addition to knowing which users belong to a group useful information to recommend places to other users with a similar profile we can also identify the characteristics that attract groups of people to a particular city to identify the profiles of tourists based on mobility patterns we use latent dirichlet allocation 42 a technique for topic modeling this technique is useful to summarize documents in a set of topics finding words that define a document ie its subject lda considers a set of documents and a set of words contained in these documents and the intuition behind this technique is that each document has several topics and each topic is a distribution of probabilities for a word in the vocabulary profiles we find a leisure tourist typical of those going to rio for sightseeing we also find business tourists frequently performing activities related to work but without ceasing to enjoy the city attractions and what it has to offer such as restaurants and beaches applicability and limitations of the study based on the findings presented in this study we can see that the understanding of how tourists behave in cities open many opportunities in different areas this information could be relevant to businesses that want to understand better how tourists that also are their consumers behave and how to differentiate themselves from the competition our study enables us to analyze the locations where people choose more often as a starting point to other places or in another way around including the corresponding time of the day for that this kind of information allows us to propose better urban planning and create more strategic business strategies for instance we could analyze international franchises such as starbucks aiming targeted marketing campaigns to the creation of new servicesproducts specifically for tourists analyzing the preferences and behavior of consumers of one particular international business franchise are interesting because typically the purpose is to reach a diverse audience in different locations aiming to expand the options of products and loyalty of customers our approach enables the comparison of this behavior with other consumers from companies of the same segment ie not only with the specific franchise being analyzed one question of interest could be is there any difference between the behavior of consumers who attend a particular establishment and consumers attending all establishments of the same category analyzing the visits in two types of business locations we can better understand the dynamics of establishments in the city and how to differentiate themselves from their competitors our approach helps business owners to understand how to provide a better service for tourists in different locations especially culturally distinct ones the understanding of how consumers interact with the franchise can be a competitive advantage in sales also we could understand the different profiles of consumers who visit a particular company for that we can explore for example the same approach shown in section 7 our study also enables the development of new applications for instance we can mention the recommendation of places to the enduser considering its relevance and temporal aspect the recommendation could focus on offering suggestions for places according to their spatial and temporal popularity collectively elected by other tourists in the city conduct research using social media data may allow us to capture what is happening in the world in near real time the use of this data is proving to be increasingly powerful for the study of urban behavior 443 providing advantages for example to faster responses and cheaper cost over other traditional methods for this purpose such as surveys and interviews although it has many advantages data from social media may have limitations one is the amount of data that can be collected from those services for example twitter api has a restriction of 1 of the total volume of data produced this means that we may not have all the data we want for a given application also less than 25 of foursquare users push their checkins to twitter 2 the strategy adopted in this study so we may not get all checkins shared in foursquare following this strategy another limitation is the possible bias towards users who have smartphones with internet access this means that what is identified with the use of these data might not represent the entire population besides that irregular contents shared on social media might exist 44 but we are not aware of any significant evidence that this happened with foursquare data our dataset also has another limitation because it does not enable an indepth evaluation of the impact of different weather conditions or seasons in user behavior conclusions and future directions the exploration of social sensing has great potential to conduct studies about urban societies by studying tourists and residents mobility behavior using foursquare we found significant differences between these two groups based on our findings we can improve the understanding of tourists mobility identifying where and when places are more important to users in different cities in this study we performed a largescale study of tourists mobility considering several aspects besides we proposed an approach to help uncover user profiles based on their visited locations this studys results are an important input for cities planning allowing those responsible for tourism promotion to think in new strategies to foster this economic activity and prepare the city in case of unusual events and changes in the behavior of tourists in addition one can also create more personalized recommendations systems encouraging visits to places that have a profile more similar to the tourist which can potentially improve user satisfaction besides companies might also benefit from this information with the possibility of creating new touristic products this work can open up new studies in the same area and also in other domains an interesting possibility is the study of big events many tourists travel to other regions motivated by participation in special events such as carnival marathons and music festivals such as rock in rio analyzing the city dynamics before during and after the events can be beneficial for urban planning and better business organization it is also worth mentioning the potential to explore our results to improve information dissemination for tourists with the help of checkins performed by each user we can know the number of times each user visited each subcategory of place we then consider the subcategory of the visited place as the word of a document that represents the user a subcategory of place can be repeated in the document describing the user subcategories such as office and coffee shop are examples of words considered in our documents with this approach we can get results that indicate in a certain way user profiles we can view the topics found for tokyo residents in table 7 based on the subcategories attached to each topic we classify them with a name that represents a profile the commuter profile is a topic that urban public transportation such as train and subway stations appears frequently in this group residents of the tokyo metropolitan area might represent a significant part of the users the topic representing several bars and restaurants was named food lover in the academic profile we have a group of people who in addition to performing routine activities such as using public transport and eating in restaurants attend universities frequently tourists profiles in tokyo can be seen in table 8 many tourists go to tokyo motivated by the technological appeal of the city as well as motivated by local cuisine we can view in the profile electronics enthusiastic a strong presence of electronics stores following the same line the gamer profile is similar to enthusiastic electronics however with a bias to games similar to the residents case we also have a profile called commuter considering tourists we understand that this profile is composed of users who are visiting tokyo but do more checkins at the visited train stations than in other types of visited places as we pointed in section 42 a checkin in a train station might be a way to reveal to friends key areas of the city that a user is visiting in tokyo looking at the other side of the world table 9 shows the profiles of residents of rio de janeiro in this case we also found a commuter profile similar to that found in tokyo which is characteristic of the frequent use of urban transport rio de janeiro has a cluster of merged cities making many residents commute to metropolitan areas helping to explain this profile we also have the profile academic marked by the significant presence of educational institutions another profile identified is the one called citizen marked by the popularity of shopping malls visits in the city quite common among residents of rio de janeiro table 10 shows the profiles of tourists of rio de janeiro rio one of the largest cities in brazil attracts many tourists for its natural beauty since it is also a metropolis it also receives different types of tourists among the identified

tourism favors more economic activities employment revenues and plays a significant role in development thus the improvement of this activity is a strategic task in this work we show how social sensing can be used to understand the key characteristics of the behavior of tourists and residents we observe distinct behavioral patterns in those classes considering the spatial and temporal dimensions where cultural and regional aspects might play an important role besides we investigate how tourists move and the factors that influence their movements in london new york rio de janeiro and tokyo in addition we propose a new approach based on a topic model that enables the automatic identification of mobility pattern themes ultimately leading to a better understanding of users profiles the applicability of our results is broad helping to provide better applications and services in the tourism segment

introduction adolescent is a young person aged 1019 years who is experiencing both physical and developmental changes it is the transition phase from childhood to adulthood globally adolescents make up 16 of the total population the highest percentage of adolescents live in developing countries adolescent reproductive health is one of the twentyfirst centurys most important healthcare indicators globally a large number of adolescents give birth every year additionally a significant number have had an abortion in 2013 an estimated 13 million deaths occurred worldwide between 10 and 19 years due to pregnancyrelated causes adolescent marriage is a serious violation of human rights although there are many factors that fuel such practices such as poverty religious practices that permit early marriage the search for protection community myths and a sense of entitlement to respect cultural laws that support early marriage and inadequate legislative frameworks adolescent marriage should not be condoned adolescents make up a significant population in africa accounting for 23 of the total population the greatest proportion of adolescents who have begun childbearing are found in subsaharan africa adolescents reproductive health has long been a grey area due to ethical and religious practice issues in many areas of subsaharan africa sully and mumah revealed that there was low uptake of contraceptives in subsaharan africa yet the region recorded the most unplanned pregnancies among adolescent girls usage of modern contraception methods lingers very low despite the various efforts by kenyas national and county governments and nongovernmental organizations to promote abstinence among adolescents in kenya the impact of unsafe sex has continued to be felt in the country it has been found that at 16 years 14 of the adolescent girls in kenyan slums already had experienced sexual intercourse while this truth remains in kenya sex education is limited in our schools also there is low or no modern contraception services directed to the adolescents which has resulted to high adolescents pregnancies in kenya in kenya adolescents face a higher danger of unplanned pregnancies than adults however adolescent pregnancy is one of the causes to maternal and child mortality leading to intergenerational series of poor health muhammad et al found that adolescents face a high risk of eclampsia puerperal endometritis and breast conditions due to physiological and psychological prematurity again the adolescents are at high risk of maternal complications like obstructed labour fistulas lowbirthweight and premature births due to their physical and mental prematurity women besides death adolescents who procure unsafe abortions are prone to post abortal complications like postabortion sepsis hypertension hemorrhage and infertility sex education is viewed as though it encourages the adolescents to engage in sexual activities by the parents and educators but studies have shown sex education does not seduce the adolescents into sexual activities for example in kitui county of adolescent girls who are active sexually only 93 use contraceptives predisposing them to unintended pregnancies problem statement worldwide adolescent births are estimated to be 143 million with 25 million girls procuring unsafe abortions every year adolescents generally encounter barriers and discrimination while seeking reproductive health services leading to low modern contraceptive utilization globally and predisposing them to unintended conception and the likelihood of unsafe termination of pregnancies in kenya onefifth of adolescents have never escaped pregnancy therefore reducing preventable maternal deaths remains a major challenge to embrace and promote maternal wellbeing efforts to increase adolescents access to and utilization of contraceptives should be advocated by the end of 15 years the highest number of adolescents have already had their first sexual experience although most of them would like to avoid pregnancy they are not using any contraceptive method predisposing them all to unplanned pregnancies and sexually transmitted infections the population council revealed that the number of adolescent girls getting pregnant was higher in rural than in urban areas 30 and 28 respectively the proportion of adolescent girls reporting experiencing unintended pregnancy was also higher in remote areas than in towns 30 and 28 respectively the contraceptive prevalence rate for any contraceptive methods has remained very low at 23 among unmarried young girls aged 1519 years in kenya the kdhs reports the current cpr in kenya for both married and unmarried adolescents as 62 in kitui county only 369 of adolescents aged 1519 use contraceptives which is lower than the national level therefore the gap for contraceptive use currently among married adolescents in kitui is above the national level now 34 of married young girls aged 1519 are not planning to conceive but are not taking measures to prevent pregnancy compared to 23 at the national level consequently it is logical that after the first pregnancy an adolescent will start taking contraceptives to prevent future pregnancies 37 to 64 of adolescent mothers will conceive again within 1824 months after the first birth in kitui county research objective to assess the prevalence of modern contraceptives and the social demographic factors affecting the uptake of modern contraceptives among the adolescents attending pnc after first birth in kitui county literature review this section presents the literature review of the prevalence of contraceptive use among adolescents and sociodemographic factors affecting uptake of contraceptives among adolescents prevalence of contraceptive use among adolescents adolescent contraceptive use is one of the most important issues of the 21st century worldwide over 16 million adolescent girls conceive children each year and a significant number of them terminate the pregnancy notably half of these births take place in subsaharan africa over 60 of adolescent girls in subsaharan africa and asia who wish to avoid pregnancy have an unmet need for family planning methods adolescent girls who do not use contraception or rely on traditional methods of family planning have the highest number of unplanned pregnancies thus the need for highly customized adolescent reproductive health and reproductive health services has become increasingly urgent in kenya 13000 adolescent girls drop out of school each year due to an unintended pregnancy additionally adolescent unintended pregnancies lead to unsafe abortions which can lead to serious conditions such as anemia sepsis and even death therefore contraceptives have been prioritized as a good approach for achieving good health promoting the wellbeing of individuals of all ages and realizing gender equality and empowerment for all adolescent girls by 2030 however achieving the above sdg goals is unlikely with the current trends in the low uptake of contraceptives among adolescents in kenya a large gap still exists in the utilization of contraceptives among adolescents as seen from the statistics that approximately 16 million of them aged 1519 years give birth annually with unintended pregnancies forming a majority of the statistics consequently this translates into the need for research on its associated factors at the local level to inform the strategies needed to improve contraceptive use among adolescents in the country sociodemographic factors affecting uptake of contraceptives among adolescents this section consists of the age level of education parity and marital status age age is one of the sociodemographic factors that influence the uptake of contraceptives among adolescents it is a major variable in determining the uptake of contraceptive methods since reproductive matters begin from age 15 to 49 years in addition age is a criterion when determining a suitable contraceptive method the effect of age on the uptake of contraceptive methods has been established in research for example nakirijja et al reported a higher likelihood of older women utilizing contraceptive methods than adolescents in addition age also determines the sexual encounters of adolescents as a majority of them engage in sexual intercourse between the ages of 15 and 19 as a result there is an increased need to use different family planning methods among them however apanga and adam found contrasting evidence in their research as there was no significant association between participants age with the use of contraceptives therefore this study sought to explore whether age determines adolescents uptake of contraceptive methods after their first pregnancy level of education education among adolescents also determines the uptake of contraceptives education in women is highly correlated with the increased use of contraceptives as they can make healthy choices during childbirth for example apanga and adam showed that the use of contraceptives was higher in participants with primary and secondary education when compared to those without formal education furthermore their partners education level positively predicts an adolescent using contraceptive methods however the negative relationship between education and nonuse of contraceptives has been documented in other studies including solanke alemayehu et al obwoya et al ontiri et al nyewie and blackstone et al further the effect of education also extends to those with hivaids blackston et al found that hivpositive women and adolescents were least likely to bear children and use contraceptives to prevent pregnancy as they did not want to infect their children this was contrary to those with low education as they had children irrespective of their hiv status the uptake of contraceptives increases with ones level of education adolescents with tertiary education were highly likely to utilize contraceptive methods compared to those with primary or no education parity parity also determines the uptake of contraceptives among adolescents adolescents with more children are highly likely to use contraceptives compared to those with less than one child the effect of parity is also seen in the studies by apanga and adam and obwoya et al which strongly predict the lifetime use of contraceptives marital status whether an adolescent is married or not also determines the uptake of contraceptives the prevalence of contraceptive use is generally higher in married adolescents than in unmarried adolescents this is attributed to the perception that contraceptives are used for child spacing purposes and limiting the number of children the decreased use of contraceptives among unmarried adolescents is attributed to societal norms that do not allow contraceptive use and disapproval from parents as it increases the risk of early sexual activity the nature of the marital relationship also influences the uptake of contraceptives blackstone et al found a positive association between marital gratification and contraceptive use this relationship is attributed to the perception that having more children stabilizes marriages and prevents infidelity however apanga and adam found that marital status did not have any statistically significant effect on the use of contraceptives methodology this study was conducted in kitui county using a crosssectional descriptive survey design the study targeted adolescent girls aged 1019 years who had given birth in the last six months and attended postnatal care in kyuso tseikuru mwingi nguni and nuu subcounty hospitals a purposive sampling technique was used to select five subcounty hospitals for inclusion in the study population the total number of young mothers served in these facilities is approximated to be 957 a sample size of 127 was used data were collected using structured questionnaires the quantitative data were analyzed using descriptive and inferential statistics results and discussion usage of modern contraception the usage of modern contraception among female adolescents considered in this study was 352 sociodemographic factors and usage of modern contraceptives in a descriptive analysis the usage of modern contraceptives was high among the respondents aged 19 years and those with college education qualifications additionally the usage of modern contraceptives was more pronounced among the respondents who did not belong to any religion married and not schooling at the time of this study sociodemographic predictors and usage of modern contraceptives the results of the multivariable logistic regression analysis of the association between the sociodemographic characteristics and usage of modern contraceptives are presented in table 3 as indicated female adolescents aged 19 years were 281 times more likely to use modern contraceptives as compared to those aged 17 years however female adolescents aged 18 years were 145 times more likely to use modern contraception compared to those aged 17 years however this variation was not statistically significant in addition female adolescents with a college education were 355 times more likely to use modern contraception than those with primary school qualifications likewise compared to female adolescents with primary school education those with secondary school education were 274 times more likely to use modern contraception however their likelihood to take up contraception methods was slightly lower in comparison with those with college education qualifications further nonreligion female adolescents were 155 times more likely to take up the contraception methods than christians similarly in comparison with female adolescents who were single the married female adolescents were 620 times more likely to use modern contraception while schooling female adolescents were 190 times more likely to take up modern contraception compared to those who were nonschoolers discussion usage of modern contraceptives the overall uptake of modern contraceptives among the female adolescents in this study was 352 this low uptake suggests that modern contraceptives for fertility prevention are still a sociodemographic predictors of modern contraceptive use consistent with nakirijja et al finding that age is one of the sociodemographic factors that influence the uptake of contraceptives among adolescents and is a criterion when determining a suitable contraceptive method this study found that female adolescents aged 19 years were more likely to use modern contraceptives compared to those aged 17 years however previous research by apanga and adam has revealed that age factor was not always related to the uptake of modern methods of contraception additionally female adolescents with college and secondary school qualifications were more likely to use modern contraceptives than those with primary educational qualifications this finding resonates with apanga and adam who found that womens education is significantly associated with the increased use of modern contraceptives the higher modern contraceptive use might be because female adolescents with college and secondary school educational qualifications might be more informed about the effective use of modern contraceptives in controlling pregnancy another plausible reason might be that female adolescents with college and secondary school educational qualifications might not want to have another child to interrupt their educational activities they might be in a position to make informed choices regarding their needs of reproductive health better than those with lower educational qualifications nevertheless insignificant associations between the level of education and uptake of modern contraceptives have been found in northwest ethiopia among married women subsaharan africa and in kenya among women with an unmet need for modern contraception moreover in unity with tamang et al finding that religion influences the uptake of contraceptives among adolescents this study found that female adolescents not affiliated with any religion were more likely to use modern contraceptives than those who were christians this finding might be because religious beliefs shape peoples knowledge and behavior regarding reproductive health religious resistance to modern contraceptive use may be more pronounced among christians than among nonreligious affiliated female adolescents similarly previous research has indicated that religion reduces the uptake of modern contraceptives among adolescent girls for example previous research in ethiopia by tigabu et al found that contraceptives were not utilized despite being available at the healthcare facilities and attributed the low utilization to religion in addition this study reported higher chances of modern contraceptive use among married female adolescents than those with single marital status a plausible reason for this finding could be that married female adolescents might not want to have another child given the challenges associated with caring for a baby moreover schooling female adolescents might not want to have another child interrupting their educational activities adebowale et al found similar results in nigeria among women with no fertility intention conclusion this study concludes that there is low usage of modern contraceptives among female adolescents with one baby and visiting postnatal clinics within the first six months after birth in addition the higher the age of female adolescents the more likely they are to use modern contraceptives moreover the higher the educational qualifications the more likely female adolescents will utilize modern contraceptives besides christian and singlemaritalstatus female adolescents are less likely to use modern contraceptives recommendations increasing uptake of modern contraception methods among female girls aged years in kitui county is a multifaceted problem that will require concerted efforts by all key stakeholders to provide wide interventions such stakeholders include the community parents guardians peers school teachers and tutors religious leaders healthcare practitioners and policymakers in addition the interventions should aim to inform female adolescents through appropriate information while counteracting negative perceptions beliefs and myths from the study the married and the higher the educational level were more likely to use contraceptive method which gives good entry for any implementational project in an area with low modern contraceptive uptake targeting the population who are likely to use the modern contraceptive methods would boost the uptake and as well will become role models to those who were less likely to use the single and the primary school level female adolescents who were less likely to use the contraceptive methods using their peers as role models group counselling and organizing seminars to provide the correct information about modern contraceptive use among the adolescents would improve the uptake moreover adolescent girls shy off seeking reproductive health services together with older population age of their parents adjusting the health facility working hours to attend to them over the weekends and later hours of the day like from five to six in the evening would yield better results

globally adolescents make up 16 of the total population and 55 of unwanted pregnancies among adolescents end in abortion africa has the highest number of adolescents 23 adolescents in kenya experience a higher risk of unintended pregnancies than older women but contraceptive use among them remains very low despite various efforts by kenyas national and county governments and nongovernmental organizations to promote abstinence among adolescents these efforts have not been successful in light of this this study sought to assess the prevalence of modern contraceptives and the social demographic factors affecting the uptake of modern contraceptive methods among female adolescents after the first birth in kitui county kenya the study was conducted in kitui county and employed a crosssectional descriptive survey design targeting adolescent girls between 10 and 19 years who had given birth in the last six months the results showed that the usage of modern contraceptives was generally low 352 however based on the factors influencing uptake it was higher among respondents aged 19 years 574 and those with college education 500 adolescents with a college education were 355 times more likely to use modern contraception aor355 p000 than those with primary school qualifications the results revealed that age education and marital status were determinants of modern contraceptive use among adolescents the study advocates for increasing the use of modern contraceptives among female adolescents in kitui county recognizing that this is a multifaceted problem that will require concerted efforts by all key stakeholders to provide a wide range of interventions such stakeholders include the community parents guardians peers school teachers and tutors religious leaders healthcare practitioners and policymakers

background with the rapid expansion of mobile phone ownership in lowand middleincome countries over the past decade the field of mobile health has emerged as a novel and potentially costeffective way to increase access to health information and improve health knowledge as well as health outcomes 1 2 3 4 mhealth programs have been particularly popular in the area of adolescent sexual and reproductive health where knowledge gaps remain large 5 6 7 8 9 10 11 a recent review of evidence and progress over the past 20 years in adolescent srh highlights the persistent lack of access to srh information and services as well as the large knowledge gaps with respect to use of contraception 12 a growing body of evidence highlights early sexual debut and oneparent households as key risk factors for adolescent pregnancy and childbearing and knowledge about contraception as a key protective factor against these outcomes 13 structural influences such as low parental socioeconomic status low parental education and lack of parental support with regards to srh have also been associated with adolescent risky sexual behaviour and inconsistent contraceptive use in the literature 13 14 15 recent evidence suggests that mhealth programs can increase average health knowledge and that these programs are generally wellreceived by youth 5 6 7 however very little is known regarding the reach and effectiveness of these programs in populations with key risk factors 16 while mobile phone ownership and usage has greatly expanded among young people in many lmic settings 17 adolescents from disadvantaged groups generally have reduced rates of phone ownership or may only have limited access to a shared household phone 18 19 20 21 in addition youth from these key populations may face other barriers pertinent to mhealth such as decreased technological literacy inferior network coverage and lower linguistic competency 23 in this study we analyse detailed data collected as part of a randomized trial of a textmessaging intervention conducted among secondary school students in accra ghana as part of the trial adolescents were invited to participate in an interactive mobile phone program aimed to increase knowledge of srh we seek to answer the following research questions how effective was the program in engaging adolescents from key target populations including adolescents with low parental education early sexual debut low parental support and low knowledge of srh how did the impact of the program on srh knowledge vary with level of engagement and how successful was the program at improving srh knowledge and reducing incidence of pregnancy in key target populations methods study setting the study was conducted in the urban area of accra ghana 1 in a survey from 2015 in ghana 31 of respondents aged 1418 years and 71 of respondents aged 1925 years owned a mobile phone while 77 of those aged 1418 and 91 of those aged 1925 used a mobile phone in the past 4 weeks 20 despite enacting a national adolescent reproductive health policy in 1996 the srh of ghanaian adolescents remains a significant challenge according to the 2014 demographic and health survey by age 19 36 of women have given birth or are pregnant 22 among adolescent mothers under 20 years of age 58 had not planned on having the pregnancy at that time use of contraception among adolescents is low among sexually active unmarried adolescents aged 1519 less than a third use a modern method of contraception 22 though adolescents are generally aware of hiv and pregnancy risks srh knowledge tends to be limited and mostly superficial results of a 2004 national survey of ghanaian adolescents found that while more than 95 of girls aged 1519 knew of at least one method of modern contraception only 67 were aware that a woman is more likely to get pregnant on certain days than others only 28 knew both previous items and were able to reject two common misconceptions 23 moreover widespread misconceptions about the correct way to use contraception and fears about longterm side effects on future fertility add to the barriers to modern contraception use among adolescents 24 25 26 procedures we used secondary data from a recent randomized trial that provided srh information by text message to adolescent girls in ghana the original trial which is described in further detail in rokicki et al found relatively large and persistent increases in srh knowledge among adolescents participating in the interactive mhealth program 5 the sampling frame for the study was provided by the 20122013 ghana education service register of secondary schools in greater accra we randomized 38 schools to the interactive mhealth intervention a simplified unidirectional messaging intervention and the control group after randomization we found 3 schools to be ineligible and 1 refused to participate due to time constraints 5 in this paper we focus only on the interactive mhealth intervention arm and the control arm the analytic sample consisted of 10 schools assigned to the intervention and 12 schools assigned to control we blocked randomization by school category and by whether the school had a home economics class we chose classes within schools based on maximizing the number of eligible girls if a home economics class was offered in the school it was chosen because it was always a large class of nearly all female students home economics was not offered at all schools so stratifying ensured even distribution across arms the inclusion criteria for schools was senior high day schools in the greater accra region boarding schools were excluded within schools sampling was restricted to female students aged 1424 years in one class in the second year of senior high school participants used their own mobile phones or could use a family members phone no phones were provided participants gave written consent those aged younger than 18 years obtained parental consent institutional review board approval was granted by harvard university fwa00004837 as well as locally by the ghana health service the study design was registered on clinicaltrialsgov we visited schools at baseline immediately after the intervention was completed and 1 year later at each visit participants completed a selfadministered questionnaire participants demographic information was completed at baseline reproductive health knowledge was assessed at each timepoint information on sexual behavior and pregnancies was collected only at the 15month followup the mhealth platform the mhealth platform was designed as an interactive mobile phone quiz game in which participants could win airtime for texting correct answers to srh questions to design the message content we first conducted focus groups with adolescents to understand their most prevalent srh concerns followed by a round table discussion with the health promotion unit at ghana health service who approved appropriateness of topics and finalized wording for a period of 12 weeks participants were sent one multiplechoice quiz question about srh each week via text message to which they were invited to respond free of charge these messages focused on pregnancy prevention and contained information on topics of reproductive anatomy pregnancy sexually transmitted infections and contraception including male and female condoms birth control pills and emergency contraception upon responding participants immediately received a confirmatory text message informing them whether they answered correctly the correct answer and additional information participants were sent up to 2 reminder messages if they did not respond those who had not responded by the end of the week were sent a text message with the correct answer and the additional information at the end of the week participants in the same school were encouraged to discuss messages with each other participants were told that correct answers were rewarded for every 2 correct responses participants were sent 1 ghs of airtime credit at the end of the week over the same 12week intervention period the control group participants were sent one message each week with information about malaria the content of all messages is shown in table 4 in appendix participants in the control group were interviewed at baseline 3 months and 15 months using the same procedures as participants in the intervention group all messages were sent in english the official language of instruction in all secondary schools in the country using secure servers via telerivet service nondelivered messages were resent measures to measure program engagement we used two separate variables first we measured the total number of times the respondent replied to the weekly textmessage quiz questions from data extracted from the mobile phone records second we measured selfreported message exposure at the 3month follow up respondents were asked how often did you receive messages from the program more than once a week about once a week about once a month less than once a month we created an indicator for having received messages at least once a week to evaluate reproductive health knowledge participants completed a trueorfalse test consisting of 24 items items on the test were adapted from the guttmacher institutes 2009 national survey of reproductive and contraceptive knowledge for the setting of ghana 27 knowledge scores were calculated as the percentage of items answered correctly we then calculated knowledge zscores by subtracting from each score the overall mean at baseline and dividing by the standard deviation in calculating knowledge scores dont know answers and missing values were treated as incorrect answers the percentage missing for each item was low and is shown in table 5 in appendix at the 15month followup data collection was done using tablet computers so there were no missing values in those scores for the baseline and the 3month followup which were done on paper questionnaires we recalculated knowledge scores such that items with missing values were excluded from the calculation the correlation coefficients between treating missing values as incorrect and excluding missing values from the calculation was 092 at baseline and 099 at the first followup selfreported pregnancy was assessed at the 15month followup with the question in the past year have you been pregnant yes no i dont want to answer our explanatory variables were selected exante on the basis of theory and prior evidence of risk and protective factors for adolescent srh 13 we identified these as 1 adolescents from households of low socioeconomic status 2 adolescents who were sexually active at baseline 3 adolescents who have a larger than average srh knowledge deficit and 4 adolescents who have low parental support statistical analysis our analysis is divided in three parts first we evaluated characteristics associated with engagement with the interactive mhealth program we used a poisson regression model to examine the association between number of responses to the textmesssage quiz questions as our outcome and parental education sexual experience parental support and srh knowledge as explanatory variables we also verified similarity of results to a negative binomial model to account for overdispersion additionally we used logistic regressions to examine the associations of these characteristics with a binary variable for any response to the textmessages as well as with a binary variable measuring participation as whether the participant selfreported to have received messages at least once a week during the course of the program next to evaluate the impact of engaging with the program on reproductive health knowledge we used linear regression models of knowledge zscore at both 3 and 15 months as a function of level of engagement of the intervention group we used quantilequantile plots to assess normality of the residuals finally we assessed variation in program impact across target subgroups we used linear regression models stratified by subgroup to estimate the impact of the intervention on knowledge zscore we then used models with an interaction term for intervention group and subgroup indicator to test equality of the coefficients for these interaction tests marginal effects were derived from the interaction model and then compared using linear hypothesis tests due to the small cell sizes in subgroups we used exact logistic regression models again stratified by subgroup to estimate the impact of the intervention on selfreported pregnancy in the past year missing values and item response refusals were included in the analyses as separate categories results for these categories are shown in tables 6 and7 in appendix we adjusted all models for blocking variables which were category of school and an indicator for the presence of home economics class and we clustered standard errors at the school level to correct for withinschool correlation of outcomes 2829 we used stata v14 for all analyses 30 results table 1 shows the baseline characteristics of the participants which were similar for intervention and control groups at baseline 58 of participants were 1718 years of age while 18 were 16 and under and 24 were 19 and over almost 70 of participants were not sexually active at baseline while 13 were sexually active another 13 refused to answer the question 8 of participants reported that both parents had low education 23 reported that at least one parent had higher education 49 reported that both parents had higher education while 20 did not know about a third of participants reported that they had high parental support while the rest reported low parental support differences in program engagement by target subgroups association between engagement and knowledge figure 1 shows the difference in average knowledge zscore between intervention and control groups as a function of the intervention groups engagement with the program higher levels of engagement were associated with higher knowledge scores both at 3 months and at 15 months difference in program impact on high risk groups figure 2 shows the difference in knowledge zscore for the intervention compared to the control stratified by target subgroups the mhealth program was effective at significantly increasing knowledge for every subgroup at both 3 and 15 months we found no heterogeneity in the effect of the intervention across any subgroup population finally table 3 shows the impact of the mhealth program on selfreported pregnancy in the past year stratified by target subgroups among those sexually active at baseline 2 of 25 participants in the intervention group reported a pregnancy while 6 of 39 participants in the control group reported a pregnancy however the odds ratio estimate was not significant and confidence intervals were wide due to the small cell sizes in these subgroups discussion the results presented in this paper suggest that mhealth programs are not only an effective tool to increase srh knowledge overall in the studied setting but that these programs can also engage and increase srh knowledge of adolescents from key target populations who are at higher risk of poor srh outcomes including adolescents with low parental education adolescents with low srh knowledge adolescents with early sexual debut and adolescents with low parental support we found that overall engagement in the program was high and that participants in target groups were just as likely to interact with the program as their counterparts in fact participants whose parents had low levels of education had a higher rate of responding to messages than those whose parents had high levels of education program engagement also appears to be important for knowledge absorption we found that those who interacted more with the program had significantly greater knowledge of reproductive health in both the shortterm and in the longerterm compared to those who did not interact those who did not reply to messages still received the reproductive health information at the end of each week however knowledge improvements were minimal at 3 months and not significantly different from the control at 15 months we cannot interpret the differences causally as there may be confounding factors such as motivation that affect both desire to interact with the program and knowledge however the findings point to the potential importance of including features such as interaction and feedback in the design of mhealth programs for adolescents 331 we also found that the mhealth program was effective at increasing srh knowledge across levels of parental education srh knowledge sexual experience and parental support in both the shortterm and longterm a surprising finding considering the number of potential cultural and technological barriers that participants in target groups may encounter finally we found no significant impact of the mhealth program on selfreported pregnancy within subgroups although girls in the intervention group who were sexually active at baseline had fewer selfreported pregnancies than their counterparts in the control group the difference was not significant and sample sizes were too small to draw strong conclusions providing information via mobile phone to the population that needs the information mostin this case girls who are sexually active and who immediately benefit from information about contraception and pregnancy preventionmay be an effective way of reducing unintended pregnancy rates however the study analyzed here was not powered to directly address this question and more research is needed to understand the effect of mhealth programs on unintended pregnancy in sexually active adolescent populations this analysis has a number of limitations first there may be measurement error in some of the outcomes studied sexual activity and pregnancy were selfreported and thus may be subject to recall bias and social desirability bias the bias may be differential by intervention group if for example provision of sexual health information by mobile phone made participants more likely than those in the control group to respond accurately and honestly to srh questions it may also be differential by target subgroup for example those with stronger parental connectedness or more baseline srh knowledge may also respond more honestly however neither the size nor the direction of such biases is obvious in other studies adolescents selfreported sexual behavior data has been reported to suffer from inconsistencies recall error and misunderstanding or confusion surrounding the survey question 32 in future studies biological markers of pregnancy would be ideal to fully understand the health impact of the program another data limitation of the study presented is that a large proportion of girls did not know the level of their parents education it is also worth noting that participants were recruited from secondary school in an urban area and thus are not representative of the general population heterogeneity in terms of socioeconomic and demographic characteristics in the general population may be much larger in particular girls from rural areas and girls who stopped schooling before secondary school may have less access to mobile phones or reduced literacy skills than the girls in our sample as this study was a small scale pilot study we did not include boys in terms of interpreting impacts the intervention was a multicomponent program that included participant interaction with quiz questions reminder messages and rewards we are not able to differentiate impact as a result of individual components finally only about a third of participants had ever had sex at the 15month followup resulting in small sample sizes longerterm impact of the program once a majority of girls become sexually active is unknown our analysis also has a number of strengths the original trial was a randomized design and thus reduces the risk of confounding biases relative to observational data in addition followup rates at both 3 and 15 months were over 95 5 previous research has found that boys are more likely than girls to use mobile phones and youth from higher socioeconomic backgrounds are also more likely to own and access mobile phones 18 19 20 an evaluation of a districtwide hivaids mhealth campaign in uganda found that women and those with lower srh knowledge were less likely to respond to sms quiz questions than men and those with higher srh knowledge 933 conversely our findings show that girls from across socioeconomic strata and levels of srh knowledge do actively engage in such programs when they are directly targeted and when intervention content is tailored to their needs for future interventions developing such customized content is undoubtedly of critical importance and will likely require additional qualitative work of a wider range of age groups and geographic areas from a policy perspective it will also be important to use additional approaches to enrol socially disadvantaged girls into the program since many may not pursue secondary education actively recruiting girls from disadvantaged neighborhoods for mhealth programs rather than promoting programs through general advertising may be an effective way to reach these vulnerable populations conclusions adolescent girls in lmics face substantial sexual and reproductive health risks including unintended pregnancy unsafe abortion and hiv infection 34 accessing srh information and services is challenging for adolescents due to a large number of barriers including a lack of availability of accurate comprehensive and timely information 12 as access to mobile phones among young people continues to rapidly expand implementing mhealth programs in the area of adolescent srh is becoming popular among academics and policymakers 5 6 7 8 9 10 11 at the same time concerns have grown that mhealth programs are not reaching vulnerable populations 182135 our results suggest that mhealth platforms for adolescents have the potential to engage and increase health knowledge of adolescent girls across sociodemographic strata including those who may be at higher risk of poor srh outcomes to put on a condom you should first unroll it all the way and then try to put it on the penis 7 5 appendix when putting on a condom it is important to leave space at the tip 28 6 when using a condom it is important for the man to pull his penis out right after ejaculation while it is still stiff home economics class in school 1 abbreviations ci confidence interval irr incidence rate ratio lmic lowand middleincome country mhealth mobile health or odds ratio srh sexual and reproductive health sti sexually transmitted infection authors contributions both sr and gf conceived the idea for the article sr analyzed the data and drafted the manuscript gf contributed to the data analysis and edited the manuscript all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background while mobile health mhealth programs are increasingly used to provide health information and deliver interventions little is known regarding the relative reach and effectiveness of these programs across sociodemographic characteristics we use data from a recent trial of a textmessaging intervention on adolescent sexual and reproductive health srh to assess the degree to which mhealth programs reach target adolescent subpopulations who may be at higher risk of poor srh outcomesthe study was conducted among girls aged 1424 in 22 secondary schools in accra ghana the mhealth intervention was an interactive mobile phone quiz in which participants could win phone credit for texting correct answers to srh questions we use detailed data on individuals level of engagement with the program srh knowledge scores and selfreported pregnancy collected as part of the original trial to assess the extent to which engagement and program impact vary across parental education sexual experience srh knowledge deficit and parental support results eightyone percent of participants engaged with the mhealth program with no evidence that the program disproportionally reached betteroff groups the program was effective at increasing knowledge of srh across all strata higher levels of engagement were associated with higher knowledge scores up to year later there was no significant impact of the program on selfreported pregnancy within subgroups conclusion mhealth programs for adolescents have the potential to engage and increase srh knowledge of adolescent girls across sociodemographic strata including those who may be at higher risk of poor srh outcomes

introduction the main responsibility of society is to shape guide and influence the next generation of leaders and to help them discover their potential they are important because they represent the countrys future and they must be hopeful entrepreneurial and productive among all other qualities they must develop skills to be prepared to face todays and tomorrows challenges one of the goals of higher education is to prepare students for their profession or occupation it was also reported by foubert and grainger that more involved students have greater skill development compared to those uninvolved students literatures discovered the impact of participation of students in clubs and organizations on the development of students higher education has a significant impact on the development of critical skills that improve students academic outcomes however academic institutions have not adequately focused more on the role of student organizations in supporting and improving student outcomes assessing what students learn from their participations in different programs helps in evaluating and justifying effectiveness of the programs offered outcomes can be used as way to make improvements on the services and programs ndmu as one of the schools in soccsksargen offered different programs that helped develop different skills in its learners and enhancing their educational wellbeing by developing knowledge skills and competencies through engagement in some of the extracurricular activities these programs provide sufficient skills for learners to hone their potential in different fields such as leadership formation sociocultural performing arts advocacy programs clubs and organizations involvement sports and wellness programs but in order to achieve the sufficient skills these programs should be assessed thus this study aimed to assess the degree of needs for the betterment of these identified programs and to demonstrate what is gained from a particular programs or services provided by the institution to develop their leadership abilities young people require chances to assume leadership roles this is why leadership development programs should offer practical leadership experience a practicebased infrastructure as opposed to academic understanding and handson learning activities a university setting should offer plenty of opportunities and favorable conditions for developing leadership skills undergraduate students college experience should be a time for independence and learning about their personal leadership skills as winchester explains we enhance young leadership development and their ability to have a good impact on society if they find affirmation in who they are and are empowered to realize their agency in tackling issues that concern them the longterm effects of this leadership development could be seen in social political or economic situations but they might be significantly influenced by how our young people perceive their leadership potential gould and voelker suggest that leadership is a process wherein an individual influences a group of individuals towards achieving a common goal young people have an extraordinary chance and obligation to affect the world around them the prospect of being able to influence others positively and helpfully is exhilarating i do not believe i am alone among those who work with teenagers in believing that their vigor and aptitude are just what we need to address some of the major issues that society is currently facing as winchester argues our young people have increased ability and agency to address the issues they perceive around them as a result of actively teaching and enabling kids to be leaders the deliberate development of our students as leaders has additional advantages besides this one they are choosing student leaders and relying on them to figure it out as they go nelson lists several benefits of purposeful leadership development for young people he discovers that one of them is that by treating learners as leaders throughout training activities learners form a leadership identity that results in behavioral and attitude modifications collins and rosch concur students who experience success through their involvement often experience threefold levels of growth they note as their skills improve their leadership selfefficacy grows as well given the realworld impact they see in such a volunteerled setting their motivation to lead also grows students who understand their capacity to address issues they encounter gain from this leadership development but it also benefits our school and community students who develop their capacity to successfully lead groups toward a common objective have an effect on the organizations they participate in both now and in the future for many educators it is enriching to see how students leadership develops and matures the people that assign young pupils to various jobs within their schools will gain if these students grow into the obligations and expectations of these roles resulting in a more positive experience for everyone an educators biggest focus and most enduring legacy should be inspiring and developing tomorrows global leaders in a contemporary secondaryschool setting the term performing arts refers to genres of art in which performers communicate their artistic vision through their voices bodies or inanimate objects most people believe that performing arts do not require much intelligence compared to achieving art competencies people have many different types of intelligence such as musical interpersonal spatialvisual and linguistic intelligence in addition to their intellectual potential a quality arts education is based on and reflects an understanding of the distinctive and remarkable ways in which the arts influence peoples thoughts and lives d booth according to the strategies are means of understanding exploring responding disclosing and exhibiting imagining depicting and making sense the particular kind of civic participation known as advocacy is frequently viewed as a precursor to or a supplement to direct action or civic activism groups and organizations utilize advocacy to solve problems with the criminal justice system environment health care education and civil rights they support causes and work to sway judgments in the social political and economic spheres typically advocacy groups voice their concerns about institutions that are insensitive to the needs of people or about laws and practices that they believe to be unjust effective lobbying changes public policy and decisions about the distribution of resources giving people more power to change institutions to serve human needs better the purpose of advisory programsalso referred to as advocacy programsis not to take the role of school guidance counselors on the other hand they are intended to increase the number of kids whose requirements are satisfied in a school environment its objectives are to raise achievement levels decrease discipline referrals and enhance students attitudes about school many schools have started advisory programs where students meet in groups with adult mentors to work on selfesteem and developmental concerns to address the changing requirements of the students today smaller nonacademic contexts are intended to be created by advisory programs within the more extensive educational system students personal development can be encouraged in smaller settings and they can develop good relationships with teachers parents and other students the essential to advisory programs is that at least one adult in the school gets to know each student well participation in student organizations is seen as one of these chances to develop ones skills according to foubert and grainger more involved pupils have higher skill development scores than their lessinvolved peers with lower developmental scores according to research student groups give members a chance to learn or strengthen essential communication skills provide them an opportunity to deal with others of diverse ethnic origins and support and care for those who are less fortunate participation and participation in universitysponsored organizations appear to give students various chances to familiarize themselves with campus life and promote intellectual growth student organizations function as social opportunities for students to network on college campuses and also serve as a significant link for students to college or university experiences although the concepts of campus involvement provide a valuable context to examine and analyze the connection between college experiences and student outcomes this reveals several inquiries according to hall student organizations provide strategies to enhance learning outside the traditional classroom curriculum students with similar personal and professional interests can network with one another thanks to them increasing their chances of connecting to larger communities outside their organization students who participate in student organizations see involvement as a critical component of their socialization and academic persistence providing participants with resources and opportunities students who participate in student organizations view involvement as a significant element of their socialization and academic persistence providing participants with recourses according to research student involvement in sports has positive effects on a universitys overall wellbeing institutional loyalty and cohesion increased revenue and prestige to the institutions reputation and ultimately improves student applications enrolment fundraising and sponsorship therefore it becomes crucial that colleges recognize the significance of studentathletes wellbeing to capitalize on the potential advantages of student participation in sports university studentathletes who comprise one of the key clients of the university is also regarded as the heart and soul of every educational institution they have been referred to as a particular population with a unique college experience from nonathletes multiple stressors working together to put physical and psychological demands on individuals impact their wellbeing some of these stressors include time restrictions rigid schedules negative media stereotypes of students instructors and players physical stress and exhaustion commitment to attend practices and games and juggling multiple roles as students and athletes the current study analyzes studentathletes wellness focusing primarily on their physical intellectual social and emotional wellness the studentwellbeing of athletes needs to be addressed early in their university career because this is a crucial time for them to build a healthy lifestyle that will ultimately affect their academic and athletic performance students growth is greatly impacted by their participation in sports more studies have been conducted in this field as researchers have come to understand the value of participating in sports participating in sporting activities has been linked to less depression symptoms higher levels of enjoyment and life satisfaction and better student health in addition students will increase their social networks broaden their range of life experiences and open up career and educational options in sports by participating in sports they need to engage in sportsrelated activities to unwind from difficult academic work furthermore most students will enter a sophisticated culture after graduating from college where social connection is essential therefore it is undeniable that the social events on campus benefit students much for instance many other universities may participate when the university hosts a sporting event as a result the students can interact with many individuals and meet new people while exchanging ideas and opinions on various topics students education will also be aided by participating in athletic events that the institution has planned methodology this study utilized a quantitativedescriptive research design since it assessed the degree of need for students involvement in five categories leadership formation sociocultural performing arts advocacy programs clubs and organizations involvement sports and wellness programs it was conducted at notre dame of marbel university koronadal city south cotabato in the school years 20192020 and 20212022 the respondents of the study were the 345 students of ndmu selected through convenient sampling the researcher developed a needs assessment survey tool that was used in gathering data an online survey was the method employed in collecting the data descriptive statistics were employed in analyzing the data a weighted mean was used to analyze the degree of need for students participation in different categories results and discussion i leadership and formation mean overall mean 330 high degree of need based on the results there is a high degree of need to address the leadership and formation of the students who have an overall mean of 330 the study also shows a high need for learning more about the styles and qualities of effective leadership with a mean of 332 it is also important for them to learn more about their selfdiscovery and to have awareness about leadership students who participated in this study wanted to learn more about how to manage groups and team building to have an effect on leadership with a mean of 333 they believe that there is a high degree of need to improve their communication skills good decision making and effective handling of meetings there is also a need to learn more about cash flow preparation and basic auditing in contrast there is a moderate degree of need for students to learn more about marist leadership marcelins mission and spirituality to be effective marist leaders with a mean of 311 from the perspective of the students learning more about value clarification has a moderate degree of need to develop with a mean of 320 they wanted to experience more pastoral leadership by joining community and extension activities which should be addressed moderately ii sociocultural and performing arts overall mean 310 moderate degree of need the table presents the extent of the need to address the sociocultural and performing arts of the students who are participating in the activities related to them the results show that there is moderate degree of need to intensify the program that will help the students improve their skills in performing with an overall mean of 310 based on the data gathered students have a moderate degree of need to learn some basic skills in dancing singing acting and playing instruments with a mean of 318 with a result of 316 there is also a moderate need to experience tedious training and practice to improve their skills be more flexible as a performer and be exposed to develop their confidence in performing there is a need for them to have an enrichment session that will help in developing their discipline as a performance and they wanted a person who would look at the progress of their performance the results also reveal that a need to develop their professionalism as performers and learn more techniques for performing garnered a mean of 301 and 314 respectively which means that they moderately need it iii advocacy program overall mean 323 moderate degree of need the table shows the specific needs of the students to facilitate their advocacy programs based on the results there is a moderate degree of need to enhance the social and communication skills of the students who wanted to organize a community project with an overall mean of 323 a majority of the respondents wanted to moderately address their needs which included the need to learn project development evaluation and develop their facilitating skills for the implementation of programs and initiatives with a mean of 324 there is also a moderate degree of need to intensify the communication skills of the students when facing other partners in the programs and projects and learn how to analyze the problems needed in the community the results of the data gathering show that the involvement of the students in clubs and organizations has a moderate degree of need to be improved with an overall mean of 320 based on the data students need moderate training for the organizations financial management with a mean of 324 officers and members also need training on conflict management in the organization with a mean of 323 there is a moderate degree of need for students to have more training in effective leadership and sports and wellness programs and activities are essential for them as students participating in sports programs allows students to balance their time with academics and develop their conscious effort on it for a mean of 326 all in all the sports and wellness programs of the university have a moderate degree of need to intensify or address with an overall mean of 319 iv involvement in the v sports and wellness conclusions and recommendations based on the findings of the study it was found out that four categories gained a moderate degree of need such as sociocultural performing arts advocacy program clubs and organizations involvement sports and wellness program however leadership and formation resulted to high degree of need it was revealed that the school should intensify the programs that will help students improve their skills in performing also there is a need to enhance the social communication skills of the students who want to organize community projects in addition involvement in the clubs and organizations of the students must be improved the institution should address sports and wellness programs in order to strengthen the activities lastly there is a need to evaluate the leadership and formation of the students since the result is a high degree of need recommendation given the findings of the study researchers recommended the following 1 all students should be extended opportunities for formal and informal leadership responsibilities 2 reevaluate the conduct of leadership training support guidance and mentorship 3 there should be a development of competencies in sociocultural performing arts advocacy programs clubs and organizations involvement sports and wellness programs 4 reexamine the programs with a moderate degree of need it should be evaluated and improved effectively

this study assessed needs for development programs of ndmu students in terms of leadership formation sociocultural performing arts advocacy programs involvement in clubs and organizations and sports and wellness programs it was conducted at notre dame of marbel university with 345 respondents enrolled in the school year 20192022 and was selected through convenient sampling researchermade on needs assessment survey questionnaire was employed and online survey method was used in gathering the data this study also utilized a quantitativedescriptive research design using descriptive statistics in analyzing the data the mean was used to determine the degree of involvement of students in different categories data revealed that there is a high degree of need to address the leadership and formation of students with an overall mean of 330 also in sociocultural and performing arts it was found out that there is moderate degree of need to intensify the program that will help the students improve their skills in performing with an overall mean of 310 in terms of the advocacy program there is a moderate degree of need to enhance the social and communication skills of the students who wanted to organize community projects with an overall mean of 323 further the data gathered showed that the involvement in the clubs and organizations of the students has a moderate degree of need to be improved with an overall mean of 320 and when it comes to sports and wellness there is a moderate degree of need to intensify or address with an overall mean of 319 since there is a high degree of need for leadership and formation there is a need to strengthen the activities involved in this category on the other hand four 4 categories were assessed as having moderate need there is also a need to revisit and evaluate to justify making these programs more effective

introduction dropping out of higher education is a global phenomenon and it affects virtually all universities that is why higher education institutions have researched the kinds of dropouts their causes and consequences ever since the early 20th century and in particular since the 1970s duránaponte and pujol argue that university dropouts can be classified under one of three heads voluntary temporary scope however research currently under way on the phenomenon tends to focus on initial or early voluntary dropout that is because this is when most dropouts tend to occur also for practical reasons most studies focus on internal dropouts and institutional dropouts practical reasons lie behind this focus especially with regard to sample identification such studies cover a wide range of variables in order to avoid the biases that were once common detailed study of the factors involved in university dropout has both given rise to different explanatory models of the phenomenon and revealed its complexity some models focus solely on the possible influence of economic variables other models focus on the various psychological characteristics of students who dropout yet others stress the influence of sociological factors that go beyond the individual or that affect the education institution itself or on the interaction between these two all models look at variables that may explain dropout and shed light on the phenomenon that said at present one of the most commonly applied ones is a reformulation of tintos adaptive explicative model this model highlights the importance of characteristics predating university entry and variables such as background and student adaptation to the institutions social and academic atmosphere as factors determining student dropout this model has been criticized for failing to take into account the cultural diversity of students or variables outside the academic context such as family involvement notwithstanding these criticisms the variables included by tinto in his model seem to carry weight in studies regardless of the context in which they were carried out this is especially true in those covering the first year of university on the other hand learning theorists believe that a students commitment to his studies and ability to tackle tasks in a strategic fashion are important variables in academic performance they argue that these variables bear heavily on students deciding whether to stay on at university or to dropout students academic adaptation to the university setting thus assumes great importance in the decision to either continue ones studies or to dropout it seems reasonable to think that it is the students who fail at university that dropout not those that succeed of the dropout related variables falling under the head of background it seems that the students academic track record and the students financial possibilities are constantly found to be relevant factors some research shows that preuniversity training can play a role in fostering continuation and completion of the students academic studies thus some university entrance options are associated with higher dropout rates than others reserved place schemes stand out in this respect this seems to be because students entering through reserved place schemes have different backgrounds from those entering straight from school here students joining from school are more likely to complete their studies than those that do not similarly student performance at this stage lays the foundations for future academic attainment this is because academic grades prior to entry are a good predictor of university performance something corroborated by casaravilla et al and thus of the likelihood of a student dropping out however one must also take into account the link between choice of degree and reasons for dropping out as duncan noted this is because informed choice of degree is a predictor of both switching studies and of dropout from higher education here we should bear in mind that although students may know and wish to entry in a particular degree a limited availability of places and the requirements of the institution often prevent them from getting enrolled in their first choice not surprisingly students who have to make do with another choice of degree are more likely to dropout in fact 80 of students who dropout of certain degree programs had not taken them as their first choice this was so because either the students matriculation grade was too low to get their first choice or factors other than student motivation played a role in addition to the students academic background financial support is also a constant factor students financial circumstances and the opportunity cost of undertaking university studies play a role students who depend on their own slender resources at university and especially those doing a fulltime job during their studies are the ones who are likeliest to dropout while these variables have been shown to be highly relevant they only partly predict university dropouts that is because dropping out is a complex phenomenon accordingly other variables need to be taken into account to explain why students facing similar risks and challenges and taking the same degrees still manage to graduate given this the students social adaptation to university his motivation commitment and ability to meet academic demands could be the answer there are many variables that influence a students decision on whether to dropout or to continue studying a point noted by tinto some of these variables lie beyond the universitys control an example here might be the cultural level of the students family so while we concede the theoretical interest of analyzing all aspects bearing on dropping out of university in this paper we shall focus on those where universities have a chance of making a difference university study habits and techniques are linked to both academic performance and student dropout given the results obtained by vermetten et al and schmeck we acknowledge that the most suitable study techniques may vary with the kind of academic training imparted and the students preferred learning styles depending on the degree chosen the students study techniques may or may not be those required for successful completion of the course hence the need to detect mismatches between students study techniques and academic requirements and to take remedial action are necessary in this regard regular class attendance makes it easier to freshmen to adapt and develop their skills in order to match the requirements of their particularstudy program promoting a good academic progress at university regular class attendance also facilitates social contacts helping to forge links among students parents faculty and other university staff such relationships not only foster students social and academic adaptation but also help keep students in the degree program student support services play a particularly important role in this regard however the results may be mediated by the teaching methodology and teaching method as braxton et al have highlighted these variables are highly relevant it therefore behooves universities to delve into them so that they can improve their teaching and organizational methods here universities cannot shirk their responsibilities by laying all the blame for dropouts on student fecklessness a point made by tinto instead universities should strive harder to meet students needs one should not blithely assume that a student who drops out does so because he is poorly motivated does not work hard enough or lacks ability nor should such arguments be taken as an excuse for the university to wash its hands of the situation instead the university must grasp the risk factors so that the right remedial measures can be taken the university should work with both the student and others providing as many tools as possible to ensure students graduate one should also bear in mind the longitudinal dimension of dropping out a point stressed by tinto in order to explain different kinds of dropouts regarding on the moment when the student makes this decision tinto draws on anthropological studies on trive rites of passage arguing that access to higher education is comparable to these ancient rites symbolizing the transition of individuals from one social group to another here it is necessary to to recognize feelings of isolation and weakness similar to those described by durkheim under the term anomie given the plethora of research studies undertaken to date and for diverse purposes one wonders whether further contributions to knowledge are needed in this field nevertheless studying which factors affect dropping out in every cultural context is vital if one is to come up with effective welltargeted countermeasures that is because students circumstances and educational levels vary among countries and the regions within them as lamb et al state some educational systems are more effective than others at hanging on to students and making sure they graduate in northern spain although students show many similarities with those in other countries they also exhibit major differences spanish students tend not to live on a university campusunlike the case elsewhere this means that most interaction takes place in classrooms classes tend to be large sometimes over a hundred students making it hard if not impossible to cater to individual needs there is little cultural or ethnic diversity and nontraditional students who are more likely to dropout as found in other studies such as those by stoessel et al are very thin on the ground in spanish universities that is because such students tend to dropout of school and do not make it to higher education or opt for vocational training instead the link between getting a university degree and a job postgraduation is weaker than in other countries few students resort to bank loans to fund their studies and hence the financial disincentives for dropping are not as stark as di pietro highlighted dropping out is a phenomenon that is linked to time and setting it therefore behooves universities to constantly update their analyses of the problem accordingly our study analyses the differences between those students who dropout and those who stay on the variables examined for this purpose cover personal social and academic characteristics that may affect adaptation between student and institution regarding the literature review we assume the following hypothesis students that decided to dropout have worse integration than those who persist students than quit their university degree migth have worse relationships with teachers and peers than those who do not quit participants behavior would be better in the persistence groups in comparison to the dropout group materials and methods procedure and instruments this paper has followed an ex post facto design the information was gathered in three stages and from two sources initially the university filtered personal information of students who were dropping out it then chose a control group with similar characteristics to the dropouts informed consent was then obtained from each of the students who were to take part in the study once consent was given the third step was for students to answer the ad hoc questionnaire which was administered remotely the questionnaire applied within the alfaguide project framework consisted of over 100 items to be completed by the institution and students it gathered information on the students that was of a demographic personal social institutional and academic nature this questionnaire solely covered information on those personal variables bearing on the study objectives that is to say it bore on variables linked to university entry reasons for taking a degree adaptation to the institution student behavior in performing academic tasks but discounted performance accordingly the study excluded variables whose natures were demographic family institutional and nonacademic specifically the questionnaire used comprised background variables four of them dichotomous bearing on the reason for the students choice of degree a nominal variable on matriculation route two nominal variables on the students financial means and a 5point likert scale covering socialacademic data two personal variables on the students perception of his academic and social adaptation to the institution and four academic and personal variables on general performance data analysis differences between those students who stayed on and those who dropped out were considered in relation to reason for degree choice the entry path to college and financial dependence the results were analyzed using the chisquare test given the dichotomousnominal nature of the variables used the students ttest for independent samples was used to see whether there were statistically significant differences between stayers and dropouts depending on the impact of personal social and academic variables in each case all the variables met the assumption of normality following the criterion proposed by finney and distefano but not all of them met the assumption of homogeneity of variance accordingly equal variances in the variables was not assumed the effect size of statistically significant differences was estimated by the d cohen statistic applying the criteria set out in cohens results regarding students first choice of degree a statistically significant relationship was observed for matriculation being made mainly on vocational grounds with students who continued their university studies showing a higher percentage for this reason than was the case for dropouts as for the other reasons for choice no statistical differences were observed in any of the cases interest in the labor market family tradition and professional orientation as for the remaining background variables there are statistically significant differences in both cases that is to say in both the path to college being more common for students who stay on to have joined university straight from school and in relation to financial aspects being more common for students who are financially independent to show higher dropout rates table 2 shows the descriptive results for the group of students that persist and the dropout group depending on the personal variables bearing on students coexistence in the institution social and academic adaptation and general performance the posible values of these variables rank from 1 to 5 as can be observed theses means go from 35 to 441 being relationship with peers the one with the highest mean for both groups also obtaining remarkable puntuations the rest of variables from this group adaptation and performance also obtained high puntuations regarding their means as for the variance within each group class attendance present the highest standard deviation showing a relevant variablity in class attendance habtis in both groups results of mean comparison showed that boththose who presist and those who quit atribute a good value in regard to its social relationships no difference was found between the two groups regarding university atmosphere and coexistence or peer relationships however this rating is significantly higher in the case of the persistence group when it comes to the studentteacher relationship although the effect size is small in spite of the general perception by students that the relational environment is good data also reveal how the level of social adaptation to the institution is higher in students who didnt give up resulting in statistically significant differences with a small effect size in other words whether students continue studying or dropout a positive interaction between students and between students and teachers can be observed that said the students who dropout adapt whose than those who stay on on the other hand there are statistically significant differences regarding the level of academic adaptation again students who persist show greater adaptation than the dropouts with statistically significant differences with a medium size effect as for students academic performance there are statistically significant differences between both groups in terms of the time they devoted to studying the use of study techniques and class attendance in regard of the size effect a greater effect was found for study time and the use of study techniques than for class attendance showing how stayers spend more time working on their own and taking a more strategic approach to academic tasks in addition statistically significant differences between the two groups were observed with regard to program compliance although the effect size is small discussion the beginning of university studies is the turning point in a transition that spans from the start of the course predating college entry to the end of the first year of university both students and institutions need to make social and academic adjustments in the light of the degree program however as tinto noted freshers may encounter problems from the outset if they are not given sufficient support they may end up adapting poorly to their new university setting here one needs to be aware that many of the variables that affect the dropout rate lie beyond universities control two such factors are the students socioeconomic status and his entry path that is why it is advisable to focus analysis on those problems where the institution has some leeway that is why under the european alfiaguide project for dropout management the university of oviedo considered studying those variables that might hinder such adaptation between the student and the institution and which the university was in a position to do something about it was also planned for the study to take into account the reasons given by students for their choice of degree vocation and the financial and other support provided by the university thus both socalled background variables were examined as for variables bearing on social integration and adaptation to academic life three of them did not influence either relations with peers or rating of coexistence this finding may have been colored by the tendency of stayers and dropouts alike to positively rate both aspects the results confirm that the relationships forged between teachers and students contribute to academic results and the completion of degree studies these findings are consistent with those obtained by other authors and confirm our first and hypothesis a university is a very different beast from a secondary school not only in terms of academic and administrative size but also with regard to its social scope hence the need to ensure student adaptation to this new context here our study has shown that a student is more likely to persevere with his studies if he is well adapted similar results were obtained by tinto duncan and elias in this regard one should note that the world health organization recommends that education institutions should foster good relations as part of their duty to care for their students health and welfare this makes it vital to improve university teachers initial and continuing training so that faculty members have the knowledge and skills they need to effectively play their tutorial role in the way described by troyano and garcía in this respect it is also essential that this tutoring role be institutionally acknowledged something also suggested by albione et al in connection with the foregoing it has been found that some paths to university facilitate this adaptation better than others here our findings are similar to those obtained by lassibille and navarro and rodrigo et al that is why we recommend special remedial measures be taken for students entering university by paths other than straight from school leaving freshers educational backgrounds aside adaptation to the university setting is a long and often arduous process for many students this fact makes it advisable to take measures aimed at the student body as a whole here one should note the impact of the passing and application of the university student statute in recent years at spanish universities the statute followed on from implementation of the european higher education area which recognizes students rights to tutoring and guidance as part of their education the statute has encouraged spanish universities to set up specific plans of action for tutoring in the various programs offered the aim of these plans is to provide career and lifelong guidance and to monitor student learning putting such plans into action is fraught with difficulties given universities lack of sufficient resources in any event it is worth faculties drawing up a comprehensive plan of action for student tutorials and monitoring on the lines suggested by álvarez and gonzález as for the variables reflecting the students performance and its relation with the studied phenomenon our findings reveal that only these three variables are linked to dropping out from university poor class attendance has been proven to be strongly linked to dropping out from university this is in line with the results obtained by iñigo et al andbernardo et al nevertheless the variable has a low size effect because merely attending classes is no guarantee that the student will benefit from them as pintor et al highlight on the other hand time spent studyingworking on ones own in an assiduous fashion outside exam periods helps shape a students study habits and has proven to boost degree completion rates there is a medium size effect in this case similar results were obtained by elias and trevizán et al and are supported by the findings of broadbent and poon who concluded that almost all research studies found a link between time management and academic success likewise intensive use of study techniques has also been shown to correlate strongly with degree completion in view of the advanced specialized content found in modern curriculums it comes as little surprise that university students can now bring a wider range of learning strategies and study techniques to bear in their academic work these findings are consistent with those of bethencourt et al who affirm that this of variables play a remarkable role in dropping out of university thus students who persist spend more time working on their own and do a better use of study techniques such students are more authonomous in the teachinglearning process which confirms that training measures focusing on these skills will yield better academic results for example azevedo et al proposed the use of metatutor software which purpose is to provide diagnosis and training for selflearning in virtual settings the software also allows one to broaden scientific knowledge of these highly popular environments and provides a useful tool for greatly boosting students academic performance one of the questions that now arises is how to put theory into practice ie get the students retention in university classrooms given the results of our research it seems that the institution as a whole and its role in the eheas work are both on the right track however one must also give students tools to help them adapt academically and its diverse demands the introduction of hosting programs all help boost academic performance and completion of studies however at this point one should recall the recommendation made by tinto and pusser on the need to systematically tackle the issue of university dropouts all remedial measures need to form part of an institutional action plan that involves the various groups and ensures proper resource management the aim should be to exploit synergies to render plan implementation more effective nevertheless the greatest limitations here stem from the savage cuts that have been made in spanish universities since the beginning of the present economic crisis makes it hard to implement such plans and research into the problem of university dropout future research might employ a representative sample of students from other universities operating in similar cultural settings and analyze whether the results here are consistent with those found in other branches of knowledge limitations and future reseach this paper show results obtained in an ex post facto research althougth this research method have important limitations such as the inability to manipulate the independent variables our research team considered that was the most suitable design it is not practical to apply experimental design to study university dropout as this kind of design would oblige us to wait at least 1 year between the aplication of the pretest and the posttest in order to wait for the phenomenon to occur however the cost and time savings result of this kind of research are remarkables advantages that we took into account it is also neccessary highlight that in this research we have not explored in depth the psychological characteristics of our participants and are often related to dropout due to budget and time limitations therefore it would be advisable to develop further research to analyze the influence of these variables in the phenomenon funding alfaguia project was developed thanks to the european union funding conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest copyright © 2016 bernardo esteban fernández cervero tuero and solano this is an openaccess article distributed under the terms of the creative commons attribution license the use distribution or reproduction in other forums is permitted provided the original author or licensor are credited and that the original publication in this journal is cited in accordance with accepted academic practice no use distribution or reproduction is permitted which does not comply with these terms

dropping out of university has serious consequences not only for the student who drops out but also for the institution and society as a whole although this phenomenon has been widely studied there is a need for broader knowledge of the context in which it occurs yet research on the subject often focuses on variables that although they affect dropout rates lie beyond a universitys control this makes it hard to come up with effective preventive measures that is why a northern spanish university has undertaken a ex post facto holistic research study on 1311 freshmen 20089 200910 and 201011 cohorts the study falls within the framework of the alfaguia european project and focuses on those dropout factors where there is scope for taking remedial measures this research explored the possible relationship of degree dropout and different categories of variables variables related to the educational stage prior to university entry path to entry university and main reason for degree choice variables related to integration and coexistence at university social integration academic integration relationships with teacherspeers and value of the living environment financial status and performance during university studies in terms of compliance with the program time devoted to study use of study techniques and class attendance descriptive correlational and variance analyses were conducted to discover which of these variables really distinguish those students who dropout from their peers who complete their studies results highlight the influence of vocation as main reason for degree choice path to university entry financial independency social and academic adaptation time devoted to study use of study techniques and program compliance in the studied phenomenon

introduction with the changing and transforming world generations and the expectations of generations are changing 1 a generation is defined as a group of people born in the same date range and affected positively or negatively by the factors experienced within this date range as well as having common characteristics with each other 2 when defining generations four generations are mentioned the traditional generation was born between 1927 and 1945 the baby boom generation was born between 1946 and 1964 generation x was born between 1965 and 1980 and generation y was born between 1981 and 1999 the generation born in 2000 and after is called generation z and this generation is also called different names such as internet kids digital generation and crystal generation the essential characteristics of this generation are trust speed and dependence on technology 3 4 5 6 generation z is the future generation trying to understand the world in a changing world although they are a socially empowered generation sociability is often seen as social media activity and diversity of connections differ for example the name of the examination for transition to anatolian and science high schools was changed in 2000 and the high school entrance examination was introduced in 2004 the scope of the exam was expanded and private schools and police colleges were included in this centralized system the secondary education institutions selection and placement examination were renamed the seis was administered until 2007 and was replaced by the placement examination which was introduced in grades 67 and 8 in 2008 the pe exam was abolished in 2014 in 2012 at the same time as the decree law no 6287 the 444 system was introduced compulsory education was increased to twelve years and secondary education was included within the scope of mandatory education in 2014 the teog system was introduced in 2017 the teog system was abolished and replaced by the education regionaddressbased secondary education transition system 14 likewise there have been many changes in the university entrance exam in a short period just like the high school entrance exam millions of generation z students in türkiye take university exams every year and strive to have a profession however university education does not eliminate the problem of unemployment 15 increasing unemployment rates in our country 13 further increase young peoples anxiety and hopelessness about the future therefore the mental health of generation z students who experience anxiety and hopelessness can be negatively affected 16 furthermore university life is generally seen as being when people travel see and have fun the most the quality of life of generation z students is related to the welfare level of their country naturally the countrys prosperity level affects the social lives and health of generation z students in our country 15 the perspectives of this generation which develops and grows with technology and their attitudes and behaviors towards the future differ from those of other generations based on these differences professional organizations and public health bodies need to measure the careerand future expectations and perceptions of individuals in this generation with the start of generation z students participating in business life 117 generation z students thoughts about their future and the stress and anxieties they experience inevitably affect both the physical and mental health of this generation for this reason public health and community mental health nurses working in this field should know the views and expectations of generation z students well accordingly this study aimed to determine generation z students perceptions about the future at a foundation university in türkiye this study might contribute to the literature on determining the futureoriented perceptions possible stressors and hope levels of generation z university students in türkiye additionally intervention programs can be developed for these stressors to protect the mental health of generation z university students materials and methods in the reporting of this study the consolidated criteria for reporting qualitative studies which are frequently used in reporting qualitative studies were followed 18 aim and study design phenomenological research aims to understand how people evaluate the events they encounter daily it investigates the phenomena that are not foreign to participants but cannot be fully grasped and expresses the feelings that develop against these phenomena 19 since this study aimed to determine the thoughts of a group of generation z students studying at a university about the future it was conducted using qualitative research and a phenomenological design in this study the following fundamental question was sought to be answered what are the perceptions of generation z university students about the future setting the studys data were collected through online indepth individual interviews with a group of university students studying at a foundation university in istanbul between 16 february 2022 and 19 june 2023 in the spring semester of the 20222023 academic year via the online zoom platform the reason for conducting the study at a foundation university was related to the experiences of the authors involved in the study and the collaboration with the data that could be collected at the university the data collection was planned to be facetoface however due to the devastating earthquake on 6 february 2023 in türkiye the study data had to be collected online as universities switched to distanced education data collection the most frequently used data collection method in qualitative research is indepth interviews in interviews individuals can express their opinions understandings and feelings about experiences that they have not been aware of or thought about before and about issues that they frequently encounter daily which are not unfamiliar but which they cannot comprehend 19 in this study individual indepth interviews were conducted with the participants first a post was prepared about the purpose and scope of the study announcements about the study were made on the researchers social media accounts with the study post the students who gave feedback that they wanted to participate in the study were contacted and the days and times of the interviews were planned interviews were conducted via the online zoom platform and lasted an average of 30 min the fact that the researchers conducting the study experienced similar phenomena and wanted to investigate the phenomenon and were students at the institution where the study was conducted facilitated the collection of study data the interviews were conducted by three females and one male senior nursing student before the interview training on interviews was given by senior faculty experienced in qualitative research and supervision continued during the process interviews were recorded with the consent of the participants three participants were then asked to read the themes and subthemes and changes were made individual indepth interviews were conducted using a semistructured interview form this form consisted of two parts in the first part seven questions were about the students sociodemographic characteristics the second part had two questions to determine the generation z students thoughts about their futures 21 22 23 24 25 26 these questions were what do you think and feel about your future what are the perceptions of generation z university students about the future ethical consideration the ethics committees permission was obtained from the fenerbahce university noninterventional clinical research ethics committee dated 3 november 2022 and numbered e88813803204010714256 institutional permission was obtained from the university rectorate numbered e62751 84510014638 and dated 14 november 2022 in addition verbal and written informed consent was obtained from the students participating in the study the study complied with the declaration of helsinki and the personal data protection law using the participants statements their anonymity was preserved without giving their names or genders data analysis in this study descriptive data were analyzed in excel the primary descriptive data analysis used mean minimum maximum number and percentage qualitative data analysis aims to explain describe and explore the study of qualitative data starts with the data collection process and continues until the report is written after the analysis 27 in phenomenological research the researcher is expected to be more than a simple recorder the study begins with the researchers encounter with the phenomenon and the formation of their first awareness interest and expectations regarding the phenomenon the researchers listened to and read the participants experiences of the phenomenon thus accessing the embedded data the authors did not utilize any structured themes or subthemes from the literature the themes were created according to the interviews in this study colaizzis phenomenological interpretation method was used to analyze the data and followed the following steps 28 important statements directly related to the phenomenon were selected these crucial statements were interpreted and their meanings were coded the coded definitions were grouped into subthemes themes and categories the results obtained were combined with rich and comprehensive life experiences the basic conceptual structure of the phenomenon was defined three participants were asked to read the themes and subthemes obtained and to validate the findings by comparing the participants own experiences gd who is experienced in qualitative research and is a psychiatric and mental health nursing academician analyzed the data with the other researchers in addition another researcher who was not involved in the study provided feedback on the process results the content analysis revealed three main themes and eleven subthemes the first theme was the students thoughts on the current situation of the country under this theme there were findings about economic problems immigrants the education and justice systems and the rapidly changing agenda of the country in the second theme students shared their thoughts on being a student in the country this theme included the economic impossibilities experienced by students their inability or limited participation in social activities and the housing problem they face in the last theme future anxiety it was determined that students experienced hopelessness versus hope this uncertainty caused anxiety and a belief that they had to in future go abroad find a job or improve themselves the current situation of the country during the interview the participants first provided information about the current situation of the country they mentioned that the economy is not good the number of migrants is high and that migrants are a problem for the countrys security some of the participants talked about the negative aspects of the education and justice systems in contrast some participants talked about the positive aspects of the justice system in particular finally under this theme participants stated that the countrys agenda can change rapidly and that they cannot follow it economy most participants expressed that the economic situation in the country is not good participants mentioned that purchasing power is decreasing basic needs can be considered luxuries and that people must work more due to inflation and price hikes one participant summarized his views on this issue as follows let me start with the economy i would not say i like it conditions are awful and purchasing power is deficient even the smallest thing has become a luxury for people i can say that this place türkiye has turned into hell a wonderful country has turned into hell economically i do not want to say other bad things this is enough while one participant stated that the situation in the country is related to the recent kahramanmaraş earthquake on 6 february 2023 and that the problem is not going well another participant commented on how the economy affects their daily needs and their opinion on the past and current economy as follows like everyone else i find the current conditions of our country bad right now it is more difficult to make a living compared to the past for example it used to be possible to live in a house with one person working but now this is impossible everyone is having a tough time because the money earned is not logical enough whether it is kitchen expenses or rent it is costly compared to the past it used to be easier to make a living in the past immigrants most participants discussed the rapid increase in the migrant population and the resulting security problems some however argued that the rising population could become a problem due to overcrowding and that migrants should be sent back to their countries the migrant problem started years ago it is not something new i think the borders should be closed and migrants should be sent to their own countries we have a very crowded population and we see migrants coming to our country every day on the news they cause a lot of trouble our people started to feel very uncomfortable so i think they should be sent back to their own countries for the countrys security some of the participants stated that there are cultural conflicts due to migrants and that there was more love and tolerance in the past which has now deteriorated they also mentioned that there is a lack of a policy on immigration which leads to other problems one participant stated that immigrants in our country are given more privileges than citizens and that this situation is harrowing for example when there was respect love tolerance when people were trying to understand each other trying to taste each others cultures now on the contrary everyone is at war this may cause the refugees to have a bad situation a solution should have been found for them the citizens of that country should not have come to this country if they are coming there should have been a strategic plan do the current conditions of the country fit this what problems will arise as a result at the simplest level the people from there coming here as refugees have affected many of our people here both numerically and culturally everyone is in a conflict of interest at the simplest level our citizens here cannot find a house it is excruciating that they should prioritize their citizens give priority to them when they should come first and that this is negative the education and justice systems most participants were dissatisfied with the countrys education system and said it changes frequently one participant argued that the foundations of primary school education should be laid firmly and that change should start in this direction our education system is horrible i think primary school is the most important there is only teaching and no education in this system the foundation needs to be laid solid primary school education is the most important step for a country some of the participants stated that the overall situation of the country depends on the level of education of the people in the country and that low levels of education can pose a problem in managing the crisis unfortunately since the population of uneducated people in society is very high i think the current situation of our country is automatically affected by education so i do not know it must go through a solid education and be shaken up solutions need to be produced most of the time something negative happens in the country such as a disaster and people support each other this should not happen what do other countries do they all need to have strategic planning unfortunately i am sorry to say i think we can say that education is very bad terrible furthermore some participants mentioned that the education system and the current justice and legal systems have improved positively one participant stated that the judiciary is fair and the country is more accessible as follows in the current era our country has positive and negative aspects generally speaking türkiye is a country where everyone is judged fairly and speaks freely for these reasons i like türkiyes justice system very much the countrys agenda participants stated that the countrys agenda changes rapidly and needs help in particular they said that issues such as earthquakes and politics are at the forefront of the agenda and that they often follow the agenda on social media some of the participants said that the agenda often consists of adverse situations one participant interpreted this situation as follows our current agenda is the election our agenda before that was the earthquake since it was an election year the earthquake somewhat suppressed the earthquake agenda since it was an election year the earthquake normally remained in the background i mostly follow the news i use social media i use instagram on social media i follow news channels i check twitter now and then our agenda changes very quickly in türkiye it is hard to follow türkiye there is different news on every platform i mean i go to instagram and there is different news i go on twitter and there is different news since our agenda changes frequently it is challenging to follow it but we never see anything good we always see negative news again a participant who thinks that the countrys future is not positive stated that television channels present biased news therefore the participant follows the agenda on social media i usually follow the countrys agenda on social media because i think television journalism is generally biased it is either rightwing or leftwing none of them in my opinion convey the right information honestly thats why i usually follow them on twitter or news sites i trust i do not see a good trend i am not hopeful some participants said they often follow the countrys agenda on social media because they find it more reliable however sometimes social media is blocked one participant summarized this situation and how she had become accustomed to receiving more and more negative news as follows i usually follow the countrys agenda on twitter unless of course it is blocked because sometimes it is unfortunately shut down the agenda is bad right now in fact it is bad in general but after a while we get used to the events because every day we encounter more bad news than the day before i guess we are partially used to it now therefore we are not very surprised one of the participants said that sometimes the same information is shared in the news so she cannot obtain uptodate information and that she follows the countrys agenda from international sources it is minimal to access this timeliness every passing day let me put it this way the same things are repeated every day or one day is such a day that it never matches a day in the past i mean its like the state of the economy when there is an earthquake there is a burst of inflation and everything falls apart im using linkedin right now i follow the new york times to see whats happening in the world rather than in türkiye let me tell you that the world is shaping the countrys situation on the one hand on the one hand i follow the european union page i think i looked yesterday there were meetings about türkiye like an aid fund or something like that i look at such things and wonder what is being done in our country being a student in the country under this theme participants defined being a student in this country as an economic impossibility with an inability to participate sufficiently in social activities and having to face housing problems economic impossibilities participants stated that being a student in this country is economically challenging especially because studying in a city other than where the family is located brings economic difficulties for this reason it was determined that all participants lived in the same city with their families one participant stated that this situation could be due to economic and security reasons it is challenging economically speaking it is tough it is challenging to leave your home and live in a student house because of the current economic conditions families do not want to send their children to university because of the security problems in other cities i have seen this many times from my friends from my environment it is difficult both financially and in terms of security participants stated that even buying books constitutes an expenditure one participant thought that being a student in our country is a bad thing not good compared to the past or the present and that the economic situation affects normal and social life as follows being a student in our country is a bad thing because students in our country seem to be good compared to the past but they are not because everything in our country depends on the economy since the economic situation is not very good students need to be more efficient in their normal social lives and student life one of the participants stated that being a student in our country is related to ones financial situation if ones financial situation is terrible it is challenging but if it is good one can receive a quality education and student life is fun if your financial situation is bad being a student in our country is complicated unfortunately we must pay a certain fee to get a quality education from quality dormitories in this case receiving an education is complicated for students with poor financial situations if your financial situation is good i think being a student in our country is quite high quality and fun another participant stated that being a student is a period that excites entertains and makes people feel happy still it is necessary to think about the economy in every moment of being a student being a student not only for our country but in general is a period that excites and makes people feel happy and they even describe it as the best period of their lives but for our country yes it is fun we spend time with our friends we have fun but at the end of the day we always have to think about material things some of the participants stated that they may have nutritional problems as a student and that they calculate whether to drink a coffee or eat a dessert one of the participants stated that it was difficult for a student to commute to and from school even to eat where do i start this answer is very long and broad honestly it is not very good i do not think it is economically good i mean for young people like us who are studying at university even when we go to and from school without doing anything even when we go to and from school the cost of transportation and food is too much we are paid more than we should be i think this is also the case with inflation most participants stated that they felt the need to work while studying due to economic conditions that their desired life was not possible under these conditions that they had to work to earn money and that they were stressed because of working and studying simultaneously one participant summarized this situation as follows we feel the need to work while studying at the same time as i said we are struggling otherwise life cannot be earned in any other way we would also like to get an education everything is good at the time but unfortunately this is impossible within these opportunities the inability to participate in social activities most participants mentioned that they could not participate in social activities due to economic impossibilities and futurerelated concerns they stated that being a student constitutes the best years of ones life but that some peers cannot participate in ethical activities and spend these years at home one participant emphasized that they did not want to do anything due to futurerelated anxiety the best years of my life should be student life i think so both socially and in terms of age when people are freer have not yet started a family have not taken responsibility and are most comfortable they continue by not living a university life this way i think the economic situation is the most problematic people cannot do what they want we have students who cannot even participate in activities some students spend their student life only at home this is only because of economic problems i think there is also the sociability side because nowadays students are worried about the future honestly people do not feel like doing anything because of future anxiety the energy of the students has been exploited thats why the student years are not good for students it is the same for me some of the participants expressed that they are in a more disadvantaged situation compared to university students in other countries one of the participants stated that although there are discounts for university students art or cultural activities are a luxury and that these activities should be free of charge for students instead of discounted when we look at our peers in other countries while they can travel comfortably and get their visas easily we cannot even go from this city to city a having such a disadvantage is the simplest i am a student but must visit museums for free not at a discount whenever there is an activity for art in this country it has become a luxury doing these things is a luxury and being a student does not solve anything housing problems all participants stated that they live in the same city with their families and have economic difficulties despite staying in the family house they stated that rent prices have increased a lot in the country recently one of the participants stated that if there is no family home finding a dormitory or moving to a separate house is a financial burden for students and is impossible in these circumstances she stated that living in the family home allows her not to think about expenses but it is still difficult for a student to commute to school and eat i live with my family i do not have to worry about rent this is also a huge factor you even buy toilet paper when you are in a students house even though i dont have such a problem i still have economic difficulties even if i want to study in another city i want to travel and see those places a lot again i dont do anything like that here i worry about making a living it is difficult to make a living even though i pay for food drink transportation to and from school futurerelated anxiety under this theme participants expressed their concerns about their futures some participants said they were hopeful while others said they had no hope participants expressed anxiety due to uncertainties about going abroad finding a job and improving themselves hopelessness versus hope most participants said they tried to have hope in their different situations but some expressed hopelessness one participant stated that people in this country have no hope and can commit suicide i honestly do not think that any young person even the elderly i mean any person trying to live in türkiye has any hope left people commit suicide out of hunger thats why i do not find it beautiful some participants said that they hope to practice their professions in this country and to achieve anything if they make the right moves my plans for the future are that i am working i am in my third year and my school will end this year im considering working in a place like this for another year or two and opening my own sports gym i mean if i work in the right way and if the conditions of that time are suitable i think i have a capacity that i can do according to the current situation of course i dont know what time will show or do but i say there is hope what do i feel i have hope nothing is impossible if i proceed in the right way with the right logic if i take the right step at the right time i think anything can happen thats why my plans for the future include opening a studio of my own and i am hopeful about that uncertainty and anxiety most participants reported experiencing anxiety due to uncertainty some participants said that the uncertainty in their lives affected their sleep patterns as the country had recently experienced an earthquake a participant commented that thoughts about the earthquake made her feel bad that she was anxious and wanted to isolate herself from everything that her mental health was negatively affected and that she could not direct her life with the following words psychologically sometimes i can not sleep at night because of these thoughts i am with these ideas and thoughts every day every day there is such a thing as looking at the ceiling and sleeping there is no such thing as looking at the ceiling and sleeping there is such a thing as continuing to stare at the ceiling so for me now the nights and mornings are mixed up i do not know what to do we are in a constant state of uncertainty maybe a natural disaster is affecting us today but on the other hand im thinking about what we can do if there is an earthquake right now my psychology has deteriorated so much now that im thinking about the future and now im thinking about what i can do if i experience a bad situation i cant escape it anymore my soul is shrinking like this i can not come to my senses i have been isolated from everything for a long time these thoughts spoil my psychology like every young person and i cant direct my life anymore constant uncertainty some participants stated that this uncertainty is more pronounced in our country than in other countries and is felt less in other countries one participant expressed this situation and the fact that he only wants to receive an education at the moment as follows i want to get rid of it as soon as possible i am still determining how it will be the worst part is that while a person in another country can say i will do this i will go there i will do these things we cannot say that either the only thing is our own need what we want right now yes i only need to go but i am still determining where or what i will do in the future i want to educate myself at least i want to touch someone with my education i want to educate myself well brain drain some participants stated they wanted to go abroad due to the countrys economic situation participants stated that they dreamed of going abroad because they thought that both job opportunities and living conditions were better elsewhere and that they made plans for this one participant expressed their views on this as follows i wish we all did not have to worry about leaving the country let me put it this way my current problem is leaving the country maybe it is the effect of my department i do not know but i do not want to live in türkiye right now i do not want to live in istanbul either im sorry to say that i wish i were satisfied with where i was born i wish things would settle down on the other hand one participant said he was getting less hopeful and would only stay in the country for a short time i dont see an excellent trend i am not hopeful if my plans for the future continue this way unfortunately as much as i would like to stay here because of the love and debt i feel for atatürk i have lost hope for the rest of my life i will not stay for long 334 finding a job and selfdevelopment most participants expressed that they wanted to graduate find a job and improve in their professions as part of their plans one participant stated that he aimed to be successful in his profession and expressed his positive thoughts in this direction as follows in the future i plan to make valuable works and structures that will be important and remembered in architecture of course i want to do these works in a way that will not harm my ethical values as i said at the beginning i believe my future will be bright and beautiful therefore i always look at my future with positive feelings some participants expressed that they were very stressed and anxious about finding a job and that even if they were successful in the exams for the civil service in this country they could be eliminated in the interviews and were insecure honestly i am in a great anxiety i am burdened with stress i can never cope with stress i constantly think should i do this or that if i do this it will be like this if i do that it will be like this if i take the kpss i will be eliminated in the interview not the exam discussion this study aimed to determine the thoughts of a group of generation z students studying at a foundation university about the future and the data obtained were discussed in line with the main themes of the current situation of this country being a student in this country future anxiety and the literature students frequently expressed negative thoughts about the general condition of the country they stated that the countrys economy is not good inflation is high everything is constantly getting more expensive and as students they are negatively affected by these economic impossibilities especially under the theme of being a student participants stated that they stay in the same city and live in the same house with their families due to economic constraints at the same time their friends have difficulties finding dormitories and homes in addition to housing participants stated that nutrition transportation and social activities are almost luxuries more than half of the participants reported having a job to be able to do or buy what they want according to a study by özkan et al in türkiye students housing and nutrition expenditures accounted for 50 of their total spending 29 however the increasing inflation rates after climate change and the pandemic worldwide have enveloped the countries economies in this case these expenditures are thought to be more than 50 participants frequently referred to economic hardship they stated that their university years were good however they had social housing and economic difficulties due to a lack of opportunities the inflation rates confirmed the difficulties felt by the participants in meeting their housing nutrition and social needs therefore the participants mentioned that they have worked at the same time in addition in the current study the participants stated that they were considering migrating abroad due to financial problems migration is an experience that negatively affects mental health as it entails adapting to a new country culture and language 30 in this respect improving the countrys conditions for young people is essential in ensuring that generation z students remain in the country and thus would protect mental health in this study the participants mentioned that the agenda in türkiye changes rapidly that they cannot follow the agenda that they often cannot obtain reliable news from the media and that they follow social media due to its geographical location türkiye is adversely affected by many situations such as earthquakes fires wars and terrorism 10 therefore the countrys agenda changes rapidly the recent earthquake and elections have quickly changed the agenda in addition to the changing agenda participants stated that social media is sometimes blocked in the country this situation affects the trust of individuals living in the country in the government and hinders their right to receive news one of the subthemes identified in this study was related to migrants participants made negative statements about refugees and the refugee crisis with its number of refugees türkiye ranks first among the countries hosting the most refugees globally 11 in the study conducted by yılmaz and günel it was determined that generation z who participated in the study thought that the refugees in our country restricted their job opportunities and that their participation in the labor market would bring unemployment 24 it is believed that there may be negative attitudes towards refugees especially among individuals in countries like türkiye that are crowded and experiencing an economic crisis therefore the government must create and comply with a migration policy on the other hand it is crucial to change young peoples negative attitudes towards refugees in generation z students workshops and courses on multiculturalism and cultural sensitivity can be conducted at universities to reduce the negative attitudes of young people who will come into contact with refugees in their professional or daily lives in addition some of the participants in this study stated that they were thinking of going abroad in the future participants thinking of migrating to another country due to the problems experienced will be of immigrant status at this point it should be ensured that generation z university students empathize with immigrants in this study students mentioned that they were not satisfied with the education system that it changes frequently that primary education is critical and that getting a good education is related to the economic status of individuals kahya found that when the difficulties faced by young people were examined in his study it was found that they could not receive the education they wanted 26 in this study the participants emphasized similar points in the scoping review of shorey et al 9 they found that technological and innovative educational strategies should integrate with the education schedules of generation z therefore it may be recommended that technology integrations 31 have free permanent and effective systems in education educational institutions need to change their teachinglearning strategies which have to become more technologybased such as being visual and interactive with the information available instantaneously and most importantly incorporating technology and social medianetworking 6 in this study some participants expressed hope about the future while others said they were hopeless hopelessness is a significant risk factor for futurerelated anxiety with increased fear the individual may become desperate about their future and not know what to do increasing unemployment rates in our country 13 further improve young peoples anxiety and hopelessness about the future in turkey 13 million generation z individuals are expected to participate in business life soon the anxiety of universityeducated generation z individuals about finding a job is increasing since current employment opportunities are not sufficient and there are widespread opinions that the knowledge and experiences of generation z are not suitable for traditional professions an inability to stay with family or start a life due to possible unemployment can cause despair in this generation 32 furthermore it is stated in the literature that generation zs use of technology together with competition or exposure to social media creates a standardofliving difficulty and increases anxiety about the future 533 vultaggio found that the anxiety of generation z students was simply what is next the fear of the unknown was heightened by the existence of and reliance on social media the author addressed that social media highlighted stressors that these students already had such as school finding a job financial burdens maintaining a perfect image and an overall fear of the future 34 in this study the participants mentioned that they used social media to be aware of news about the country that might contribute to their hope hopelessness and anxiety the participants in this study emphasized that they wanted to improve themselves in professional fields a systematic review that evaluated the career aspirations of generation z by barhate and dirani emphasized that gen z would instead fully develop their potential and grow professionally by learning new competencies and aspiring to become functionally competent and technically strong in their chosen careers 17 still some stressed that even if they were successful they could be eliminated due to the current system the number of young people who have completed their education but cannot find a job or have unemployment anxiety is increasing in a study unemployment anxiety and hopelessness levels of preservice teachers were examined and it was found that preservice teachers with severe hopelessness had high anxiety levels 16 therefore to protect young peoples mental health increasing their employment opportunities and counselling them on their professional careers is vital 5 thus the rate and desire of young people to go abroad can be reduced conclusions in the data obtained from the participants in this study under the main themes of the current situation of the country being a student in the country and futurerelated anxiety the subthemes formed included economic crisis and impossibilities the variability of the agenda the education system the immigration problem the inability to participate in social activities uncertainties the desire to go abroad and hope and hopelessness all these factors may negatively affect the life and mental health of generation z university students therefore defining generation zs possible futures or career plans is essential for professional organizations and public health 1 providing counselling and career planning supervision to young people in universities can make it easier for them to cope with these situations in addition providing mental health services in universities and changing curriculum according to this generations characteristics is also crucial this could recommend the evaluation of the mental statuses quality of life and education satisfaction of generation z students in future studies this study has some limitations first of all the results of this study were limited to the perceptions of a group of generation z university students who participated in this study at a single foundation university in istanbul because of the nature of the qualitative research it could not generalize the other limitation of the current study was that the participants were students in istanbul which is the most crowded expensive and has the most migration which might affect their perspectives on their futures determining the future perceptions of generation z in different geographies of turkey and government universities is fundamental furthermore the students who lived in dormitories or owned or shared houses did not participate in the study for future studies it could be recommended to investigate the perceptions of generation z students who did not live with their families data availability statement the data presented in this study are available on request from the corresponding author informed consent statement informed consent was obtained from all subjects involved in the study

this study explored the futureoriented perceptions of generation z students in a foundation university this study was conducted using qualitative research and a phenomenological design the study sample consisted of 11 university students over the age of 18 who agreed to participate in the study data were collected online through individual interviews in türkiye colaizzis phenomenological analysis method was used in the data analysis the content analysis determined three main themes and eleven subthemes the first theme was the students knowledge acquisition about the current situation of the country under this theme were four subthemes economic problems the immigrant situation the education and justice system and the countrys agenda in the second theme students shared their opinions about being a student in the country this theme included economic impossibilities their participation in limited social activities and housing problems in the last theme future anxiety the subthemes of the students were found to include experiences hopelessness versus hope uncertainty caused anxiety as did going abroad finding a job and improving themselves it was determined that the participants were worried about the current situation in the countries they lived in during this period due to economic problems while some were hopeful about the future some were hopeless and would go abroad this study might contribute to the literature on determining the futureoriented perceptions possible stressors and hope levels of generation z university students in türkiye additionally intervention programs can be developed for the management these stressors to protect the mental health of generation z university students on the other hand it is necessary to protect the mental health of young people who are the adults of the future and to create policies for the youth of this country where social opportunities are maintained

introduction socioeconomic disparities in health have been well documented since the birth of epidemiology and public health in the mid nineteenth century 1 the eras of epidemiology reflect the evolution of the diseasespecific model from the pursuit of a single cause of infectious diseases to the consideration of myriad causes of specific conditions with the rise of chronic diseases as the major public health threat 23 and while much of the focus of epidemiology is on etiologic contributors to single specific health conditions or behaviors social epidemiology has taken a specific interest in the myriad health consequences of social exposures 4 5 6 7 8 9 10 11 12 theoretical perspectives from the social sciences such as medical sociology suggest that the effects of social exposures such as socioeconomic position are fundamental causes of poor health and do not cause a single health outcome but rather have a generalized impact on wellbeing 1314 evidence supporting this perspective includes the persistence and concentration of morbidity and mortality among the poor compared to wealthier populations across the centuries despite major shifts in the major causes of death during this time from infectious diseases to chronic conditions 1516 the resurgence of interest in social conditions within epidemiology in recent decades 517 may have deepened our understanding of the relationships between social position and health but did so while remaining attached to the diseasespecific analytic approach pervasive within epidemiology the diseasespecific approach of identifying etiologic factorsboth biological and socialis appropriate when a particular condition or problem is of interest for example to uncover the primary determinants of smoking during pregnancy to design effective interventions but when the primary focus is on a social exposure and its impact on overall health or wellbeing the diseasespecific model is theoretically incompatible with this research agenda the diseasespecific modeling of fundamental social conditions may misor underestimate their impact on health 141618 in practice the diseasespecific model treats all potential causes as if they had the same ontological status however sep differs in several aspects from other more proximate determinants commonly studied in epidemiology such as tobacco smoking diet environmental contaminants or genes first sep may lead directly and indirectly to ill health through several complex pathways that change and evolve over time with the history of a given society 16 social organization is thus seen as a distal upstream or fundamental force that put individuals at risk of risks 151619 second as noted earlier the effects of social organization on health are nonspecific 1420 third the negative effects of low social position accumulate longitudinally and cluster crosssectionally 15 these considerations suggest that the diseasespecific approach of studying only one disease manifestation of social determinants prevents us from capturing the full impact of social causes on health 141618 and while there are times when researchers with an exclusive interest on multifactoral determinants of a single health condition should rely on the diseasespecific model the growing interest in social disparities with a primary focus on social determinants of wellbeing would benefit from the use of alternative models that facilitate evaluation of a generalized effect of social factors on outcomes 1418 we draw from the sociological literature which distinguishes two types of models etiologic or diseasespecific models and consequences models or models that measure the generalized impact of a particular social exposure models that examine the consequences or generalized impact of social exposures have as their point of departure the social cause not the disease 61418 21 22 23 while the conceptual or theoretical underpinnings of the two models are quite different the operational distinctions are quite simple and focus on the outcome variable 1418 while the diseasespecific model uses a single health outcome models of the consequences of social exposures use a composite outcome use of composite outcomes is not new to the field of health 24 25 26 in the case of the study of the consequences of social exposures the composite outcome must be grounded in sound theory those conditions included in the dependent variable should have solid evidence supporting its relation to the social exposure of interest despite its promise models of the generalized health impact of social exposures have been applied by social scientists in studies on mental health 141827 but have not been widely applied by epidemiologists our objective was to apply the model to the study of maternal and newborn wellbeing using a national survey of canadian childbearing women and to compare it with the traditional diseasespecific approach of examining one outcome at a time reproductive health may be suitable for this endeavour since social disparities have been amply demonstrated for multiple pregnancy related outcomes 828 methods study population the maternity experiences survey is a populationbased survey conducted by statistics canada during 20062007 on behalf of the public health agency of canada the mes target population consisted of biological mothers who were age 15 and older at the time of their babies singleton live birth in canada and lived with their infants at the time of the survey 2930 a stratified simple random sample was selected without replacement using recent births drawn from the census 2006 sampling frame the sample was stratified on province or territory in which the mother resided at the time of the census and on maternal age among 8542 women selected from the frame 8244 were estimated to be eligible cases based on the target criteria the questionnaire was successfully completed by 6421 women after applying the survey weights which were adjusted for nonresponse these women represented approximately 76500 canadian women 30 the data were collected in a 45 min computerassisted telephone interview by professional female interviewers in english french and 13 nonofficial languages paper versions were used when telephone interviews were not feasible 30 information on postal code of the respondent was used to link the data to the 2006 canadian census to characterize residential neighborhood further details of the survey design and methods have been reported elsewhere 30 31 32 33 34 outcome measures to compare the diseasespecific and the social consequences models we chose a priori several conditions that were strongly associated with high levels of deprivation and low sep 728 35 36 37 38 39 40 a adverse birth outcomes was a composite measure defined by the presence of low birthweight preterm birth or small for gestational age 41 these measures were constructed based on maternal reports of gestational age infant sex and birthweight the resulting rates of singleton preterm birth and small for gestational age in the survey were consistent with national surveillance data based on birth certificates 29 b postpartum depression was assessed using the edinburgh postnatal depression scale a ten item screening tool to identify postpartum depression at the time of its administration 42 a score of 13 or more out of a maximum possible of 30 was used to indicate the presence of postpartum depression validation studies have showed that the scale can detect depression in postpartum women with 86 sensitivity and 78 specificity 4344 c serious abuse was defined as the combination of threats and physical or sexual abuse suffered right before during or after pregnancy the mes contained a section to assess abuse and violence the questions were adapted from the violence against women survey 45 to capture abuse and violence during the childbearing year threats or potential hurting acts were defined by the occurrence of direct threats of physical harm throwing objects at them and being pushed grabbed or shoved in a way that could have hurt respondents physical or sexual abuse included at least one episode of slapping kicking hitting with a weapon beating choking use of a gun or knife and being forced into unwanted sexual activity thus serious abuse involves at least two episodes of violence of different kinds d hospitalization during pregnancy was defined as an affirmative answer to the question of whether respondents stayed at a hospital overnight before labour and the birth e frequent stressful life events were considered as such when respondents identified three or more stressful events in the 12month period before the babys birth 32 in the diseasespecific models each of the previous conditions is considered as a separate outcome in contrast to be consistent with the theory underpinning the ghi models we created a compound outcome variable by counting the number of conditions experienced by respondents 18242527 and categorizing them into 0 1 2 and 35 conditions exposures a total household income before taxes and deductions of all household members from all sources in the 12month period preceding the interview the unexposed group was considered to be composed of households with annual incomes of 80000 dollars and higher and exposed groups were those in the income brackets of 20000 2000049999 5000079999 dollars and unknown income b neighborhood deprivation was a contextual variable assessed by the proportion of households whose income in 2005 was below the statistics canada low income aftertax cutoff 46 the licoat identifies households spending 20 percentage points more of their aftertax income than the average family in the region on food shelter and clothing thus leaving less income available for other expenses such as health education transportation and recreation the licoat cutoffs are differentiated by size of family and area of residence proportions of licoat were computed at the dissemination area level which is the smallest standard geographic area for which all census data are disseminated with a population of 400700 persons 46 c immigrant status was categorized into canadianborn recent immigrants and long term immigrants variables for confounder control were maternal age parity and place of residence 46 for the latter place of residence was categorized into urban areas and rural areas following the statistics canada standard geographical classification 47 levels of these variables are specified in table 1 analytic methods survey weights were used to account for the unequal probabilities of selection of respondents and thus obtain unbiased point estimates representative of the canadian population special procedures for the analysis of survey data were used to obtain weighted proportions and odds ratios with 95 confidence intervals using the taylor series method of variance estimation 48 for modeling the five diseasespecific conditions the logistic model was used to compute ors for each condition separately to model the generalized impact of social exposures and to take into account the multiple categories of our compound outcome we used the multinomial model to obtain ors for the occurrence of one two and three to five conditions relative to none the general regression equation of the multinomial model with a single predictor is given by log a j b j x where the response levels are j 1 … j 1 and the baseline response category is j to avoid overestimating relative risks odds ratios were converted to prevalence ratios using a simple formula that provides a good approximation to estimates of the relative risk when direct estimation is not feasible 49 in the formula pr i or i p i is the weighted proportion of cases in the exposure level i p 0 is the weighted proportion of cases among the nonexposed and or i is the or for exposure level i this conversion further allowed comparing the disease specific and social consequence models in terms of population attributable fractions based on the weighted proportion of cases at each exposure level and on the adjusted prs as expressed in the formula paf pr i where pd i is the weighted proportion of cases in stratum i and pr i is the adjusted pr in stratum i 50 pafs facilitated the comparison of the etiologic fraction attributed to low sep between the diseasespecific and ghi models missing data were very low for most variables and therefore were not considered in the analyses with the exception of household income for which we created a category labelled unknown to prevent a significant drop in the sample size the study was approved by the st michaels hospital research ethics board and by the research data centre access granting committee of statistics canada results among the 6421 respondents in the mes 406 women were excluded due to missing or invalid responses in at least one of the outcomes or covariates the final sample for analyses was 6015 about four out of 10 women had at least one adverse condition among affected women 70 had only one and seven percent three to five outcomes the proportion of women experiencing at least one outcome decreased with advanced age higher household income and lower neighborhood deprivation this pattern was more evident as the number of concomitant conditions increased among affected women the number of concomitant conditions increased while the proportion of immigrants decreased regression models for each single condition showed moderate to strong associations between low household income and each outcome with pr ranging from 14 to 57 after adjustment in comparison the multinomial model showed two types of gradients the wellknown gradient by which the lower the income the poorer the outcomes and a new gradient by which within each exposed income group the pr increase with the number of conditions reaching a prevalence ratio of 17 for women in the lowest income households having 35 conditions the prevalence of 35 conditions was 1036 among women living in households making 20000 dollars versus 054 among those whose household income was 80000 or above in the fully adjusted model neighborhood deprivation was not consistently associated with the outcomes in contrast to the findings for the socioeconomic exposures logistic models show that being an immigrant was associated with higher risk of postpartum depression but lower risk of abuse hospitalizations and stressful life events particularly among recent immigrants multinomial models show a trend towards lower risk of concomitant adverse outcomes particularly among recent immigrants another approach to compare the magnitude of effects is to examine the population attributable fraction for the social exposures here we show pafs for income low income pafs ranged from 15 to 55 for single conditions based on the single outcome model in comparison pafs in the composite condition model were substantially larger at 51 and 78 for 2 and 35 conditions respectively discussion to our knowledge this is the first study to apply the ghi approach to model pregnancy related outcomes in a representative sample of canadian childbearing women we found that compared to the diseasespecific model a ghi model detects stronger effects of social position on pregnancy related outcomes both approaches showed the well documented gradient of decreasing risk with increasing household income in addition we were able to demonstrate a strong doseresponse relationship using the ghi model the stronger gradient is explained in part by having fewer individuals with conditions related to low sep in the condition free category of the ghi model which is not true for the disease specific models immigrants also exhibited linear trends according to the number of adverse outcomes but in contrasting directions even after controlling for household and neighborhood income immigrants were less likely to experience multiple conditions particularly recent immigrants this observation is consistent with the healthy migrant effect and also suggestive of its loss with increasing time spent in the new country 51 strengths of our study are the use of a highquality nationally representative survey and the simultaneous consideration of a wide array of adverse outcomes such approaches are particularly relevant for research focussing on social determinants for example in the study of social disparities 62352 our findings are strengthened by the existence of a doseresponse relationship between lower income and increasing number of adverse outcomes although we focused our attention on household income which cannot capture the full complexity of social location 1952 we also considered additional indicators such as immigration which was also associated with the compound outcome in a doseresponse fashion several weaknesses exist first as data are selfreported recall bias is always a possibility however our variables focused on the 2year period preceding the interview and bias resulting from inaccurate recall is likely to be small second the main exposure was total household income since disposable income after application of redistributive policies was not available in the survey which would be more accurate as a measure of the material resources actually available to the households the use of pretax income is likely to bias the estimates toward the null yet we found strong and consistent associations it is unlikely that reverse causation could explain our findings as prospective studies suggest that the crosssectional associations between income and health chiefly reflect the influence of income on health rather than the opposite 1353 unfortunately we did not have life course data to fully explore the problem of reverse causation in the case of immigrant status it is a fixed attribute that cannot be affected by the outcomes third our list of outcomes and exposures is not exhaustive and we were constrained by what we could include by the survey with regard to outcomes we chose a priori a limited number of known consequences of low individual and neighborhood sep for comparison purposes but the use of a different set of outcomes may result in different effect estimates we anticipate that if low sep is associated with each single outcome the use of the ghi model would reveal similar patterns moreover the ghi approach is well suited for documenting the impact of social determinants on well being but may be less appropriate for revealing the mechanisms or pathways by which social factors result in adverse health given the outcome is a composite of many variables some of which may have unique pathways resulting from deprivation we did not control for correlates of income such as maternal education and marital status because of potential overcontrol or colinearity issues adjustment for smoking and substance use was discarded since these are conceptualized as mediators of the relationship of interest 8 finally while we used logistic and multinomial regression alternative approaches such as structural equation modeling might have been employed to explore the same research questions we anticipate that if such approaches were used a similar set of findings would result despite these limitations our application of the ghi model provides further evidence supporting the hypothesis that the negative consequences of social position cluster among the socially disadvantaged while socioeconomic gradients constitute one of the most robust findings in social and perinatal epidemiology 28 our study reveals a less known gradient towards the simultaneous occurrence of multiple adverse outcomes associated with increasing disadvantage income inequalities accounted for 51 and 78 of the excess risk of having 2 and 35 conditions respectively supporting their role as a fundamental cause 16 while we provided evidence supporting the existence of a clustering of multiple adverse outcomes with increasing deprivation we did not have appropriate longitudinal data to test the related hypothesis that at a given level of lower social position the occurrence of concomitant adverse outcomes would be higher among those who have been exposed longer or repeatedly to low sep 1315 such approaches might be useful for examining specific questions around social exposures such as discrimination 54 or issues of deprivation such as the weathering hypothesis 5556 further research in this area will benefit from adopting a lifecourse perspective 57 and analysing longitudinal datasets our findings have important implications for research and practice from an analytic perspective the diseasespecific model underestimates the negative impact of low sep on health in particular it overlooks the fact that socially disadvantaged individuals are also affected by related conditions other than the one under investigation thus the broad nonspecific effects of sep on health domains may be better captured by the ghi model from a policy perspective the understanding that low sep is not only independently associated with various adverse outcomes but also with their simultaneous occurrence suggests that greater health gains may be achieved if investments focus on reducing the social inequities behind the health disparities rather than on tackling proximate risk factors that may hopefully prevent one but not all negative consequences of low social position 5859 it is important to clarify that the ghi model does not intend to replace diseasespecific research which is the model of choice when the interest is to unveil the mechanisms and pathways for specific and welldefined health outcomes however when the goal is to weigh the nonspecific sequels of sep on a general domain of health such as mental health or reproductive health the ghi model has clear advantages

there is increasing interest in the study of the social determinants of maternal and child health while there has been growth in the theory and empirical evidence about social determinants less attention has been paid to the kind of modeling that should be used to understand the impact of social exposures on wellbeing we analyzed data from the nationwide 2006 canadian maternity experiences survey to compare the pervasive diseasespecific model to a model that captures the generalized health impact ghi of social exposures namely low socioeconomic position the ghi model uses a composite of adverse conditions that stem from low socioeconomic position adverse birth outcomes postpartum depression severe abuse stressful life events and hospitalization during pregnancy adjusted prevalence ratios and 95 confidence intervals from diseasespecific models for low income 20000year compared to high income c80000year ranged from a low of 143 109185 for adverse birth outcomes to a high of 569 359884 for stressful life events estimates from the ghi model for experiencing three to five conditions yielded a prevalence ratio of 1872 9293577 and a total population attributable fraction of 78 while diseasespecific models are important for uncovering etiological factors for specific conditions models that capture ghis might be an attractive alternative when the focus of interest is on measuring and understanding the myriad consequences of adverse social determinants of health

introduction online social networks have been extensively studied in the last decade with most efforts focusing on static properties computed on single snapshots of the network gradually attention of the community has shifted towards temporal properties of osns with the goals of understanding patterns and mechanisms underlying their growth however most temporal studies are limited to analyses of dynamics using logical clocks despite the growing recognition that a full understanding of graph dynamics requires analyses using physical clocks recent studies of network dynamics on the renren network provided a macroscopic view of network evolution by measuring the trend of some measures in each temporal snapshot later work took it a step further by adopting a microscopic approach using physical time its nodecentric analysis showed that users create links in a highly bursty temporal pattern in this work we focus on the dynamic formation of two fundamental networkbuilding components dyads and triads we propose two new metrics to aid the temporal analysis on physical clocks link creation delay and triangle closure delay link delay is the time period required before two users of a network create a link between them ie the delay between when a friendship is possible and when a friendship link actually forms on the other hand triangle closings capture the transitivity of friendships which has proven to be effective in modeling network evolution and link prediction triadic closure delay captures the time of formation of all the links of triads by considering the temporal process of triad formation these two metrics enable us to study the dynamic creation of dyads and triads and to highlight network behavior that would otherwise remain hidden the main contribution of this paper concerns the temporal features characterizing the links and the triangle formation measured on two temporal annotated datasets from facebook and renren in our analysis we find that link delays are generally very low in absolute time meaning if two people want to become osn friends they do so very shortly after both have joined the network link establishment is especially fast in early stages of social networks in addition link delay results are largely independent of the dates people join the network to highlight the social nature of this metric we introduce the term synchrony to quantify how well linked users overlap in lifetimes finally we study if link delays correlate to distance in the social network and find that links spanning more distant nodes generally form faster our triadic closure delay takes into account how long a temporal triangle takes to form we first introduce an algorithm to extract temporal triangles which enable us to monitor the triangle formation process and to detect sudden changes in the triangle formation behavior possibly related to external events in particular we show that the introduction of facebooks people you may know functionality had a disruptive impact on the triangle creation process in the network while in renren we highlight the impact of real life changes on the network structure from a microscopic perspective we shed a light into the physical time of the triadic closure process by introducing a formal definition of the delay of the triangle formation the triangle delay represents a normalization that accounts for the node and link arrival processes by analyzing the above quantity we find that triad formation is very fast accounting for the fact that if two persons have a common friend and want to be online friends they instantiate the relationship very quickly yet this new metric shows slightly different behaviors in our two datasets in fact the bootstrap phase captured by the renren dataset is also faster in the triangle formation dynamics compared to facebook growth finally triangle closure delay allows us to identify when latent triangles have been triggered by external events thus allowing us to evaluate the impact of these types of events related work with the availability of datasets on online social networks that evolve over time researchers have begun to study mechanisms by which nodes arrive and links form or disappear one promising approach has been the microscopic perspective ie the growth and the properties of a network result from choices made by nodes based on local information from their neighborhood or other closeby nodes however microscopic mechanisms have been studied only using logical time where the number of nodeslinks represent the clock of the system this has led to the study of link formation in terms of likelihood or in term of age of nodes only discussed the issue of predicting when a link will be built recently online social networks have been studied from a physical time perspective with particular focus on bursty behavior in the neighborhood expansion mechanism however the temporal properties of each link have never been faced in the physical time framework among other proposed link creation mechanisms triadic closure is the most basic and powerful principle to model the evolution of social networks specifically this principle states that individuals with a common friend have a higher chance to become friends themselves at some point in the future due to the strong relationship between triadic closure and clustering coefficient a few works have faced the dynamics of the triadic closure process by analyzing the temporal trends of the average clustering coefficient by exploring the social network dynamics of a portion of the arxiv repository showed that the average clustering coefficient is quite constant a more detailed analysis of the average clustering coefficient in a chinese social network has been presented by variations in the clustering coefficient have also been observed by and they show that google structure has become less clustered as new users joined the largest connected component and that the average clustering coefficient seems to follow a threephase evolution pattern first decreasing then increasing slowly and finally decreasing again in general the previous approaches all suffer from the averaging effect ie wide fluctuations affecting the clustering coefficient of single nodes are lost in the average this produces a measure of the whole network that poorly captures the triadic closure process while these studies focus on the temporal trend of the clustering coefficient to quantify the magnitude of the closure process others combine the snapshot paradigm with the likelihood of a link given the number of common friends one of the seminal work has been carried on by they found that two users are more likely to close a triangle if they share many friends while the method does not explicitly focus on the process timing it heavily depends on the choice of the temporal gap between two snapshots a more detailed and wider study of the triadic closure process has been conducted by they model how a source node decides to add an edge to some other node two hops away they have found the most likely mechanism is given by a combination of the number of common friends between the nodes and the presence of recent activity at the candidate neighbor while this work is the most related to ours it focuses on the choice mechanism and not the temporal trend of triangles or the time it takes for them to form have studied triadic closure in the evolution of online social networks in particular they analyzed the proximity bias ie the tendency of nodes to link with those nearby in the network graph the results on flickr and friendfeed have shown that proximity bias influences the formation of new links making two nodes which are two hops distant more likely to form a link these studies only confirm the predominant role of the triadic closure but do not explore the closure process finally studied the triadic closure process on the twitter network finding heterogeneities in the process when they consider high degree nodes in contrast we investigate the temporal dynamic properties of the triadic closure process and link formation to the best of our knowledge this is the first study that explores how long the triangle formation lasts in triadic closures given our use of physical time we are able to correlate changes in the triadic closure process with social and environmental contexts as well as the introduction of new services by the social network provider measurement methodology the main goal of our work is to introduce metrics that can quantify the microscopic dynamics in the growth of online social networks using physical time as reference system one advantage that physical time offers is the possibility of relating the global and local changes in the growth process to events external to the network system since physical time connects events inside the social network structure and any external events to introduce the new metrics we start by presenting the theoretical framework we adopted to describe the growth processes in physical time then we introduce the datasets on which we apply the dynamic metrics in particular we need data from online social networks with finegrained temporal information so as to stress the microscopic dynamics of their evolution using artifacts in our datasets ie the bootstrap phase in renren and the facebook transition from a university service to a business company we highlight and measure how different types of external events impact on the network topology and its dynamics notation in the following we introduce the notation we adopt to describe the growth of the whole network and its constitutive elements formally we represent the social network of our datasets as an evolving undirected graph usually the network growth is represented by a sequence g 1 g t where each g t is an undirected graph denoting the state of the network at time t having v t nodes and e t links as we have no information about node and edge removals the number of nodes and edges always increases in time up to the end of the measurement process indicated by t at last graph g t will contain the whole set of nodes and edges appearing during the growth to analyze the microscopic structural properties and to simplify definitions we project the sequence g 1 g t into an undirected graph g where links are timestamped by the time function τ e → r that assigns to each edge e its creation time given the increasing monotonicity of the sequence v v t and e e t in accordance with this framework we use γ t wτ ≤ t to denote the set of neighbors of u at time t and consequently the degree of node u at time t as k t γ t while its final degree is k t since we only have temporal information about edges we define the time of the first appearance of node u into the network b we call this its birth date assuming that b minw ∈ γ t ie the time of the first link incident to u finally since the main subject of section 5 is the dynamics of transitivity we denote a triangle composed by the vertices uw and z as û wz exploiting the time function we can assume that for each triangle τ τ τ holds consequently we have an ordering of the edges in a triangle and we lose the triangle isomorphism typical of static undirected graphs ie û wz is not equivalent to ŵ zu dataset the main obstacle to study dynamics is the challenge of obtaining detailed data describing osn dynamics in this study we study two online social networks renren and facebook first we received from renren access to an anonymized dataset that contains the timestamped creation of all users and edges in the renren network renren is the largest online social network in china like facebook renren was originally designed for college students renren was original named xiaonei and changed its name to renren when it expanded beyond universities the anonymized dataset describes the growth of each node as a timestamped edge in the network the first edge created in the entire renren history dates back to november 22 2005 and the dataset includes the complete evolution of the first 600000 nodes for a total of 8 million timed edges events in total our dataset covers the first year of renren from november 2005 to december 2006 the second dataset is publicly available1 it includes the growth of the new orleans facebook network with about 60000 nodes and 800000 links from september 2006 to january 2009 while we have evidence of the time creation of all edges in renren because this dataset covers the network dynamics from the kickoff date the facebook dataset contains the timestamped creation of all users and edges except for 42 of vertices and 60 of links these were not considered in our analysis as this phenomenon is very limited we believe the results we obtained are applicable to the entire new orleans network link delay in this section we introduce link delay a novel indirect measure of the eagerness of a tie measuring the elapsed time between the potential establishment of a link and its real creation a link is possible when all the enabling conditions are set but the link has not yet been created below we first define the metric capturing the time spent to establish a link between two nodes ie the delay of that link then we evaluate the link delay properties on renren and facebook we find that link delay is very low meaning if two users wish to establish a friendship relation they create the link very quickly once both users join finally we correlate link delay with the ages of the connected nodes and with their topological proximity the results confirm that the delay is independent of age difference of the nodes and point out that few fast links have been established between topologically distant users definition we assume that nodes are free to enter the network anytime during the network lifetime to properly mirror this assumption in the link delay definition we apply a simple normalization on the values returned from the time function τ including the birth date b of a node this leads us to define link delay d as follows given g and its time function τ the delay d e → r of the link is defined as d τ max b where the max function on the birth date implies that both nodes need to be created in the graph d measures the elapsed time between the potential link creation time and the actual link creation time the lower the delay the faster the two nodes actualize the potential link the trends of links organized by link delay during the growth of renren and facebook color intensity is inversely proportional to link delay 1 and 1 cdf of the link delay for links grouped by hop distance 1 1 and 1 relative and absolute volume of links grouped by link delay considering links spanning more than 4 hops and 2 hops in renren and links spanning more than 4 hops in facebook new orleans link delay analysis link delay analysis can shed light on a few properties of osn friendship i how much time people take to become friends once they both join the osn ii how link delay differs between different networks as a function of their different user populations and the stage of their evolution captured by our datasets we analyze dynamics of a network at its infancy and the first year of facebook dataset where facebook becomes an open service and its consolidation period first we compute and analyze the distribution functions of link delay in both datasets figure 1 shows the cumulative distribution function of the link delay extracted from the renren dataset from the first year of facebook dataset and from the entire facebook dataset the link delay distribution always shows a very quick shift from potential to actual link state in fact for all three distributions links were created within a day in 20 27 of the cases and within a week in 32 50 of the instances these results highlight that generally speaking a pair of nodes create friendship links soon after both users have joined the network beyond this property some differences can be noted among the two networks and different time periods first a comparison between renren and facebook shows that the two distributions diverge right after the first week when renren users begin forming friendships more quickly than their facebook counterparts the same trend remains true if we consider the first year of facebook secondly the comparison between facebook and its first year strengthens the existence of different behavior in link delay as the network grows ie links are formed faster in early stages of the network a possible explanation of the slight differences between renren and facebook lies in the different phases captured by the datasets in the bootstrap of the network the information about the presence of possible friends nodes spreads faster than in a later period because of the social environment where renren initially operated namely a university campus where renren was adopted as a social service information about a friends network presence might have spread not only on the network but also via other forms of offline networks accelerating the adoption of the service this effect although smoother because its coverage of users over a larger geographical area remains visible in the first year of facebook the same phenomenon may underlie the different behaviors during the different facebook macroscopic snapshots in a networks early phase the information about the establishment of new friendship relation reaches nodes faster while it has slowed down significantly for a network in its consolidation phase we can obtain more information by taking into account when links are created this way we obtain the temporal trend of the link delay groups as shown in figures 1 and 1 we group all links into delay groups based on their link delays we compute for each week the percentage of new links belonging to the different groups obviously the number of groups depends on the dataset because they cover different time periods renren is characterized by three different stages from its birthdate to the end of january ie the first three months most links are established suddenly at the beginning of february a drastic change in link delay occurs because users tend to establish unexpressed links and the volume of quick links increases abruptly during the summer the delayed links increase in number and quick links decrease before a reversal after the summer the resulting phenomenon is characterized by a certain degree of fluctuation in the ratio of link delay in order to quantify the instability we measure the standard deviation of the groups timeseries the further the standard deviation is from 0 the more the timeseries is dispersed and fluctuates in time the computed values indicate that 714 and the 1430 days delay groups are the most stable and contain on average 28 of the overall created links while the quickest link and most delayed groups are the most unstable in addition the relative timeseries seem to be inversely correlated when the portion of quick link increases the most delayed diminishes and vice versa we observe different results in our facebook dataset the component of links having a delay within a week represents 32 of overall links and is characterized by a quite constant trend in fact the dark green group in figure 1 is always between 20 and 40 a more evident phenomenon happens on march 26 2008 where we observe a drastic increase in the volume of delayed links this date corresponds to the introduction of facebooks people you may know functionality by analyzing the delay we can highlight i how this features acts and ii how long its effect lasts the friend recommendation system highly amplifies the tendency of establishing old potential links that could have been created a long time ago 60 of links created in the week of the pymk introduction have a delay greater than 6 months and 20 had a delay greater than a year observing the group trends the weeks after pymk introduction we note that the initial behavior in preferring delayed links disappears and after the summer of 2008 reaches prepymk percentages although the link delay reveals interesting characteristic in edge creation process it is not able to capture the reason behind it ie which process causes the observed effects or which algorithms were active in the early rollout of the pymk feature in section 5 we explore these effects correlating them to the triadic closure process finally we apply the stability timeseries analysis as we did for renren excluding the 10 weeks after march 26 to reduce the pymk impact the analysis of the standard deviation shows that fluctuated and stable components simultaneously act during the facebook new orleans growth 1 unstable quick links and 2 stable more delayed links link speed and link synchrony the link delay observations provided so far are independent of the reciprocal network age of the nodes involved in links however the birth date b allows us to verify whether or not link creation favors pairs of nodes with similar network ages to quantify this type of behavior we introduce the notion of synchrony of a link given g and the birth date function b synchrony s e → r of a link is defined as s b b in figure 1 we show the metric of synchrony obtained from our datasets in both cases we observe that the probability of having a link between peer nodes is low and nearly 50 of links are established between nodes with different creation times one month apart in renren and 5 months in facebook we argue that this result is the direct consequence of previously observed bursty behaviors in the edge creation process in fact old nodes continue to generate or receive links even if they are aging because 20 of links are created 9 months or one year after a nodes birthday respectively by comparing link delay and synchrony distribution as shown in figure 1 we can derive that low link delay has an higher influence on the link population than low link synchrony in fact the impact of low synchrony is at most 10 and lower than the contribution given by low delay links this proposes the link delay as a relevance feature in the future growth of the networks and on the underlying processes link delay and edge locality we relate two kinds of locality of the edge topological and temporal topological locality of a link is measured by the number of hops h it spans ie the length of the shortest path from u to w removing the edge temporal proximity is given by the link delay in figure 1 andfigure 1 we study the distribution of the link delay in four groups of geodesic distance for renren we observe that the distribution for the 4hops group lies above the other groups indicating that edges that connect nodes more than 4 hops distant establish earlier than closer nodes the same behavior to a lesser extent involves also the 4hops group this fact characterizes not only the early bootstrap phase of the network where the service has a small group of subscribers but remain constant during the network growth as shown in figure 1 it reports both the absolute number and the percentage of links spanning more than 4 hops divided in the same delay groups adopted in the temporal analysis we note that more than 80 of the far links keep actualizing in less than 2 weeks figure 1 shows a different phenomenon occurs in the 2hops group here we observe that some friendships were created with an delay greater than 3 months even though the two users were already connected by at least one common friend in facebook we obtain a trend similar to renren but smoother as shown in figure 1 edges spanning four or more hops exhibit a lower delay compared to those that span closer nodes also in this case the lowest components score the 40 50 of links along the period indicating a stable behavior as shown in figure 1 in general these results suggests a quite surprising behavior involving link delay and edge locality while some works report that closer nodes are more likely to establish a new link our results suggest that a high link likelihood does not always corresponds to fast link creation links that span farther nodes generally instantiate faster in such cases the network connectivity is less important than offline friendships to go deeper we explore the degree and the age of the nodes forming far and close links we find that on average nodes further away in the network are the youngest and are characterized by low degrees that strengths the observation that nodes just entering into the network exploit some external relationships during link creation the triadic closure process the availability of temporal annotated networks has allowed the study of the networks evolution over time and has led to a deep understanding of the mechanisms governing node and link arrival and creation in this section we study the evolution mechanisms of online social networks mainly focusing on the basic growth principle underpinning these networks triadic closure observed as one of the most frequent processes of link formation triadic closure has been widely adopted in different disciplines for instance the sociological principle for triadic closure is the transitivity of friendship which says that two individuals have a high likelihood of establishing a friendship if they share a common friend the transitivity of friendship has been proved to be effective in modeling network evolution and predicting future link formation despite its commonly accepted value the foundational principles governing triadic closure have not yet been analyzed in depth here we characterize the triadic closure process by delving into its temporal aspects we consider two perspectives first we analyze the triangle formation growth from the network point of view by counting new formed triangles on the overall dataset to reach this goal we adopt an algorithm able to extract temporal annotated triangles temporal information are used to monitor the number of triangles daybyday by analyzing the triangle timeseries we are able to map sudden changes of the triangle formation onto events external to the network such as the introduction of a new feature in the service or seasonal events involving most of nodes we move apart from the network perspective to embrace a microscopic point of view focusing on the formation of the single triangles in particular we study the speed of the formation of triangles our goal is to shed a light on the dynamical properties of the triadic closure process by introducing the formalism to capture the time a triangle takes to be established this way we define the triadic closure delay and we show how this new metric captures different behaviors in the datasets under investigation temporal triadic closure we believe that the dynamical analysis of network evolution cannot disregard the transitivity closure process for the literature has shown its importance in the formation of social networks despite the fact that a temporal analysis of the triadic closure poses both algorithmic and methodology issues the first concerns the extraction and counting of temporal annotated triads while many approaches have been proposed in literature most are suitable for static networks and so cannot be adopted in our microscopic view our approach in the study of triadic closure dynamics advocates rather an extension of the triangle enumeration methods in order to swallow the temporal information 3 our starting point is the observation that time annotation impacts the number of isomorphic triangles in a simple undirected graph the number triangles isomorphic to û wz is 6 while in the temporal case the ordering induced by time makes the isomorphism disappear once the triangles have been extracted we have all the information we need to study the triangle creation process during network evolution in figure 2 we show the volume of triangles that are created daily in renren and in facebook on december 13 2006 the renren network was composed of more than 12 million triangles two thirds of which resulting from an activity of triangle creation started in august in facebook instead during the three years of observation we count more than 17 million temporal triads by observing the triangle trend in the two datasets over the overall periods we note a general skew in the triadic closure process obviously triangle and link volumes are strongly related as the increasing number of triangles could impact the overall number of new links this is true even though not all links derive from the triadic closure process for instance they could be the consequence of new node arrival or some other effects namely a preferential attachment process or search for new friends by graph exploration a first hint in the validation of the impact of triadic closure on the creation of new links can be given by the comparison between the arrival of the new edge and the formation of the new triangle in fact by comparing the link and the triangle timeseries in figure 2 we observe the same trend an increasedecrease in the new link volume corresponds to an increasedecrease in the number of triads in order to quantify this relation in the same figure we plot the ratio between the triangle and the link timeseries thus we can quantify on average the number of triangles closed by a link obviously the average value does not account for the perlink fluctuation although it gives an idea of the role played by the triadic closure process despite the above limitations by analyzing the linktriangle ratio we find two interesting results both of which are related to events more or less external to the network in the renren network the ratio in the last eight months remains quite constant and stabilizes at 15 trianglelink suggesting a steadystate yet interestingly we can also observe the peak in the trianglelink ratio in late august when a spike in triadic closures occurs this peak deserves further study we conjecture that external events are intervening to speed up the network growth processes in this case we could speak of summer effect due to the combination of two facts i in the period we are analyzing renren got targeted as a service for college students and ii in those days chinese students had a break from courses so had extra time to pursue other interests and meet new people as a consequence offline encounters were also mirrored in the online network a more extensive and substantial result emerges from the triadic closure counting on the facebook network as evident in figure 2 the network shows an abrupt transition after march 26 2008 this date corresponds to the introduction of facebook people you may know functionality which promptly impacts both network and triangles in fact prior to the launch of pymk the triangleslinks ratio is quite similar to renrens then rapidly increases and stabilizes at the greater value of 34 triangleslink we note how the pymk mechanism highly impacts the microscopic characteristic of the network structure in particular it influences the link creation process to highly favor triadic closures this strong effect cannot be captured by analyzing only the link creation over time in fact we observe only a medium increase in the new link volume as shown in figure 2 this observation stresses the importance of adopting different indexes in describing the network evolution in fact the number of new links alone would not be enough to let the phase transition emerge in the triadic closure process as in the renren case we see how events external to the network topology can highly influence its dynamical properties but renren and facebook show totally different triggering events in renren the event is seasonal and behavioral absolutely external to the network in facebook the event is external to the network but internal to the service these observations have two main implications 1 new features of the service could rapidly and massively modify the structure it manages in a sort of feedback effect 2 truly external events trigger changes but have a limited temporal impact on the network topology and as a consequence are harder to detect we have shown how the triadic closure process is a fundamental mechanism in the growth of online social networks and how it impacts their evolution nevertheless we only consider the result of the process ie the triangle which has already been formed and make no mention of how it got there the question which comes to mind is how long we have to wait before observing the triadic closure effects ie how long a triangle takes to be established triadic closure delay the triadic closure process has never been analyzed in temporal networks evolution the total amount of time a triangle takes to be closed and the temporal relation among the constitutive links still await further study definition the definition of the time taken by a triangle to establish is tricker since we are considering a dynamic process where the components could appear at different times the usual definition of triangle closure is the conditional probability that a link is formed given that links and exist in physical time its delay is captured simply by τ max τ it accounts for the time to close the last link of a triangle while this metric is very useful to understand triangle features within a static context it cannot capture the timing creation of the links of a triangle and is thus unable to shed a light on the temporal formation process of triads we introduce a new definition of triadic closure delay which embeds the time of formation of all the links of triads by considering the temporal process of triad formation as given by both the nodes and the links appearing in the network for example in a triangle û wz the creation of the edge depends on the presence of nodes u and w and the remaining links to take into account these arguments we employ the birth date b which denotes the time of the first appearance of node u into the network once the birth date has been defined we can normalize the triangle creation time swallowing the temporal gap of node appearance thereby capturing the real feasibility of a triangle to attain a global definition of triadic closure time we focus on the definition of its constitutive elements we indicate the normalized time of the link in a triangle ∆ û wz as t ∆ to give a general definition of the triangle delay we follow the steps that characterize the triadic closure process shown in figure 3 in 3 we show the potential triangle with no links among nodes the first element to be created is the red link in figure 3 and we have to measure how long it takes to be established it corresponds to the delay of the link so t ∆ d the triadic process is still in node w as the link has not been created yet two possible situations could arise just before the creation of the red link in figure 3 1 node z is already in the network so τ b and t ∆ τ τ 2 node z is absent so the closure has to wait for its appearance in the latter case we have b τ so we discount the waiting time of the process in the node w τ b obtaining t ∆ τ b putting together the conditions we obtain the general definition for t ∆ t ∆ τ max τ the last step involves the creation of the link z u as depicted in figure 3 by definition of b and the ordering of the time values of the links at the creation of the link nodes w and z are already participating so t ∆ τ τ once the delay of each constitutive element has been defined we can define the triadic closure delay let g be a temporal undirected graph and û wz a temporal admissible triangle ie τ τ τ the triadic closure delay of û wz d is defined as the sum of the normalized times of its links d t ∆ t ∆ t ∆ which corresponds to d d max τ τ from the above definition we must observe that the triadic closure delay does not depend on the creation time of the middle link the normalization given by the birth date is quite important since it covers all nodes in figures 4 and 4 we quantify the effects of the normalization through the distribution of τ τ d that represents the difference between the triadic delay and the delay not normalized ie τ τ we can observe that the normalization impacts on 50 of triangles in particular 40 of triads are involved in a delay normalization of more than a month triadic closure delay properties we analyze the triadic closure delay and the t ∆ of each link in a triangle and then compare the different evolutions of the two networks we are studying in fact the temporal information not only allows us to measure the triangle delay but also to temporally place it this enabled us to verify whether or not the fast triangle trend is stable during the network growth and to see if external mechanisms eg facebooks pymk modified this trend in figure 4 we report the delay cdf for renren and facebook considering the renren distribution in figure 4 we observe that most triangles have a high speed formation given that half of the triangles close in less than 25 days this fact stresses the importance of the study of triangle formation dynamics in effect triadic closure impacts the network structure both significantly and quickly as shown in figure 4 we observe a different behavior in facebook the measured delay is much greater than in the renren case as half of the triangles get established in five months at most we question if all the elements are necessary to predict the triadic closure delay this corresponds to verifying whether or not certain relationships occur among the different elements for example if t ∆ and t ∆ are low what can we say about the delay of t ∆ will it be low too to stress possible relationships among the elements we adopt two approaches first we randomize the t ∆ s to delete any relations between the triangle elements then we compare the resulting delay distribution with the real one the randomization is obtained by shuffling the elements in each column of the matrix t ∆ t ∆ t ∆ t ∆ we find that the delay and the shuffled delay distributions are quite similar this observation suggests a lack of a particular relation between the delay elements of a triangle furthermore we confirm the above result by computing the correlation matrix among t ∆ t ∆ and t ∆ more specifically we find correlation coefficients close to 0 for each pair of variables generally these observations suggest that the single delay of the constitutive elements is not sufficient to explain the total delay of triangles in other words the triadic closure delay cannot be predicted by simply observing a single element delay dynamics in the network growth as shown in figure 2 in both datasets the triangle formation trend is not regular now through triadic closure delay we are to able to capture what kind of triangles contribute to the observed irregularity in figure 4 we show the impact of the triadic closure delay groups during network growth in figure 4 and 4 we divide the new triangles created in each week into groups according to their delays in figure 4 and 4 we maintain the same groups but we normalize the contribution of each group with respect to the total number of triangles formed during the week this way we quantify the absolute and relative contributions of each group to the triangle formation dynamics for example a group could undergo a rapid increase but have an overall low impact simply because a general boost of formation activity of the triads by analyzing the absolute and the relative volume of triangles grouped in group delay in renren and 4 we observe three behaviors first groups with a delay less than a month run into a continuous decrease from the beginning of june when they reach the maximum activity to the beginning of august ie during the summer this fact may be relevant to the relative drop of the link creation second we see a peak of the 60 90 days group that spans all august this fact indicates that during august the potential triangles begun before the summer actualize finally after the summer a component of high delay triangles appears and stabilizes on 30 of the new triangles in general seasonal effects on renren are influential and the triadic closure delay is able to measure which latent triangles it acts on as for the absolute volume in facebook in figure 4 we observe that the eight first delay groups keep slowly increasing that accounts for a component of fast triangles which is independent from the stage of the network and that involves a similar number of triangles other groups characterized by a higher delay manifest after the pymk service and stay quite constant until the end of the sampling period relative to the volume trends in figure 4 we observe that the pymk service primarily acts on the old triangles this implies that the suggestion mechanism based solely on the commonneighbors friend recommendations awakens latent links long asleep in addition we can quantity the long period effects of the mechanism specifically we observe that after a brief period from the pymk introduction the relative volumes stabilize with the exception of the 3090 groups which increase slightly by comparing the distribution of the triadic closure delay groups before and after the introduction of the friend suggestion system we observe that pymk is likely to promote higher delay triangles by analyzing the triadic closure delay during the temporal evolution of facebook we were able to quantify the effects and the impact of the pymk feature conclusion this paper takes a first step in the direction of building a set of metrics capable to characterize social network dynamics until now in fact when it comes to understanding detailed dynamics and evolution inside these networks current research offers very little in terms of metrics or models we focus our attention on two metrics link delay and triadic closure delay they can capture the time delay between when a link or triadic closure is possible and when they actually instantiate in the trace we have applied these metrics to two real traces of social network dynamics from renren and facebook and we have shown that they are generally consistent across networks but their differences shed light on interesting properties of each system

today numerous models and metrics are available to capture and characterize static properties of online social networks when it comes to understanding their dynamics and evolution however research offers little in terms of metrics or models current metrics are limited to logical time clocks and unable to capture interactions with external factors that rely on physical time clocks in this paper our goal is to take initial steps towards building a set of metrics for characterizing social network dynamics based on physical time we focus our attention on two metrics that capture the eagerness of users in building social structure more specifically we propose metrics of link delay and triadic closure delay two metrics that capture the time delay between when a link or triadic closure is possible and when they actually instantiate in the trace considered over time or across traces the value of these metrics can provide insight on the speed at which users act in building and extending their social neighborhoods we apply these metrics to two real traces of social network dynamics from the renren and facebook networks we show that these metrics are generally consistent across networks but their differences reveal interesting properties of each system we argue that they can be attributed to factors such as network maturity environmental and social contexts and services offered by network provider all factors independent of the network topology and captured by our proposed metrics finally we find that triadic closure delays capture the ease of neighbor discovery in social networks and can be strongly influenced by friend recommendation systems

introduction since the beginning of the covid19 outbreak this pandemic has challenged the healthcare systems of all countries around the globe 1 croatia and bosnia and herzegovina were once parts of the same country where their healthcare systems functioned within the framework of a centralized communist system and after gaining independence both healthcare systems were seriously challenged by devastating wars the experience of those difficult times has proven that the main strengths of the healthcare systems in both countries were its healthcare workers 2 considering the organizational structure of the healthcare systems in croatia and bosnia and herzegovina after their independence both healthcare systems maintained universal healthcare coverage but developed in different ways in croatia besides the universal healthcare system managed by the state ministry of health there are some limited private healthcare initiatives mostly attributable to the concession in primary healthcare with several secondary private healthcare institutions and the country is constantly balancing the development of different healthcare services while considering expenditure and the stabilization of effectiveness and the quality of care 2 the complexity of bosnia and herzegovinas politics which comprises three different political systems and entities namely the federation of bosnia and herzegovina the republika srpska and one autonomous district the brčko district of bosnia and herzegovina is reflected in the organization of the healthcare system and it can be said that the country now has one of the most complex healthcare systems in europe 23 because of the described structure bosnia and herzegovina is one of the few countries in the world that does not have a state ministry of health instead it is divided into two main parts the federation of bosnia and herzegovina which has ten subordinate cantonal healthcare systems and the republika srpska which has a centralized healthcare system in addition there is also the brčko district which is an isolated standalone unit to summarize in bosnia and herzegovina there are thirteen official decisionmakers in the healthcare system the federal solidarity fund and ten cantonal insurance funds in the federation of bosnia and herzegovina the insurance fund of the republika srpska and the insurance fund of the brčko district 2 during the covid19 pandemic all of the aforementioned official decisionmakers formed their headquarters for emergency situations and specific approaches to the organization and adjustment of healthcare during this crisis 3 the covid19 pandemic has revealed that all european union countries have certain weaknesses in their healthcare systems and one of the most important ones is the shortage of healthcare workers following the fact that developed european union countries are compensating for the described healthcare labor shortages by hiring healthcare workers especially medical doctors and nurses from the countries of the western balkans and croatia the actual pandemic pointed out one mutual threat to the healthcare systems in croatia and bosnia and herzegovina and that is a problem with human resources within the systems 4 the latter presents a serious threat to the resilience of these healthcare systems bearing in mind that the recent past has shown that the main strengths of the healthcare systems in both countries are their healthcare workers 2 since the beginning of the covid19 pandemic the world health organization emphasized that primary care is an essential basis for the global response to the covid19 pandemic and that its role in tackling the pandemic is crucial 1 5 6 7 8 primary care is the backbone of every healthcare system it has been proven that a strong primary care system is the basis of an effective and efficient national healthcare system that removes inequalities in healthcare access the latter is extremely important in situations such as global health crises because it has been shown that in countries with limited access to primary care the novel coronavirus spread with greater intensity and speed while countries with strong primary care systems more successfully limited the spread of covid19 and prevented the overloading of health institutions at the secondary and tertiary levels of healthcare 910 primary healthcare workers are usually the first contact for patients presenting with symptoms of covid19 acting as some sorts of gatekeepers of the entire healthcare system 6 10 11 12 furthermore only the most severe covid19 cases end up in hospitals while the diagnosis is almost always carried out by general practitioners providing treatment and support for the majority of covid19 patients who manage their disease at home 1101314 except for the described assignments gps play an important healthpromoting role during global medical crises such as the covid19 pandemic 1215 it has been shown that preventative measures are the cornerstone in managing the pandemic and gps play a crucial role in disseminating truthful information regarding the mentioned preventative measures and covid19 characteristics 121516 patients consider gps as trusted sources for different kinds of advice and medical information so the potential of their influence on the course of the pandemic in a particular area is enormous 121718 furthermore the communication of gps with patients regarding the covid19 pandemic is influenced by their knowledge attitudes and practices so it can be said that those variables influence the dynamics of the pandemic in a particular area 19 hence it is obvious that the adequate knowledge attitudes and practices of gps regarding covid19 may decrease the risk of infection and impact patient outcomes 9142021 the attitudes of frontline healthcare workers such as gps are therefore of inestimable importance for it has been shown that there is a strong interconnection between ones attitudes and practices regarding the same issue 9 21 22 23 there is a need for a deep understanding and identification of factors that may influence the attitudes and practices of frontline healthcare workers regarding covid19 24 therefore the present study aimed to investigate the attitudes and practices of gps from croatia and bosna and herzegovina regarding covid19 prevention and control as well as the factors that influence established attitudes and practices materials and methods study design and study participants according to the latest available official statistics on the number of gps in croatia and bosnia and herzegovina there are 2243 gps in croatia 25 and 1074 gps in the federation of bosnia and herzegovina 26 from those 3317 gps in both countries 500 potential participants were chosen by random selection and were sent an anonymous questionnaire via post together with the questionnaire each potential participant received an explanation of the research an informed consent form and two envelopes containing the address of the lead investigator in each country the potential participants were instructed to sign the informed consent form before answering the questionnaire and to put the signed informed consent form in one envelope and the answered questionnaire in the other envelope and then send them to the lead investigator in each country following the described process of data collection the anonymity of participants in the research was ensured and the personal data of the study participants could not be linked in any way to the answers given in the collected questionnaires all collected questionnaires that arrived via post were assigned codes and the data provided within the questionnaires were stored in the database and later analyzed using the assigned codes the overall response rate was 524 but the final sample size consisted of 200 participants since 62 questionnaires were discarded from the statistical analysis because they were incomplete accordingly the study included 45 of gps who were working in family medicine practice in croatia and 93 of gps who were working in family medicine practice in the federation of bosnia and herzegovina and those samples were considered representative for the population of gps in the surveyed countries this crosssectional study was conducted from february to may 2022 the study was approved by the ethics committee of the faculty of medicine osijek osijek croatia and by the ethics committee of the university vitez travnik bosnia and herzegovina measures a comprehensive selfadministered anonymous questionnaire was used for data collection the questionnaire consisted of twentythree questions divided into four main sections the first section comprised seven items that explored the sociodemographic and employment characteristics of the gps the second section included five items that explored the exposure of the gps from both surveyed countries to covid19 as well as the education of the study participants regarding the preventative measures of the coronavirus infection the third section comprised seven items that explored the attitudes of the gps toward covid19 prevention and control and the influence of the pandemic on healthcare workers the fourth section included four items regarding the covid19 prevention and control practices of the gps during the restrictive and nonrestrictive epidemiological measures in each country it took around 20 min for the participants to complete the questionnaire the questionnaire used in this study was constructed by using some of the questions from similar questionnaires used by moodley et al and mohammed basheeruddin asdaq et al in their studies which were reformulated according to croatian and bosnian language expressions 2223 the attitude items used a fivepoint likert response scale the practice items measured both individual and facility practices according to the world health organization guidelines that were used as the foundation for most of the items 27 the questionnaire used in this study was validated on a small group of gps from eastern croatia during the year 2021 minor changes were made at that time to improve the readability and clarity of the questionnaire the final attitude and practice scales in the questionnaire had an acceptable internal reliability with cronbachs alpha values of 0519 and 0533 respectively statistical analysis the normality of the data distribution was tested with the kolmogorovsmirnov test and thereafter all the data were processed by methods of descriptive statistics all the categorical variables were expressed in absolute and relative frequencies while the numerical variables were expressed as median and interquartile ranges the χ 2 test and fishers exact test were used for the comparison of the categorical variables between the groups while the mannwhitney u test and the kruskalwallis test were used for the comparison of the numerical variables between the groups in all the statistical analyses twosided pvalues of 005 were considered significant the level of statistical significance was set at p 005 statistical analysis was performed using the ibm spss statistical package version 220 results study participants the study included 200 gps from croatia and the federation of bosnia and herzegovina with 100 gps from each country the median age of the participants was 4200 years and 745 were females a total of 550 of the participants were in the younger age group and 450 of the participants were in the older age group being single was reported by 360 of the participants while 640 were in a relationship according to the place of their family medicine practice 450 of the participants had their practice in the county or cantonal center 435 of the participants had their practice in some other city in the county or canton and 115 of the participants had their practice in a village or suburban settlement regarding education 555 of gps had a license for independent practice without finished specialization and 445 were specialists in family medicine the median length of service was 1200 years with 520 of the participants with a length of service from 0 to 14 years and 480 of the participants with a length of service of 15 years or more regarding the type of family medicine practice 750 of the participants were employees of a health center while 250 of them had a concession or a private practice the sociodemographic and employment characteristics of the gps from croatia and bosnia and herzegovina are presented in table 1 regarding the gps coronavirus exposure or infection 700 of the participants had had covid19 or had lived in the same household with a family member who had covid19 regarding the education about the preventative measures of coronavirus infection 445 of the gps reported finishing formal education on the prevention of infectious diseases and occupational safety 390 of the gps reported finishing formal education on adequate hand hygiene 965 of the gps reported having an official protocol regarding protection from covid19 in family medicine in their place of work and 400 of the gps reported finishing formal education on covid19 prevention for general practitioners the results regarding coronavirus exposure or infection and education regarding the preventative measures of coronavirus infection among the gps are presented in table 2 attitudes toward covid19 prevention and control and the influence of the pandemic on healthcare workers the median number of positive attitudes toward covid19 prevention and control was 500 with an interquartile range between 400 and 600 the study revealed that there was a significant difference in the overall number of positive attitudes toward covid19 prevention and control between the gps from croatia and bosnia and herzegovina where the gps from croatia displayed a larger number of positive attitudes toward covid19 prevention and control and the influence of the pandemic on healthcare workers the 9ndividual attitudes of the gps from croatia and bosnia and herzegovina toward covid19 prevention and control and the influence of the pandemic on healthcare workers are presented in table 3 the study revealed that different factors were associated with the established attitudes of the gps from croatia and bosnia and herzegovina toward covid19 prevention and control and these results are presented in table 4 in the group of croatian gps it was established that the gps who had finished formal education on the prevention of infectious diseases and occupational safety had more positive attitudes toward covid19 prevention and control among the bosnian gps it was determined that there were more positive attitudes toward covid19 prevention and control among the older gps males gps with a longer length of service gps who had finished formal education on the prevention of infectious diseases and occupational safety gps who had finished formal education on adequate hand hygiene and gps who had finished formal education on covid19 prevention for gps practices regarding covid19 prevention and control the median number of positive practices regarding covid19 prevention and control was 400 with an interquartile range between 300 and 400 the study revealed that there was no significant difference in the overall number of positive practices regarding covid19 prevention and control between the gps from croatia and bosnia and herzegovina the covid19 prevention and control practices of the gps from croatia and bosnia and herzegovina during the restrictive and nonrestrictive epidemiological measures in each country are presented in table 5 the study showed that different factors were associated with the established practices of the gps from croatia and bosnia and herzegovina regarding covid19 prevention and control and these results are presented in table 6 the study revealed that among the croatian gps more positive practices regarding covid19 prevention and control were reported by older gps females gps who had a partner gps who were specialists in family medicine gps with a longer length of service and gps who had finished formal education on the prevention of infectious diseases and occupational safety the study further discovered that among the bosnian and herzegovinian gps none of the investigated factors was associated with established practices regarding covid19 prevention and control discussion the present study assessed the attitudes and practices of gps from croatia and bosnia and herzegovina regarding covid19 prevention and control and the factors influencing the observed attitudes and practices in the surveyed population this is a highly important issue since primary healthcare workers have a significant role in the containment of the spread of covid19 in any particular country and it has been proven that a response built around primary care is also a more costeffective measure which is highly important for all healthcare systems in todays modern world 6 to better understand the practices of primary healthcare workers regarding covid19 in a particular country it is very important to know their attitudes toward the same issue as well as the various factors that have a strong influence on such attitudes because it has been shown that participants with higher positive attitude scores are also more likely to score higher in their practice 21 22 23 28 29 30 31 32 the connection between attitudes and practices can be explained by the reasoned action theory which states that a persons intention to undertake a specific behavior is a function of their attitude towards that behavior 33 the present study revealed that the majority of the studied population had satisfactory attitudes toward different aspects of covid19 prevention and control as well as toward the influence of the pandemic on healthcare workers which was in concordance with some other similar studies 715192223 34 35 36 although there is also research in which only onethird of healthcare workers in primary health care centers showed satisfactory attitudes toward investigated issue 31 one possible explanation for the discrepancies between the results of a study conducted by albahri et al and other studies including ours could be the time point of the pandemic when the research was carried out it is possible that at the beginning of the pandemic due to a lot of unknown aspects concerning the new virus the attitudes of healthcare workers toward its prevention and control were somewhat less positive than in a later time of the pandemic this study further discovered that there were some significant differences between the surveyed countries regarding the attitudes of gps toward covid19 prevention and control considering the overall number of positive attitudes it was established that the gps from croatia displayed a larger number of positive attitudes toward covid19 prevention and control and toward the influence of the pandemic on healthcare workers in comparison to their colleagues from bosnia and herzegovina similarly the study that included gps from several different countries where the majority of them were from turkey greece and the united states also showed that gps from the united states had more positive attitudes toward covid19 in comparison to their colleagues from greece and turkey 7 one possible explanation for the observed differences in the gps attitudes in the cited study as well as in our study is the cultural differences among the countries that strongly influence the covid19 risk perception in the surveyed countries and the attitudes of gps toward the different aspects of covid19 prevention and control 37 when looking separately at the individual attitudes the present study showed that the gps from croatia better understood that the usage of personal protective equipment prevents covid19 infection in patients in comparison to the gps from bosnia and herzegovina while both groups of gps were equally aware that the usage of ppe prevents covid19 infection among healthcare workers both groups of study participants thought that gps should treat covid19 patients and they all equally considered that gps were sufficiently educated for their work during the covid19 pandemic and that the gps offices were sufficiently equipped with protective equipment for work during the covid19 pandemic similar studies conducted elsewhere also showed that the majority of surveyed healthcare workers would wear the required ppe and would treat covid19 patients 722 a study in saudi arabia showed that the majority of physicians believed that they were sufficiently educated for their work during the covid19 pandemic 23 but a study conducted in sierra leone showed that healthcare workers thought that their health facilities were not sufficiently equipped for an adequate response to the covid19 outbreak 38 croatian gps were more aware that the covid19 pandemic increased the level of stress among gps but at the same time they were more convinced that their country was successful in the containment of the spread of covid19 in comparison to the gps from bosnia and herzegovina studies conducted in saudi arabia sierra leone and nigeria also showed that the majority of healthcare workers believed that their countries would contain the covid19 pandemic successfully 23343839 the determined differences among the surveyed countries besides their probable cultural differences can also be attributed to the different sociodemographic and employment characteristics of the surveyed gps as well as to the overall organization of the healthcare systems in croatia and bosnia and herzegovina namely this study revealed that among the croatian gps there were no significant associations between the various sociodemographic and employment variables and the gps attitudes and the only factor that was significantly associated with more positive attitudes toward the covid19 prevention and control was whether the gps had finished formal education on the prevention of infectious diseases and occupational safety studies from several different countries also did not find significant connections between sociodemographic and employment variables and the attitudes of healthcare workers 7202329304041 studies from saudi arabia china and pakistan confirmed that the participation of healthcare workers in formal education on the prevention of infectious diseases and occupational safety contributed significantly to their positive attitudes toward covid19 prevention and control and this was also proven in this study both for the croatian and bosnian gps 28303442 considering the bosnian gps the present study further discovered that more positive attitudes toward covid19 prevention and control were also found in older gps males gps with a longer length of service gps who had finished formal education on covid19 prevention for gps and gps who had finished formal education on adequate hand hygiene studies in india also showed that older healthcare workers had more positive attitudes toward covid19 prevention and control 1921 while studies from saudi arabia and greece as well as the results of this study concerning the croatian gps did not find a connection between age and gps attitudes toward covid19 prevention and control 2934 a study from nigeria however discovered that older healthcare workers had more negative attitudes toward covid19 prevention and control 39 while studies from saudi arabia sierra leone and jordan also discovered that male healthcare workers like the male gps from bosnia and herzegovina in this study had more positive attitudes toward covid19 prevention and control 153238 another study from saudi arabia and studies from india and china contrary to the results among the bosnian gps in this study showed that females had more positive attitudes than males 193443 finally a study that included gps from the united states turkey and greece and another study that included only gps from greece found no connection between gender and attitudes toward covid19 prevention and control 729 a study among frontline healthcare workers in india also discovered that healthcare workers with a longer length of service had more positive attitudes toward covid19 prevention and control 21 unlike the results concerning the bosnian gps in this study a study conducted by gokdemir et al did not find a connection between the length of service and attitudes toward covid19 prevention and control 7 while studies from nigeria and sierra leone showed that healthcare workers with longer lengths of service had more negative attitudes toward covid19 prevention and control 3839 like our study results for the gps from bosnia and herzegovina a study conducted among frontline healthcare workers in nepal also showed that more positive attitudes toward covid19 prevention and control were connected with having finished additional formal education regarding covid19 prevention 44 in addition studies among healthcare workers in saudi arabia and jordan showed that those who participated in infection control training were more likely to have positive attitudes toward covid19 prevention and control 3234 according to the center for diseases control and prevention handwashing with soap and water for at least 20 s or the use of alcoholbased hand sanitizers when soap and water are not available is the first line of defense in stopping the spread of covid19 and because of this it is not surprising that the bosnian gps from this study who had finished formal education on adequate hand hygiene had at the same time more positive attitudes toward covid19 prevention and control 45 this finding confirms one more time that there is a strong correlation between gps knowledge about a particular issue and their attitudes toward the same issue and that additional education on a particular issue can facilitate positive changes in physicians attitudes toward the same issue 17 considering the practices of the croatian and bosnian gps regarding covid19 prevention and control the present study showed that the gps from both countries displayed a strong adherence to adequate practices regarding covid19 prevention and control which was similar to the results of several studies conducted elsewhere 1921 29 30 31 34 35 36 3844 unlike for the attitudes this study further revealed that there was no significant difference in gps practices regarding covid19 prevention and control between the the study participants from croatia and bosnia and herzegovina however when looking separately into the individual practices this study clearly showed that there was a significant difference between the surveyed countries regarding the usage of protective facial masks in everyday life during the nonrestrictive epidemiological measures in a particular country where the croatian gps significantly more often practiced the described preventive behavior in comparison to their colleagues in bosnia and herzegovina the discovered differences could be associated with the different social and cultural norms that exist in these neighboring countries because it has been proven that practices of wearing or not wearing facial masks are strongly influenced by several factors such as personal interpretations of solidarity and responsibility individual perceptions of covid19 risk and cultural and societal traditions 46 furthermore a study conducted in the general population of bosnia and herzegovina during the restrictive epidemiological measures in the country showed that despite high fines over 13 of citizens did not wear facial masks showing that the whole society of the country probably had a different pattern of covid19 practices from the beginning of the outbreak in comparison to that of croatia 47 in addition to this this study also showed different patterns of association between more positive practices regarding covid19 prevention and control and the different sociodemographic and employment characteristics of the study participants from the surveyed countries it was established that among the bosnian gps there were no significant associations between the various sociodemographic and employment variables and the gps practices while among the croatian gps there were several factors that were significantly associated with more positive practices of the croatian gps regarding covid19 prevention and control it was determined that among the croatian gps more positive practices regarding covid19 prevention and control were reported by older gps females gps who had a partner gps who were specialists in family medicine gps with a longer length of service and gps who had finished formal education on the prevention of infectious diseases and occupational safety studies conducted in greece and dubai also did not find associations between various sociodemographic and employment variables and gps practices 2931 however some studies showed significant correlations between particular sociodemographic and employment variables and gps practices regarding covid19 prevention and control considering age a study conducted in india showed that like the croatian gps in this study older healthcare workers from this country more frequently displayed positive practices regarding covid19 prevention and control in comparison to their younger colleagues 19 furthermore like the croatian gps in this study a study from china showed that female gps expressed more positive practices regarding covid19 prevention and control 43 while a study in saudi arabia discovered that male gps from saudi arabia were more likely to comply with appropriate practices regarding covid19 prevention and control in comparison to their female colleagues 34 unlike the croatian gps in this study studies in riyadh saudi arabia and india revealed that single healthcare workers more frequently displayed positive practices regarding covid19 prevention and control in comparison to their married colleagues 1923 opposite to the results of this study for the croatian gps a study in greece did not reveal a significant difference in the displayed practices regarding covid19 prevention and control between specialists in family medicine and doctors without specialization 29 regarding the length of service studies in pakistan and india showed that like the croatian gps in this study healthcare workers with a longer length of service reported more positive practices regarding covid19 prevention and control 2130 like the croatian gps in this study studies from saudi arabia and jordan showed that healthcare workers who had finished formal education on the prevention of infectious diseases and occupational safety displayed more positive practices regarding covid19 prevention and control 3234 additionally a study among frontline healthcare workers in nepal showed that more positive practices regarding covid19 prevention and control were connected with having finished additional formal education regarding covid19 prevention 44 to the best of our knowledge this was the first study that analyzed the attitudes and practices of gps from croatia and bosnia and herzegovina thus giving an indepth insight and fulfilling the knowledge gap regarding the important issue of primary healthcare workers involvement in resolving the covid19 outbreak in this part of europe the present study included gps working in state institutions as well as those who were working in private practices which is highly important because a similar study conducted elsewhere stated that healthcare workers working in the private sector may have different attitudes regarding the pandemic 21 despite the aforementioned important strengths this study is not without limitations the present study was crosssectional and because of the employed study design the demonstration of any causality between the outcome and explanatory variables is limited the research tool was selfadministered and dependent on the honesty and accuracy of the participants answers and because of this the risk of social desirability of disclosed attitudes and practices cannot be completely ignored the study in bosnia and herzegovina was limited to only one entity ie the federation of bosnia and herzegovina and the results from this country might be somewhat different if gps from other entities ie the republika srpska and the brčko district were also included in the study the final sample size of this study was rather small although the response rate was acceptable which was a consequence of the quite large portion of discarded questionnaires that were incomplete the majority of those incomplete questionnaires came from croatian gps and were probably connected with the enormous workload of croatian gps during the covid19 pandemic because it is wellknown fact that even before the pandemic croatian gps were facing an increased workload 48 despite all the previously mentioned limitations this study revealed important associations between gps attitudes and practices regarding covid19 prevention and control and pointed to the possible factors that may have influenced the investigated variables and can potentially explain the differences between the surveyed neighboring european countries furthermore the present study raised some new questions concerning the investigated issues namely a recent study by gokdemir et al 7 showed that the personality traits of healthcare workers could strongly influence their attitudes toward covid19 prevention and control thus there is a need for new studies of croatian and bosnian gps attitudes and practices regarding covid19 prevention and control with a larger sample size in both countries where in the sample from bosnia and herzegovina the gps from the whole territory of bosnia and herzegovina should be included and the survey should be conducted with a questionnaire that comprises additional items regarding the personality traits of the study participants conclusions the present study revealed that the attitudes and practices of gps from croatia and bosnia and herzegovina regarding covid19 prevention and control were satisfactory the study further showed that the croatian gps displayed a larger number of positive attitudes toward covid19 prevention and control and the influence of the pandemic on healthcare workers in comparison to their colleagues from bosnia and herzegovina while there was no significant difference in the practices regarding covid19 prevention and control among the surveyed countries finally the study disclosed that the different sociodemographic and employment characteristics of the study participants strongly influenced their attitudes and practices regarding the prevention and control of covid19 whereas the cultural differences between croatia and bosnia and herzegovina as well as the organizational specificities of their healthcare systems probably modified the observed differences in the individual patterns of associations between the outcome and explanatory variables in the surveyed neighboring countries data availability statement the data presented in this study are available on request from the corresponding authors funding this research was funded by grants from the croatian ministry of science and education and is dedicated to a multiyear institutional financing of scientific activity at the josip juraj strossmayer university of osijek faculty of medicine osijek osijek croatiagrant number ip92022 and grant number ip72023 institutional review board statement the study was conducted in accordance with the declaration of helsinki and approved by the ethics committee of the faculty of medicine osijek osijek croatia and by the ethics committee of the university vitez vitez bosnia and herzegovina informed consent statement informed consent was obtained from all subjects involved in the study

attitudes toward covid19 coronavirus disease 2019 prevention and control may have influenced general practitioners gps work during the covid19 pandemic the present study aimed to investigate the attitudes and practices of gps from croatia and bosna and herzegovina regarding covid19 prevention and control as well as the factors which may have influenced them a crosssectional study using a selfadministered anonymous questionnaire was conducted between february and may of 2022 on 200 croatian and bosnian gps the study revealed that the attitudes and practices of the surveyed gps regarding covid19 prevention and control were satisfactory the croatian gps reported a larger number of positive attitudes toward covid19 prevention and control p 0014 while no significant differences in practices were established among the croatian gps more positive attitudes toward covid19 prevention and control were reported by participants who had finished a formal education on the prevention of infectious diseases and occupational safety p 0018 while among the bosnian gps more positive attitudes were reported by older gps p 0007 males p 0026 gps with a longer length of service p 0005 gps who had finished a formal education on the prevention of infectious diseases and occupational safety p 0001 gps who had finished a formal education on adequate hand hygiene p 0001 and gps who had finished a formal education on covid19 prevention for gps p 0001 considering gps practices regarding covid19 prevention and control among the croatian gps more positive practices were reported by older gps p 0008 females p 0002 gps who had a partner p 0021 gps who were specialists in family medicine p 0014 gps with a longer length of service p 0007 and gps who had finished a formal education on the prevention of infectious diseases and occupational safety p 0046 while among the bosnian gps no significant correlations were determined the general practitioners sociodemographic and employment characteristics strongly influenced their attitudes and practices regarding the prevention and control of covid19 the cultural differences between croatia and bosnia and herzegovina as well as the organizational specificities of their healthcare systems probably modified the observed differences in the individual patterns of associations between the outcome and explanatory variables in the surveyed neighboring countries

background we are interested in identifying inequality in life expectancy and deaths of children under age 5 due to air pollution as effects of environmental threats by countrylevel income energy and natural resources from a socioecological perspective ile define as inequity in the arrangement of the expected length of life estimated based on statistics data from life tables and applying the atkinson inequity index 12 the value of these estimates relies on the evaluate of the information in the life tables 3 deaths of children under age 5 due to indoor air pollution could result from acute respiratory infections attributable to indoor smoke from solid fuels 4 5 6 countrylevel ile and dcap can be influenced by countrylevel income energy sources and natural resources as environmental indicators thus both ile and dcap are useful indicators that can aid in developing ways to diminish health discrimination partially countries have executed health effects and national income and environment studies 7 8 9 10 11 12 13 14 15 16 17 18 however few studies on countrylevel income energy and natural resource have examined the factors that affect ile and dcap from a socioecological perspective 710 13 14 15 16 17 18 19 therefore a retrospective analysis of countrylevel income energy sources and natural resources as socioecological perspective indicators that create to ile and dcap may help identify the most significant determinants of healthy life expectancy or infant and child mortality due to indoor pollution 614 ile and dcap have also been used to compare health inequality between countries these comparisons can inform policies regarding health inequality and child mortality depending on countrylevel socioecological factors in this study we considered how ile and dcap correlated with countrylevel income energy sources and natural resources and compared ile and dcap as effects of environmental threats between countries the basic thesis of this paper was that there is a connection between nationwide indoor air pollution levels and pneumonia risk in children under age five 10 moreover several studies have estimated different countries energy and health effects and dcap between 1994 and 2012 78 10 11 12 13 19 20 21 22 these studies have shown relationships between life expectancy and the environment resource depletion and welfare energy sources and health effects rural electrification and quality of life other studies have shown associations between the natural environment and health inequalities 89 including between air pollution and mortality due to respiratory diseases in children 10 11 12 13 however no studies have examined the associations between ile and dcap and countrylevel income energy sources and natural resources we examined the achievable associations between ile dcap and income energy and natural resource inequalities using the following socioecological indicators gross national income per capita which can expose people to health risks from poverty 14 15 16 17 18 nonsolid fuel for cooking 9 10 11 12 13 and electrification rates 19 20 21 and natural resources 182223 specifically the lack of access to nonsolid fuels for use in lighting cooking and heating is a worldwide issue that the world health organization estimates contributes to 4 million deaths per year 1024 the use of inefficient and harmful fuels is a significant health and environmental issue 24 besides with annual deaths from pneumonia in children under age five exceeding 2 million and scant evidence of a decline in this number in the last 510 years prevention remains a critical component of control strategies 10 thus we aimed to better comprehend the influences on ile and dcap by examining these socioecological factors for 164 countries we expected that countries with high ile and dcap would show combinations of lower national incomes the use of nonsolid fuels electricity attainment and more natural resource depletion the knowledge regarding the social determinants of health inequalities unlimited but the ile and dcap influenced by biological psychosocial and environmental factors 14 15 16 17 18 25 26 27 of these elements the abovementioned countrylevel income energy source and natural resource components in the socioecological perspective have not studied concerning ile and dcap even if studies indicate that these components are associated with healthy life expectancy 14 15 16 17 18 solid fuel use is associated health risks in children 10 11 12 13 energy and electrification is associated quality of life 1921 and natural resources are associated life expectancy 2223 but these factors can only predict health and quality of life with this study we aimed to confirm whether these factors affected ile and dcap specifically we examined the associations between ile dcap and gni per capita nonsolid fuel electrification rates and natural resource depletion moreover even though studies have researched the effects of environmental threats on health the associations between ile dcap and gni nsf er and nrd have not been examined and we were not certain whether ile and dcap would be associated with these factors methods dcap and ile framework and the socioecological perspective the suggested framework for this study represents the countrylevel income energy and natural resource indicators that we believed would affect ile and dcap to predict health inequalities in dcap and ile we treated gni per capita nsf er and nrd as sustainability as inputs and processes and dcap and ile as outputs and effects dcap referred to outputs as shortterm for the countrylevel income energy source and natural resource indicators and ile referred to the longterm effects these factors could be explicated by dcap and ile differences one is a concept model of dcap and ile and the other is a structure that comprises socioecological indexes concerning ile and dcap especially outputs and effects can be described as a sustainable change in peoples life outputs are resulting from shortterm life effects are meaning for the impact of longterm life this is likely achieved by longterm longevity thus dcap can be defined as shortterm outputs because of its short lifespan any other longterm effects maybe the side effects of health and aging including ile besides the outputs are based on nations and populations therefore we averaged the outputs of all populations and distinguished them by applying statistical criterion procedures 14 differences in ile and dcap appears to be influenced by the countrylevel income energy source and natural resource indicators thus we suggest that healthy aging is a universal multifactors characteristic measured by the quantity of health rather than its quality to impact by socioecological perspective factors 14 15 16 17 25 that is healthy aging refers to being physically active until becoming centenarians without disease and with maintaining function and socioecological wellbeing 15 16 17 27 28 29 30 consequently in this study although we excluded any discussion of heredity or biological factors ile and dcap can be controlled by countrylevel socioecological factors 14 we omit individual factors from this study 1418 instead of we focus on the broader nationallevel socioecological perspective 14 15 16 26 we hypothesized that any associations between ile dcap and countrylevel socioecological factors might differ between countries and we proposed to study these factors as targets for health promotion 31 32 33 34 specifically our model assumed that ile and dcap would be affected by countrylevel income per capital from a personal perspective solid fuel use from the environmental perspective electrification rate from a social environment perspective and natural resource depletion from a public policy perspective dcap and ile estimation dcap could be deaths from respiratory ailments lung cancer cardiovascular diseases attributable to outdoor air pollution and acute respiratory infections attributable to indoor smoke as effects of environmental threats 35 for this study we excluded deaths in children under 5 due to poor water sanitation or hygiene and only looked deaths in this group due to indoor and outdoor air pollution ile summarizes inequity in the allocation of the expected of life it used to compare health imbalance between countries 141826 and these compare policy decisions predictable on how ile variations 36 we used ile based on data from life tables estimated applying the atkinson disparity index a 12 which computed as a 1 137 specifically this study used data 2010 to 2015 from the un 2 for which the a had already calculated to calculate the ile life expectancy at birth is provided by the un population division of the un department of economic and social affairs and ile was calculated for the 20102015 period this distribution is presented over age intervals with mortality rates and average ages at death specified for each interval in other words the un estimates ile from the abridged life tables in fiveyear age cohorts and the data reflect the current inequality in mortality patterns some children die under the age of one and others die at 75 or later 3 for this retrospective study we looked at ile from 2010 to 2015 2 hypothesis setting model and statistical methods under the assumption of all conditions are constant we selected these variables in pollutants and socioeconomic factors from a socioecological perspective to analyze the associations between ile dcap and socioecological variables we developed a model that estimated ile and dcap about each variable a model represents proposed frameworks of the variables in different combinations and the two models yielded the following results for model 1 y ab x 1 x 2 x 3 x 4 … e and for model 2 y ab x 1 x 2 x 3 x 4 … e specifically we used the predictors of ile and dcapthat is gni nsf er and nrdto develop a model that combined two models thus the variables reflected countrylevel income energy source and natural resource indicators and their relationships could differ according to ile and dcap in this model derived the assumption that changes in gni nsf er and nrd result in accordant changes in ile and dcap we assessed the associations between these factors and ile and dcap using pearsons correlation coefficients and multiple regression models besides we ran univariate regression analyses to determine whether ile and dcap were independently significantly correlated with countrylevel income energy sources and natural resources our final analysis used multiple regression models 141727 besides the scatters would be able to ascertain whether correlation coefficients are the correct tool to summarise the relationships 3839 the pairwise scatter plots of 4 variables seem the correlation collected data for dcap ile and socioecological indicators the data of this study were countrylevel socioecological statistics because we were presenting not personal information it needless to obtain a permit to publish our information 1427 for the study we used demographic databases from 164 countries in different stages of development for our calculations we obtained the data for the ile and dcap analyses from a un study on ile and dcap 235 and the data on gni energy sources and natural resources from the un 35 and the world bank 40 specifically we used the following indicators dcap deaths of children under age 5 per 100000 children due to outdoor and indoor air pollution from 2004 to 2008 due to acute respiratory infections lung cancer or cardiovascular diseases attributable to indoor and outdoor air pollution 35 ile the inequity in the allocation of the expected life create on data from 2010 to 2015 undesa life tables and estimated using the atkinson inequality index 2 gni per capita gross national income per capita converted to international dollars using purchasing power parity rates from 2010 to 2015 40 nsf percentage of the population with access to nonsolid fuel from 2000 to 2012 but solid fuel is fuel such as coal or wood that is solid rather than liquid or gas these data came from the world bank and the who global household energy database 40 er percentage of the population with access to electricity from 2000 to 2012 including electricity sold commercially and selfgenerated electricity but excluding unauthorized connections 235 and nrd the monetary representation of natural resource depletion from 2008 to 2013 as a percentage of gni 35 results dcap ile and income energy source and natural resource disparities the descriptive statistics for the ile dcap income energy and natural resource indicators presented in table 1 dcap ranged from 0 in the united kingdom the united states the netherlands italy iceland ukraine belgium croatia republic of korea latvia japan luxembourg france finland and mauritius to 1218 in sierra leone and the mean was 12632 ile also varied across and countrylevel socioecological indicators gni ranged from 640 in congo to 124645 in qatar nsf ranged from 2 in burundi to 100 in australia the bahamas belgium canada cyprus denmark finland france italy iceland lithuania the united kingdom the united states and other countries with a mean of 6347 and a betweencountry disparity of 98 similarly er ranged from 435 in chad to 100 in albania canada belarus austria finland estonia the united kingdom latvia and the united states nrd ranged from 0 in lebanon and vanuatu to 676 in equatorial guinea dcap ile prediction variables tables 2 3 and 4 show the results of the analyses of gni nsf er and nrd for the 164 countries dcap and ile correlated significantly with gni nsf er and nrd gni nsf er nrd to investigate the direct relationships between dcap ile and gni nsf er and nrd we conducted a multiple regression analysis the analysis of countrylevel income energy sources and natural resources revealed the powerful predictors between two regression models namely dcap predictors were low nsf and er and ile predictors were low gni nsf and er and high nrd discussion this study shows that low gni energy source use and natural resource protection greatly affect dcap and ile that is the countries with higher incomes and electrification rates have lower expected dcap and ile national health disparity continues to be a great barricade to humanity development 14172627 it has an incrementing in manifold health extents concurring with unfair income allocation between the rich and poor 1417182741 countrylevel gni per capita nsf er and nrd have markedly reform over time but have not yet led to nationallevel health fairness from a socioecological perspective the downside in nationallevel environment health is the most fundamental source of 141726 here we examined the associations between dcap ile and these countrylevel indicators to confirm whether higher dcap and ile are disproportionately susceptible to differences in the indicators the countrylevel income energy and natural resource variables that we studied were gni nsf er and nrd all of which can contribute to dcap and ile 9 11 1319 21 23 26 higher gni nsf and er and lower nrd corresponded with lower ile indicating that these factors afford to reform ile in the current study although developed countries were higher the gni nsf and er in less developed areas were lower these factors countries the countrylevel income energy and natural resource variables that we studied were gni nsf er and nrd all of which can contribute to dcap and ile 9 11 1319 21 23 26 higher gni nsf and er and lower nrd corresponded with lower ile indicating that these factors afford to reform ile in the current study the gni nsf and er were high in developed countries but in lessdeveloped countries were low in these factors we showed in this study that nationallevel socioecological factors that impact the standard of living such as gni nsf and er afford to predict dcap and ile and equating nationallevel health imbalance 4243 gni nsf er and nrd are likely principal causing factors to low dcap and ile we are likely to need indirectly reflect or directly suggest the nationallevel these socioecological indicators that are desired for healthy aging and healthy living that is dcap and ile based on gni nsf er and nrd reflect health inequalities and standards of living 1417 gni nsf er and nrd controlled crucial determinants of countrylevel dcap and ile which is extremely major because of the surviving associations between them we investigated whether the international disparity in dcap and ile correlated with national nonsolid fuel and electrification rate unfairness the lessdeveloped countries showed lower nsf inequality and relative access to electricity 41417184445 but in the developed countries have higher nsf and er but lower dcap and ile additionally countrylevel energy and natural resource disparity have likely contributed to the poor approach in achieving health equality among humans in less developed countries 141727 during the period of our study as nonsolid fuel equality and access to electricity increased dcap and ile decreased countrylevel nsf inequality and electrification rate attainment appear to influences dcap and ile therefore we suggest that nonsolid fuel policies target socioecological factors to reduce the burden of respiratory ill health from exposure to indoor air pollution associated with household use of solid fuels access to cleaner household fuels improved stoves and better ventilation is necessary 46 and to reduce identified household indoor air pollution from solid fuels more efficient fuels should be used that improve combustion and ventilation 47 in this study we analyzed the impact of national income on dcap and ile in both of our models we input gni which indirectly reflects standards of living and income levels 14 15 16 17 47 that are necessary for calculating survival probability in children under age 5 although the relationships between economic indicators and health are unclear lower income has been associated with morbidity 47 and health inequality 48 we also investigated whether international differences in dcap and ile were associated with national income inequity there are greater income disparity and relative extreme poverty in moredeveloped countries 4950 but these countries have high per capita incomes but also low dcap and ile that is during the study period as countrylevel income increased dcap and ile decreased countrylevel gni had the influences on dcap and ile simultaneously access to natural resources such as minerals and forests can potentially improve lives and empower people about their health eventually contribute to better health 1451 individuals face health problems from factors including heavy metal use the reuse of solid and liquid wastes biomass fuels and natural gas development 52 health is affected by air emissions during unconventional natural gas production 53 strategies are needed with regard to fuel wood among impoverished rural households that have experienced a recent adult mortality because there is greater natural resource dependence among these households 54 thus from a public policy perspective natural resources can be an innovative tool for health promotion and can potentially better the standard of life a limitation in calculating the dcap was the lack of complete and reliable mortality data which required us to estimate our models based on data from 2004 to 2008 there was an insufficiency of comparability between more or less of the countries but the uns unfairnessadjusted human development index includes ile 2 and captures the inequality in the distribution of the human development index dimensions however the index is not sensitive to associations meaning that it does not account for overlapping inequalities that is whether the same people are at the lower end of each distribution 14 besides our findings are good not apply to a person in a group as a limitation of socioecological studies however this theme may apply to experimental studies and controlled attempts 1417 in this study the dcap ile and gni nsf er and nrd could predict the impact on the full health of a population in our proposed models countries with higher gni nsf er and nrd showed lower dcap and ile these nationallevel factors are anticipated to have invisible effects on dcap and ile thus the findings seem to need to execute dcap and ile projects to children and the elderly in lowincome countries for the health of mankind from a socioecological environment perspective applying countrylevel socioecological indicators conclusions this study identified nonsolid fuel inequality electrification rates and natural resource depletion that important impact on ile and dcap thus policies regarding national level ile and dcap should be considered socioecological factors such as access to nonsolid fuels and electricity as well as natural resource depletion we recommend that countries target high standards of living increase national income high access to nonsolid fuels and electricity and sustainable natural resources to reduce national level ile and dcap abbreviations dcap deaths of children under age 5 due to outdoor and indoor air pollution er electrification rate gni gross national income per capita ile inequality in life expectancy nrd natural resource depletion nsf nonsolid fuel funding the authors disclose receipt of the following financial support for the research authorship andor publication of this article this work was supported by the ministry of education of the republic of korea and the national research foundation of korea ethics approval and consent to participate not applicable competing interests the authors declare that they have no competing interests

background countrylevel inequality in life expectancy ile and deaths of children under age five due to air pollution dcap can be influenced by countrylevel income per capita solid fuel electrification and natural resource depletion the ile and dcap in the shortterm are useful indicators that can help in developing ways to reduce environmental threats this study confirms evidence for ile and dcap as the effects of environmental threats by countrylevel income energy and natural resource levels from a socioecological approach methods this study based on life expectancy and children data on 164 countries acquired from the united nations development programme we obtained the countrylevel socioecological data from the united nations and the world bank database we assessed the associations between ile dcap and the countrylevel indicators applying correlations coefficient and the regression models results these study findings showed considerable correlations between ile and countrylevel socioecological indicators gross national income per capita gni nonsolid fuel nsf electrification rate er and natural resource depletion nrd the dcap in shortterm predictors were low nsf and low er r 2 0552 and ile predictors were low gni nsf and er and higher nrd r 2 0816 thus the countries with higher incomes and electrification rates and more sustainable natural resources had lower expected dcap in the shortterm and ile in the longterm conclusions based on our results we confirmed that countrylevel income energy and natural resource indicators had important effects on ile in longterm and dcap in shortterm we recommend that countries consider targeting high standards of living and national incomes access to nonsolid fuel and electricity as energy sources and sustainable natural resources to reduce ile and dcap in shortterm

introduction violence globally represents both public health and an economic problem in health terms violence generates both mortality and morbidity violence is estimated to cause 13 million deaths annually accounting for 25 of global mortality 1 violence often requires acute health service access and can result in longterm physical disability depression or reproductive health problems 1 2 violence also affects local economies through workforce absenteeism loss of productivity and loss of human capital families can fall into poverty if a breadwinner dies or becomes permanently disabled due to violence 1 3 youth violencewhich includes bullying physical fighting sexual and physical assault and homicideis particularly problematic because it generates higher economic welfare and criminal justice costs 4 in addition to death injury and psychological harm youth violence can lead to increased subsequent health risks behaviours such as smoking substance abuse unsafe sex and further violence 5 6 an estimated 200 000 youth homicides occur each year 83 among males nearly all in lowincome and middleincome strengths and limitations of this study ⇒ a key strength of our study is the fixedeffects design which robustly removes timeinvariant confounding of effect measures ⇒ while fixedeffects analyses are powerful they cannot control for unmeasured timevarying confounding and we may not have fully accounted for factors that change rapidly among adolescents ⇒ the use of selfreported data may have led to reporting biases ⇒ generalisability from a sample drawn from a single district is always difficult to assess ⇒ using a populationbased sampling frame our analysis provides results that represent the entire local population and are likely broadly applicable in poor rural burkina faso and beyond open access countries with particularly high rates in latin america and the caribbean and subsaharan africa 4 in subsaharan africa in particular historical economic and social factors continue to expose youth to violence 7 8 although violence affects all youth adolescent girls and young women in lmics appear to be most affected 9 10 11 social and cultural norms such as arranged and teenage marriage and denial of resource access to women often keep agyw economically dependent on males and thus vulnerable to abuse especially from intimate partners 12 13 14 agyw experience all forms of violence perpetrated by men and often other females in domestic and social settings 15 16 17 18 many factors have been proposed as determinants of youth violence receipt and perpetration in lmics often adopting or adapting heises integrated ecological framework for violence against women 19 20 this framework conceptualises violence as a multifaceted phenomenon grounded in an interplay among personal situational and sociocultural factors we modified this conceptualisation to cover all forms of adolescent violence concentrating on individuallevel and microsystem factors given our focus within a specific geography we focus on two individuallevel factors believed to play an important role in determining violence experience age and education given the magnitude of youth violence evidence of associations between violence age and educational attainment and calls for youth violence interventions 1 2 causal evidence on whether policies based on age or education are likely to affect violence levels is important past longitudinal analyses of adolescent violence often focused on the consequences of violence experience rather than predictors of violence itself 21 22 we instead focus on predictors of adolescent violence experience to contribute to the upstream prevention of violence rather than efforts to break the connection between violence and its sequelae age is strongly associated with both the experience and perpetuation of violence 3 23 youth aged 1529 are more likely to both experience and perpetrate violence than older adults often experiencing violence perpetrated by their older peers or family members 3 23 males are more likely to perpetrate violence while young girls and women are more likely to experience it 9 10 14 24 25 however evidence on the causal effect of age on violence is comparatively scarce with few even crosssectional studies explicitly focused on youth 3 11 26 education is theorised to protect against violence since moreeducated persons are less likely to either perpetrate or experience violence 26 27 evidence shows that women without education were 56 times more likely than those with college education to experience intimate partner violence similarly wives of uneducated men were 184 times more likely than those whose husbands had college education to experience ipv even at the community level the likelihood of ipv declined as community male and female literacy increased 28 however causal evidence on the effect of education on youth violence in subsaharan africa is again limited two studies have used changes in national school policy as natural experiments in this context one focused on violence finding that a 1year increase in grade attainment was associated to a nine percentagepoint reduction in the probability of experiencing sexual violence in uganda but no significant effect in malawi 27 a second focused on sexual health finding an additional year of schooling was associated with 011 fewer births and 14 percentage points less teen marriage in ghana 29 both of these studies necessarily assess the overall impact of policy change rather than the increase in education alone and it is unclear how their findings extrapolate to lower educational attainment settings burkina faso is a landlocked country in west africa which despite economic and political reforms remains one of the poorest in the world with about half of its population living below the international poverty line 30 economic deprivation is strongly associated with youth violence 7 23 31 the country is very young with around 45 aged under fifteen and a further 20 aged 1524 in 2015 30 32 educational access and youth literacy are limited with only 13 of adults having completed primary education 32 33 within burkina faso poverty is highest in the boucle du mouhoun region 34 violence experience is common for young burkinabe with lifetime physical violence prevalence reported at 47 80 and sexual violence at 33 51 35 36 adverse psychological and mental health outcomes commonly follow such experiences 37 38 however studies of burkinabe youth violence have generally used crosssectional designs and have not explored the effects of education or age specifically 3 39 we therefore analysed longitudinal data on adolescents in boucle de mouhoun to assess the effects of age and education on violence experience the potential for educational interventions to have violencespecific benefits in such highpoverty loweducation settings is likely to be substantial 37 38 by using fixedeffects analysis we were able to exclude timespecific and timeinvariant confounders something particularly important given the many unobserved predictors of violence perpetration and victimisation 22 40 methods study design we used data from the nouna health and demographic surveillance site in north western burkina faso which has been gathering demographic and epidemiological health information data since 1992 the 59 villages and the town of nouna that comprise the hdss have a population of slightly over 100 000 individuals and include one hospital and 13 primary health centres 41 our study used longitudinal data from two burkina faso waves of the africa research implementation science and education adolescent health study 42 open access the nouna hdss in 2017 and 2018 data were collected from 1644 adolescents aged 1220 in 2017 based on a stratified random sample of 2544 ageeligible residents in nouna town and 10 villages 42 43 a followup round was conducted in 2018 attempting to contact all those who participated in 2017 1291 interviews were completed in both years a standardised questionnaire was used to collect selfreported information on sociodemographics health practices health outcomes and risk factors data were collected by field staff with background in public health medicine or a related field who had experience in conducting research and had general knowledge about local culture health issues and the population under study all study staff received indepth training at the beginning of the study covering the topic of research human research ethics the study protocol questionnaire modules electronic data entry and the procedures for implementing the study including anthropometric evaluation patient and public involvement no patient involved measures we used two primary outcomes of youth violence both captured as count variables experience of physical attack in the past 12 months and experience of bullying in the past 30 days we also generated binary measures of any experience for each outcome in alignment with the world report of violence and healths definitions 2 our exposures were age and education we additionally considered a range of timevarying covariates at the individual and household levels plus media use 44 45 specifically our individuallevel covariates were currently in school marital status any work in the past 12 months and sexual behaviour our householdlevel covariates were household size household wealth quintile parental vital status parental support level parental coresidence respondent has their own bedroom our media covariates were any access to television and frequency of watching television or reading magazines full variable definitions are provided in online supplemental tables 1 and 2 statistical analyses we first described our data using frequency and percentages in both waves including a comparison of those lost to followup versus those completing both waves we then dropped any respondents who were missing data for the outcome variables either due to preferring not to respond not know their answer or where fieldwork errors affected responses while for some the question was not applicable when considering the causal effect of education and age on youth violence a major concern is unobserved confounding given the difficulty of implementing randomised controlled trials since age is not directly manipulatable and intentional exposure to violence unethical 46 47 we exploited the panel nature of the data structure to run fixedeffects regression models to remove all timeinvariant confounding we specified our model as y it α i βx it γz it δ t ρ i where y it is youth violence for each individual i at each time point t x it represents our timevarying exposures z it is other timevarying factors for each individual δ t is a periodspecific fixed effect to capture all individualinvariant factors and ρ i are individualspecific fixedeffects which capture all timeinvariant factors for each individual for example gender ethnicity underlying proclivity to violence for each outcome we implemented three linear regression models of the count of reported events that is assuming an observationspecific error structure ϵ it ∼ n we attempted to use poisson and negative binomial models that is modelling y it as count data using a loglink and assuming that the variance of y it is either equal to its mean or its mean plus a dispersion term however neither model converged model 1 considered only meancentred age and years of fulltime education in model 2 we add all timevarying covariates in model 3 we included interaction terms for gender with age and education to identify any genderspecific effects results description of sample at baseline in 2017 1644 young people were interviewed of whom 948 were male by 2018 215 of respondents comprising 167 females and 186 males were lost to followup leaving 1291 respondents who participated in both rounds we dropped 32 individuals who had missing values for the question on bullying leaving 1258 respondents for the bulling analysis similarly we dropped 14 individuals who did not answer physical attack question to arrive at 1276 respondents figure 1 provides a flow chart of how the data were managed we compared those who were and were not lost to followup and found only one significant difference with those who were retained those not reinterviewed were less likely to be in school and had lower school attainment in wave 1 open access the 1291 respondents were aged 1220 years in 2017 median 155 iqr 1418 around half were enrolled in school at each interview 703 in 2017 671 in 2018 around onequarter of respondents never completed a year of fulltime education while most others had at most attended primary or postprimary level over 90 of respondents were single at both interviews and less than 20 in both 2017 and 2018 reported ever having sexual intercourse the proportion of respondents who ever worked fell from over 60 in 2017 to under 42 in 2018 most respondents had living fathers and mothers however around onequarter did not live with their parents media access was mixed about 20 had no access to television in 2017 but around 15 watched several hours a day magazine reading was rare household wealth was by design evenly distributed across wealth quintiles households were large with a median of 8 or 9 members a substantial minority of respondents experienced bullying and physical attacks overall 189 females and 416 males experienced bullying in the 30 days preceding the interview while 111 females and 199 males experienced physical attacks in the preceding 12 months across both rounds males experienced both more violence than females males experienced 416 of 605 unique bullying instances in the past 30 days and 199 of 310 associations in all four models were more positive for men than for women with wider gaps for the impact of age on both outcomes than for education all these results were independent of a substantial but imprecise negative association between currently being in school and bullying or attacks discussion in this study we employed individual and time fixedeffects models to assess the effects of age and education on violence experience in the form of bullying and physical attacks among adolescents and young adults in a panel study in rural burkina faso we found bullying experience prevalence in the past 30 days ranging from 20 to 30 and physical attack experience of 10 15 in the previous 12 months while there is little directly comparable data in burkina faso both levels seem concerning if in line with studies elsewhere 3 39 in fixedeffects models we found bullying was associated with more education and weakly with greater age both effects stronger in males while physical attacks were associated with younger age but not with education our findings on the effect of age on youth experience of physical attacks are consistent with some observational evidence elsewhere for example physical violence from both peers and caregivers falls with age in lac 39 evidence on the causal effect of age on violence is rare with even crosssectional studies focused on youth uncommon 3 11 26 studies of ipv among women suggest rates are higher in older teenage girls compared with adults 48 49 but this does not allow withinadolescence comparisons the faster decline with age that we see for males is important to note while criminal interpersonal violence appears peaks around age 18 in many settings our findings and past work suggest that overall frequency of violence experience may in fact decline across teenage years at least in nonurban settings 50 in combination this evidence suggests a shift in violence experience composition for adolescent males that would be worth further investigation the implications of this negative association between age and violence experience in adolescence depend on what mechanisms are generating them first age might be a proxy for predictors of violence that we have not open access captured in this analysis this might include adolescent autonomy in decisionmaking for example relating to bedtime and the amount and type of television watched which typically rises with age 51 adolescent autonomy was negatively associated with youth violence among us latino youth 52 alternatively age might be a distal determinant of factors leading more directly to violence experience for example older adolescents may be better able to protect themselves against aggressive behaviour from their peers or adults if this is the case then structural interventions or behaviour change interventions might be beneficial in protecting younger adolescents 53 54 further research to understand these causal mechanisms and thus design effective interventions will need to include more detailed quantitative data on who perpetrates violence against younger adolescents and qualitative information on how and why such violence comes about our finding that bullying increases with age contradicts some past research observationally bullying victimisation rates are higher in younger children than in older adolescents both in the usa and in subsaharan africa 55 56 our results may reflect the stronger control our fixedeffects approach provides against betweenindividual and temporal confounding suggesting that the decline in bullying seen elsewhere is a function of factors associted with age rather than age itself our finding of a stronger association for males adds to a mixed literature aligning with studies from taiwan and saskatchwan canada 57 58 but in contrast to findings from the usa and manitoba canada 57 59 we found that education was not associated with violence experience in our setting a similar null effect of education was reported for malawian women aged 1931 years 27 a recent metaanalysis of 86 studies in 60 lmics noted that poor academic performance and weak school attachment were correlated with increased youth violence 23 in contrast to our null findings again more detail is available for ipv with a ugandan study finding that lesseducated women were more likely to experience physical ipvhowever this study included women aged 1549 which makes direct comparison difficult 60 other studies have confirmed the protective effect of education on violence in different settings 48 61 the discrepancy between others findings and ours may reflect the majority of past studies being crosssectional while we were able to use panel data it may also reflect different exposures since we considered quantity rather than quality past evidence on the effect of education on bullying is mixed with several studies finding lower bullying among those with more education 56 57 and few finding the opposite 59 our finding of a positive association between education and bullying in both males and females may reflect the a true causal association or the residual effect of being in schoolgiven the opportunities that this provides for bullying relative to the alternative settings of fieldbased work or animal herding finally our analysis covers a population where half of adolescents are not now and onequarter never have been attending school the role of education in promoting or protecting against violence at the community level may be different in settings where education is not even close open access to universal further investigation of why our results looks different from other settings including qualitative study of social norms surrounding violence across levels of educational attainment would be instructional strengths and limitations a key strength of our study is the fixedeffects design which robustly removes timeinvariant confounding of effect measures 62 nevertheless our study also has potential limitations while fixedeffects analyses are powerful they cannot control for unmeasured timevarying confounding and we may have therefore not fully accounted for factors that change rapidly among adolescents such as increased social media access or social network change the use of selfreported data may have led to reporting biases although these would have had to vary differentially over time within respondents in order to bias our fixedeffects analyses generalisability from a sample drawn from a single district is always difficult to assess however by using a populationbased sampling frame our analysis provides results that represent the entire local population and are likely to be broadly applicable in poor rural settings in burkina faso and beyond conclusion a substantial minority of adolescents in rural northwestern burkina faso report recent experiences of bullying or physical attack we hypothesised years of education received and age would be associated with violence experience in burkina faso our findings show the prevalence of these experiences was not significantly associated with years of education received even within individual respondents but did fall with age however our study was not able to identify mechanisms behind these associations and we therefore recommend a mixedmethod study that includes study of household dynamics to move beyond an individualised understanding of violence among adolescents such an understanding is central to designing interventions to better protect youth in lowincome settings from violence twitter guy harling harlingg contributors nk conceptualisation methodology formal analysis writingoriginal draft mb investigation writingreview and editing project administration lo investigation writingreview and editing project administration as investigation resources writingreview and editing supervision tb conceptualisation methodology writingreview and editing project administration supervision funding acquisition gh methodology data curation formal analysis writingreview and editing supervision project administration 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 provenance and peer review not commissioned externally peer reviewed ethics approval data availability statement data are available from the corresponding author on reasonable request and after signing a data use agreement 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

the study aimed to investigate the effects of education and age on the experience of youth violence in lowincome and middleincome country settings design using a standardised questionnaire our study collected two waves of longitudinal data on sociodemographics health practices health outcomes and risk factors the panel fixedeffects ordinary least squares regression models were used for the analysis settings the study was conducted in 59 villages and the town of nouna with a population of about 100 000 individuals 1 hospital and 13 primary health centres in burkina faso participants we interviewed 1644 adolescents in 2017 and 1291 respondents in 2018 who participated in both rounds outcome and exposure measures we examined the experience of physical attacks in the past 12 months and bullying in the past 30 days our exposures were completed years of age and educational attainment results a substantial minority of respondents experienced violence in both waves 241 bullying and 122 physical attack with males experiencing more violence bullying was positively associated with more education β012 95 ci 002 to 022 and nonsignificantly with older age both effects were stronger in males than females although the gender differences were not significant physical attacks fell with increasing age β018 95 ci 031 to 005 and this association was again stronger in males than females education and physical attacks were not substantively associated conclusions bullying and physical attacks are common for rural adolescent burkinabe the age patterns found suggest that particularly for males there is a need to target violence prevention at younger ages and bullying prevention at slightly older ones particularly for those remaining in school nevertheless a fuller understanding of the mechanisms behind our findings is needed to design effective interventions to protect youth in lowincome settings from violence

background in contrast to the ethnically homogeneous society sweden used to be people from all over the world have immigrated to sweden over the past several decades today 293 of all newborns in sweden and 14 of adolescents in junior high school are second generation immigrants children born in sweden with at least one parent born in a foreign country this major change in composition of the population over a short period of time calls for additional focus on the health and wellbeing of these children if a wellfunctioning society is to develop secondgeneration immigrant children might be at increased risk for mental health problems for reasons such as intergenerational conflicts due to asymmetric acculturation within the family lack of adequate support from their parents due to their parents´ preoccupation with their own migration stressors and restrictive processes due to discrimination and a weak social position in the society cultural characteristics that differ from previous swedish norms characteristics such as family roles values and religiosity could contribute to a better or worse mental health depending on the person involved the impact of migration on mental health varies within different migrant groups and host countries as well as different reasons for migrating in a recent review of mental health among migrant children the results were inconclusive there was no unequivocally increased risk of mental health problems in migrant children but since the studies in the field varied widely with regard to characteristics of the immigrant group country of origin host country definition of immigrants informant age and gender of the immigrant it was difficult to draw any sound conclusions the following studies referred to are selfreported studies of secondgeneration immigrant adolescents only compared to native adolescents similar behaviour problems were reported by immigrants in australia and pakistani immigrants in norway as well as similar internalising and externalising problems by immigrants in the netherlands turkish immigrants in sweden and vietnamese refugee immigrants in norway reported fewer behaviour problems and immigrants in the netherlands reported fewer externalising problems compared to the native adolescents more internalising problems were reported among immigrants in the netherlands compared to the native dutch adolescents there are few studies that compare mental health among firstand secondgeneration immigrants in europe however most studies in the united states and canada report an increased risk of behaviour problems drug use and harmful drinking among secondgeneration immigrants compared to firstgeneration immigrants pumariega and coworkers suggest that it may be a result of that secondgeneration immigrants face different stressors than the firstgeneration immigrants for example the stress of social adversity and discrimination without having a secure identity or traditional values of their parents among first generation immigrants depression and anxiety is overrepresented perhaps due to stressors like poverty unemployment and low selfesteem the majority of the studies focus on their respective study groups covering a wide age span sometimes more than 8 years only the dutch study of 11year old immigrant children and the australian study of 14year old immigrant children studied a specific age group since mental health in general varies considerably during the preadolescent and adolescent years more agespecific studies are needed aim the aim of the present study was to investigate if and how secondgeneration immigrant children in sweden differ from nonimmigrant children in their presentation of selfreported mental health at the age of 12 with gender parental immigrant status and country of origin all being taken into consideration material and methods subjects this crosssectional study is a part of a longitudinal birth cohort study from the south east of sweden on childrens mental health all children born in the catchment areas of hässleholm and western blekinge in the south of sweden between may 1st 1995 and december 31st 1996 were invited to take part the mothers of 1723 children accepted of which 236 were secondgeneration immigrants two followups of the cohort have been performed in connection with routine examination at age 3 and 55 at the child welfare centres at the first followup 1439 of the original 1723 agreed to participate and at the second followup at the age 55 due to different child welfare centre protocols only the sample from hässleholm area participated the results from the followups at 3 years of age and 55 years of age have been reported by cederblad et al at the 12 year followup 2 had died 11 had moved from the country and 24 were learningdisabled and could therefore not participate and were excluded from the original 1723 in the baseline study which leaves 1686 subjects parents of 1178 children agreed to participate of those 142 children were second generation immigrants procedures at the 12 year followup current home addresses and information about the school and class each child was attending were obtained from the swedish tax office and from local education offices respectively for the children after principals were informed about the study´s aim and design they all agreed to participation parents received written information about the study as well as a consent form to sign in order to allow the child to participate in the study parents were reminded by phone if the consent form was not returned the children received a simplified information letter research assistants met with the children of parents who had given their consent to participate in groups of 520 in school during school hours all questions were read out loud by the research assistant and the children filled out the questionnaires without talking to each other children who no longer lived in the area or were not in school that day were scheduled for a home visit or a meeting at their new school the individual child was given the same oral information and the research assistant was present in the room during the entire time when the questionnaire was being filled out by the child in a few cases on the participants or parents initiative the questionnaires were sent by mail to their home address the mother and father separately were asked to fill out and return a different study questionnaire that was sent to their home address immigrant variables all children whose parents were both born in sweden were considered nonimmigrants all children who had at least one immigrant parent were considered to be secondgeneration immigrants the children were further divided into different categories of groups in the first category the children were placed into four groups based on both parents immigrant status the first group the nonimmigrant group consisted of children whose parents were both born in sweden the second group consisted of children whose mother was an immigrant and the father was born in sweden the third group consisted of children whose father was an immigrant and the mother was born in sweden the fourth group consisted of children whose parents were both immigrants in the second category the children were placed into four groups based on the parents country of origin the first group the nonimmigrant group consisted of children whose parents were both born in sweden the second group consisted of children whose parents were born in a nordic country the third group consisted of children whose parents were born in a european country the fourth group consisted of children whose parents were born outside of europe if a childs parents belonged to two different groups the child was placed in the group that is geographically furthest away from sweden of the two child variables to assess the childrens mental health the strengths and difficulties questionnairethe self report version was used sdq is a screening instrument used in many industrialized and less developed countries worldwide designed to measures both positive and negative behavioural attributes in children and adolescents was used the questionnaire consists of 25 items divided between four problem subscales and one strengths subscale the sum of the four problem subscales generates a total difficulty score it has shown good reliability and validity as a screening tool in different populations used originally for children aged 416 years and recently also for 1719 year olds in this study cronbachs alpha for the total scale was 066 information concerning parents country of origin maternal life stress score and the level of acculturation in the family ie if one or two parents were immigrants if mother had lived at least five years in sweden when the child was born if swedish at least partly was spoken at home if country of origin was a nordic or european country vs a country outside of europe was gathered at the time of the baseline study ie when the children were 3 months old information about family structure ie if the childrens parents were living together or not was collected from the childrens questionnaires at the 12 year follow up information about the parents educational level was collected from the parents questionnaires at the 12 year follow up the children were considered to be in the universitycollege degree group if at least one of their parents had higher education if not they were considered to be in the compulsory secondary schoolinghigh school group drop out rate and analysis the total drop out rate was 30 as participants and nonparticipants were compared regarding parental immigrant status parental country of origin as well as maternal life stress score statistical difference were found children of two immigrant parents had a drop out rate of 46 compared to 33 among children of immigrant fathers 29 among children of immigrant mothers and 28 among nonimmigrant children children whose parents came from a country outside of europe had a drop out rate of 40 compared to 35 for children of parents from a european country 29 among the children of parents from a nordic country and 28 for nonimmigrant children children whose mothers had a high life stress score had a higher drop out rate 40 compared to 29 among children whose mothers did not have a high life stress score however there were no significant difference in maternal life stress score or family acculturation level among participant and nonparticipant children of two immigrant parents or children whose parents came from a country outside of europe further there was no significant difference between participants and nonparticipant at the 12year follow up regarding earlier emotional and behaviour problems documented in the sesbicstudy at the age of 3 ethical considerations the study was approved by the ethics committee of the university of lund and the ethics committee of the university of linköping statistics when data were considered as dichotomous as in a previous study of a norwegian representative sample the 90 th percentile was used as a cut off to indicate high scores on the sdq problem subscales and the total scale the 10 th percentile was used as a cut off to indicate low scores on the strength subscale the cut offs for the problemand total scales were emotions conduct hyperactivity peer problems total score and for the strengths scale prosocial to check potential differences between the chosen dichotomous model and analysing the whole variation of the sdq scales ttest was used all analyses were performed using the spss program version 170 statistical significance was defined as p≤005 in order to assess differences on sdq problem and strength subscales as well as total scale with respect to gender immigrant status and immigrant background chisquare test or fishers exact test was used in both cases two sided to further assess differences with respect to immigrant status logistic regression was performed with sdq scores as dependent variables the independent variables were immigrant status gender of child family structure and parental education where the variable addressed 0 were used as the reference level for the drop out analysis chisquare test was used results the secondgeneration immigrant children as a group did not differ significantly from the nonimmigrant children in their selfreported mental health table 1 and the same was true when stratified for parental immigrant status parents country of origin and when secondgeneration immigrant boys and girls were analysed separately in multivariate analysis gender was an independent predicting variable for the subscales emotional conduct hyperactivity problems as well as prosocial strengths after adjusting for the variables immigrant status family structure and parental education table 1 girls had almost three times the frequency of emotional problems that boys had boys on the other hand had more than double the frequency of conduct problems hyperactivity problems as well as a three times increased risk of deficiencies in prosocial behaviour compared with girls compared with girls in the multivariate analysis family structure was also an independent predicting variable for the subscale peer problems after adjustment for the variables immigrant status gender and parental education table 1 the children who were not living with both parents had more than double the frequency of peer problems seen in the children who were living with both parents in the multivariate analysis parental education was also an independent predicting variable for the subscales hyperactivity problems and total difficulty score after adjustment for the variables immigrant status gender and family structure children whose parents had low educational level had more total problems and double the frequency of hyperactivity problems seen in children whose parents had high educational level of the children whose parents were both immigrants the majority of the parents came from a european country of the children whose fathers were immigrants and the mothers nonimmigrants the majority of the fathers came from a nordic country of the children whose mothers were immigrants and fathers nonimmigrants the majority of the mothers came from a european country or from a country outside of europe there were no significant differences in the childrens mental health neither when categorizing for immigrant status or country of origin there were no significant differences in family structure ie whether the parents were living together or not among secondgeneration immigrants and nonimmigrants in any of the categories of immigrant groups discussion this study was conducted to explore if and how secondgeneration immigrant children differ in their selfreported mental health at the age of 12 from nonimmigrant children in sweden the main results of the study may be summarized in two main findings first the analyses showed that secondgeneration immigrant children as a group did not differ from the nonimmigrant children in their presentation of selfreported mental health neither when gender family structure and parental educational level were adjusted for further no significant association with childrens mental health were found in the results from the first category group ie the category groups based on both parents immigrant status or the second category group ie the category groups based on parents country of origin a previous report from the sesbicstudy indicated an increased risk of psychosocial problems in the preschool years among secondgeneration immigrant children according to parentreports studies show that parentreports and selfreports do not show high correlation since that study the families have lived in sweden longer an have had a better possibility of adapting to the swedish culture schooland health care system and therefore the children in our study would be more likely to present emotional and behaviour problems similar to those of the nonimmigrant children studies in mental health among children and adolescents in sweden have shown that preadolescent children generally report good mental health and in general better mental health than reported by adolescents and adults we can only speculate if this pattern will emerge in a future followup of this birth cohort showing perhaps an increased risk of mental disorders selfharmand suicidal behaviour as has been shown in earlier studies of secondgeneration immigrant adults an important factor to keep in mind in all epidemiological studies and especially when evaluating scores of mental health among individuals with different immigrant backgrounds is that different kinds of expectations and cultural values might have an impact on the way they score however a questionnaire which makes comparisons possible is needed and the sdq and the cbclysr are the most frequently used questionnaires in different countries and by that to some degree has minimized this problem of not being sensitive enough to cultural differences further all secondgeneration immigrants are relatively adapted to the swedish society considering that they are born in sweden speak swedish and belong to the swedish schooland healthcare system in a future study of the sesbicdata we will compare parental teacherand self reports on mental health of secondgeneration immigrants were immigrants came from a country outside of europe those two drop out analyses basically assessed the same children a possible explanation of the higher drop out may be that because of language barriers the parents had more trouble understanding the content of the study and therefore chose not to fill out the consent form allowing the child to take part in the study the drop out analysis showed however that there was no significant difference among the participant and nonparticipant children of two immigrant parents regarding maternal socio demographic stress or acculturation level in the family which indicated that the drop out in this important group was not particularly selective there was no significant difference between participants and nonparticipant at the 12year follow up regarding earlier emotional and behaviour problems documented in the sesbicstudy at the age of 3 that is valuable information although it is also known that emotional and behaviour problems varies considerably in the childhood years the study size was sufficient for the analysis on mental health among secondgeneration immigrants as a group nevertheless when stratified for parents country of origin and parental immigrant status the groups became small and consequently these results should be interpreted carefully the mental health outcome of the children in this study was measured using dichotomized analysis of the sdq this could diminish the possibility to uncover true differences between secondgeneration immigrants and nonimmigrants when using the whole variation of the scales some difference were found for instance secondgeneration immigrant girls reported less total problems than nonimmigrant girls and children of two immigrant parents reported less emotional problems than children with nonimmigrant parents both these differences supported the main findings that secondgeneration immigrant children at the age of twelve have a mental health comparable to nonimmigrant children in summary no difference was found between secondgeneration immigrants and the general population and that is a valuable contribution to the understanding of how preadolescents born in sweden but of different parental immigrant backgrounds evaluate their own mental health future follow ups will have as one goal to determine if this positive development in secondgeneration immigrants is maintained through the adolescent years emotional symptoms conduct problems hyperactivity peer problems total score and low prosocial behaviour independent variables immigrant status gender family structure parental education as well as nonimmigrant children in sweden in order to better understand the complexity that lies behind responses to these questions second our study confirms the results of other studies that mental health of boys differs from that of girls boys more frequently display conduct and hyperactivity problems as well as greater deficiencies in prosocial behaviour while girls more frequently display emotional problems these results indicate that our study population followed the pattern for gender differences in mental health that has previously been observed in the general population of children in sweden a strength of this study in contrast to the majority of other studies in the field where the respective study groups cover a wide age span was that all the children in the study were assessed at the same age since mental health varies considerably during the preadolescent and adolescent years more agespecific studies are required there were some limitations associated with the study worth discussing the study measures mental health among secondgeneration immigrant children in small cities in southern sweden perhaps the results might have been different if bigger cities were included in the study where more subcultures based on ethnicity develop and consequently makes integration more difficult the parents refugee status was not known that would have been of great interest to in our material evaluate the selfreported mental health in this subgroup since studies in the field has reported contradictory results the drop out rate was higher among children whose mothers had a high stress score at the baseline study this was expected and a high drop out is often seen in longitudinal studies with the aim to assess and interview participants on several occasions this can of course have influenced our results the drop out rate among children whose parents were both immigrants as well as among children whose parents came from a country outside of europe was higher than the drop out rate for the other children since 86 of the parents in families where both parents

background today 293 of all newborns in sweden are second generation immigrants studies on mental health among these children are few inconclusive and vary widely with regard to the informant used and the age of the immigrant the majority of previous studies focus on study groups that cover a wide age span but since mental health varies considerably during the preadolescent and adolescent years more agespecific studies are needed additional focus on the health and wellbeing of these children is necessary if a wellfunctioning society is to develop aim to investigate if and how secondgeneration immigrant children in sweden differ from nonimmigrant children in their presentation of selfreported mental health at the age of 12 methods secondgeneration immigrant children n142 from a birth cohort in southern sweden subjects of the sesbicstudy the south east sweden birth cohortstudy were compared to nonimmigrant children n 1036 from the same cohort in their presentation of selfreported mental health at the age of 12 using the strengths and difficulties questionnaire gender family structure and parents´ educational level were controlled for results secondgeneration immigrant children did not differ from the nonimmigrant children in their own presentation of mental health at the age of 12 in any of the categories of immigrant groupsit is a promising sign for future integration that secondgeneration immigrant children´s selfreported mental health at the age of 12 that was quite similar to that of nonimmigrant children

introduction to understand the societal structure of opinions or attitudes it is necessary to model the emergence of the groups that bind them much research demonstrates that people evaluate and understand their environment with reference to relevant social groups 1 2 3 importantly shared opinions and beliefs are a defining feature of social groups 45 and group identity can be fostered by coordinating attitudes in particular opinionbased groups are social structures in which people are connected by the opinions they share and clusters of opinions become interlinked signifiers of group identity when they are jointly held by the members of a group 6 in this paper we demonstrate that an adapted version of axelrods model of cultural dissemination 7 can be used to model opinionbased groups axelrod modeled people as each holding one of several available traits for each of several features the individuals culture is defined as their combination of traits and multiple individuals are said to share the same culture if they are spatial neighbours who share the exact combination of traits we remove this spatial constraint when identifying clusters and instead get groups of agents sharing the same traits for each feature we refer to these as opinionbased groups the social structure of opinionbased groups has similar properties to axelrods model specifically agents in axelrods model are linked according to the values they hold on a given number of cultural features opinionbased groups are formed by people holding a particular selection of attitudes in principle conceptualising axelrods nominal cultural features and traits as ordinal attitudes will allow us to model the emergence of opinionbased groups with a data structure that maps cleanly on to raw survey data note that opinion surveys typically use ordinal likerttype response items while these are frequently treated as interval data in analyses there is a strong argument that individual likerttype items should properly be treated as ordinal allowing only nonarithmetic operations 8 the original axelrod model of cultural dissemination relies only on swapping and our adaptions adds ranking making it an excellent fit with likerttype data the tendency toward consensus in the standard axelrod model poses a further problem for modelling the emergence of opinionbased groups with attitudinal surveys specifically it has been shown that for the final state to have many clusters a high initial number of traits q is required 9 given that attitudinal surveys naturally assess more attitudes than responseoptions an axelrod simulation of such data would converge towards uniformity however in real social systems survey data frequently reveals stable systems of cultural diversity 10 our adaptation of the axelrod model is intended to account for diversity in the structure of opinionbased groups the idea to use surveys with the axelrod model is not new for example 11 use survey data to set the initial states of the agents in this paper however we approach this as a theoretical model and do not use empirical data as in for example 12 13 14 there have been many variations on the standard axelrod model often attempting to promote multiculturality some examples of variations are the introduction of noise 15 changing the topology from a lattice to a complex network 16 the effect of media represented by an external field 17 and more recently modelling it on a multilayer network where only interactions can occur between nodes on specific layers 18 another variation treats each feature as a continuous variable which pull closer together when they agree or repel when they disagree 19 this is similar to the deffuant model 20 with more than one feature here we take a similar approach to the idea of bounded confidence in this type of model an agent only takes account of a neighbours opinion if it is within a certain interval of that 21 we treat each specific feature as having a discrete value associated with it we then only allow an interaction when the traits are within a certain distance from each other this corresponds with research from social psychology which demonstrates that social judgements mediate attitude change 22 for example according to social judgment theory 21 the amount of attitude change caused by an interaction should depend on the perceived distance between the communication and the respondents original view specifically at any given time there is a range of positions each person is open to holding known as the latitude of acceptance importantly this range is anchored by ones current opinion similarly decision making research demonstrates that people tend to display bias in evaluating evidence by favouring views that correspond to their existing attitudes 22 for example empirical evidence shows that people rate arguments as more compelling when they correspond to previously held attitudes 23 in summary it is likely that interaction does not always lead to assimilation and that social influence is anchored by existing opinions this is similar to the approach in 24 but on the traits instead of the features in general if the number of features are much higher than the number of traits there will be consensus however bounded confidence has been suggested as a method for compensating for this 11 similarly 25 show that adding influence between those with similar options is sufficient for cultural diversity a model similar in spirit in 26 uses an openmindedness parameter if two clusters are similar then there is higher probability they will coalesce there is also a probability a group will fragment this openmindedness parameter is similar to the bounded confidence threshold a model with only binary options for the traits inspired by the axelrod model with bounded confidence can also lead to multiple clusters 27 a key difference in the model we present to other approaches that use bounded confidence on the axelrod model is we take this threshold into account when computing who an agent can interact with and then again when seeing if they are converted this only introduces a single parameter and does not restrict the number of traits in this paper we firstly use bipartite network visualisations to identify opinionbased group structure in the standard axelrod model secondly we introduce an agreement threshold similar to the notion of bounded confidence axelrods original interaction mechanism was based on the principle of homophilythe likelihood that a given cultural feature will spread from one individual to another depends on how many other features they may already have in common if the nominal traits available to each agent are ordered then there is another dimension for homophily a small modification to the interaction rules allows us model the types of surveybased data evident in the field of opinionbased groups methods standard axelrod model in the social sciences attitudinal surveys are the most common way of measuring individual opinions we wish to model participants holding attitudes and the groups they form as a result to do this we start with with axelrods model of cultural diffusion 7 here each agent takes a position on a set of features and that position must be one of a fixed set of traits we begin by visualising this model using a bipartite grapha graph with two types of nodes where edges must connect nodes of different types one type of node represents the agents and the other represents their trait on a specific feature the original axelrod model on a lattice works as follows each individual has a feature set f ¼ ff 1 f 2 f f g where f k is each specific feature there are a total of f ¼ dim ðf þ features and each feature f k has q traits at each timestep individual i and one of its neighbours j are chosen at random with a probability equal to the number of common features over the total number of features person i will copy one of the traits they do not have in common with j fig 1 shows the axelrod model for 100 nodes on a lattice with f 3 and q 5 paused after 40000 time steps the absence of a line represents all five features in common dotted lines represent three or four features in common dashed lines represent one or two shared features and a thick solid line represents no features in common when multiple clusters are found the lattice is divided into regions which are physically separated from each other as seen here a cluster with no edges indicates that those nodes all have the exact feature configuration a bipartite network representation of the same data is shown in fig 2 here the underlying featuretrait combinations are revealed with each feature displayed using a different colour for example we observe that features 1 and 2 both have a majority but feature 3 is split between q 1 and q 4 this is particularly useful if using this network to represent survey data if there are three questions with a fivescale response it is clear which response is the most favoured per question projections can be taken from this representation to show which featuretrait combinations are frequently held together and to show the opinionbased groups that form in the latter projection if just full agreement edges are shown this gives the clusters usually discussed if this is reduced to one minus the full agreement it will display clusters who agree on all but one trait an example of this can be seen in fig 5 where different coloured edges represent different levels of agreement between the clusters agreement thresholds on the traits one key difference between survey data and the axelrod model is that in the axelrod model the traits for a given feature are nominally related but in survey data the response options are related to one another or on a scale 28 we introduce a mechanism to allow for traits to be related to each other below a shortcoming of using the axelrod model to represent survey data is a tendency toward uniform convergence in the final state as the number of features increase given that attitudes are negotiated properties of social interaction 29 it is plausible to assume that people hold a broad range of continuous positions on a given attitude however we are interested in how attitudes are communicated people typically communicate attitudes verbally which leads to a certain level of imprecision in their interpretation 3031 we argue that by scaling opinions to a limited number of points on a continuous scale surveys capture general limitations in attitude communication and interpretation furthermore continuous variable models show a tendency for opinions to move towards the midpoint of the scale 3233 and thereby fail to capture the stubbornness of extremists 34 in the standard axelrod model above if two neighbours interact the node originally chosen copies the state of one of its neighbours features that they do not already agree on we argue that purely copying an attitude of an individual with whom you interact even if you strongly disagree with this attitude is unrealistic hence we introduce an agreement threshold a analogous to a latitude of acceptance 29 to compute the interactions the idea is that there exists a range of positions a person is willing to hold with this range being anchored by their current position within which they copy instead of interacting with someone with probability proportional to the number of common features we now calculate the probability to interact as the number of features within this agreement threshold over the total number of features with interaction leading to a copying of one of those traits once the state to copy is chosen it only copies if the difference in values of the chosen feature between interacting individuals i and j is less than the threshold f ki f kj �a for example if the threshold is set to the smallest difference between response options in a survey scale then only those who are one point away from each other on the survey scale will interact in contrast with standard axelrod here the probability for interaction between two nodes is increased when the agreement threshold is included as features which are a traits away now add to the probability for interaction however when interaction occurs the only features that can change are those within the agreement threshold in standard axelrod once interaction happens one feature will be copied thereby increasing the probability of interaction in the future in this version only the features which are already within the agreement threshold change meaning the probability for interaction in the future is the same fig 3 displays the final state for the lattice and bipartite visualisations of this model with f 6 q 3 with the lowest possible agreement threshold a 1 for standard axelrod this would lead to consensus however here we see we have different regions and from the bipartite representation half of the six features do not reach consensus this is a simple adjustment to standard axelrod that yields more than one cluster even where the number of features exceeds the number of traits per feature as they would in a typical survey projections visualising axelrod on a bipartite space helps us realise that projections can be made to observe the connections between featuretrait combinations and nodes a 1mode projection can be generated showing features as nodes with an edge indicating that two features are held concurrently by an agent and therefore overall which attitudes are strongly connected the projection for f 6 q 3 is shown in fig 4 where the weight of an edge is the number of pairs of nodes that share that featuretrait combination these are split in thirds from weakest to strongest for visualisation purposes the strongest edges are between the three attitudes where consensus is reached as these are held together most commonly fig 5 shows the 1mode projection for agents where agents are nodes linked if they share an attitude in common the colour of the edge represents how many attitudes they share and we can identify a number of clusters where they share all six attitudes note that this figure only displays the giant component as the edges are created by shared links if a node has no features in common with any other node it will not be connected and therefore not appear in any clusters number of clusters to count the number of clusters we count the number of components where the nodes agree on all f features in the final state fig 6 shows the average number of clusters for varying features for the agreementthreshold model with q 5 and q 7 for 1000 runs with 100 nodes for small a as f increases the average number of clusters increases as there is a much larger featuretrait space due to the large number of different opinion based groups it is harder for large clusters to form so the cluster size gets smaller as a increases there are more conversions and thus less clusters in the final state as are a much larger number of clusters and with large f there are very few large clusters with many isolates who dont have the same featuretrait combination as any other nodes finally in fig 8 we increase the system size to 1024 with q 7 in the left panel we observe the same change in mean number of clusters per feature as in fig 6 in the right panel we show the density plot there is a larger jump between a 1 and a 2 when the system size increases note that for agreement threshold a q 1 every interaction will lead to copying so this will quickly yield full consensus also note that in all these simulations due to interactions now occurring when agents have a similar trait instead of exactly the same as in standard axelrod these tend to reach their final state faster than standard axelrod conclusion here we added an agreement threshold to the axelrod model this threshold yields many clusters for small values of q this addition is an adjustment to standard axelrod interaction rules that only allow those with similar features to influence each other the resulting model is suited to natively modelling survey data which frequently consists of likerttype responses since only ranking and swapping operations are required thus respecting the ordinal nature of the data the model also avoids the homogoneous endstate which tends to be the case when the standard axelrod model is used on surveytype data as there are almost always features than traits in this model extremists are less likely to change their position than moderates due to the agreement threshold an agent with an attitude on either extreme can only move in one direction an agent in the middle can move in either direction so is twice as likely change their position this helps with avoiding a problem some models have causing agents to move towards a centrist attitude and achieving polarisation 35 this behaviour is also observed in real social systems 34 here this model is entirely theoretical and uses random seeding of the initial system on a regular lattice going forward we would like to use empirical data to seed the initial values rather than randomly assign them something which is used in the following approaches to axelrod models 11 12 13 14 further work needs to be done on testing this method on topologies other than a lattice similarly varying q per feature should be tested as there is no reason the number of traits per feature should be the same this last suggestion is made in 11 a further extension could specify that if the agreement threshold is larger than one the traits move towards each other rather than one agent copying the other we also wish to relax the rules for group membership here we took groups where everyone agrees with everyone however going forward we wish to investigate this with agreement on a smaller number of core attitudes in this case we would get larger clusters similar to when f is in the middle range of fig 6 future work will seed this extended axelrod model with real survey data to compare the sensitivity or resilience of various realworld attitude network topologies to cultural diffusion the data is generated randomly using the model presented in the paper we expect that it will be relatively straightforward to make similar modifications to other opinion dynamics models to allow the consideration of surveytype data the code to run bipartite simulations and the agreement threshold can be found here

shared opinions are an important feature in the formation of social groups in this paper we use the axelrod model of cultural dissemination to represent opinionbased groups in the axelrod model each agent has a set of features which each holds one of a set of nominally related traits survey data has a similar structure where each participant answers each of a set of items with responses from a fixed list we present an alternative method of displaying the axelrod model by representing it as a bipartite graph ie participants and their responses as separate nodes this allows us to see which featuretrait combinations are selected in the final state this visualisation is particularly useful when representing survey data as it illustrates the coevolution of attitudes and opinionbased groups in axelrods model of cultural diffusion we also present a modification to the axelrod model a standard finding of the axelrod model with many features is for all agents to fully agree in one cluster we introduce an agreement threshold and allow nodes to interact only with those neighbours who are within this threshold ie those with similar opinions rather than those with any opinion this method reliably yields a large number of clusters for small agreement thresholds and importantly does not limit to single cluster when the number of features grows large this potentially provides a method for modelling opinionbased groups where as opinions are added the number of clusters increase

• • experiences of loneliness are heightened for people impacted by terminal illness • • individuals who experience loneliness are at risk of a variety of physical and mental conditions including heart disease obesity a weakened immune system anxiety or depression • • loneliness is a global public health issue that has become more prevalent during the covid19 pandemic what this paper adds • • loneliness is perceived by healthcare professionals as a common experience for patients and carers at the end of life which has become more commonplace during the covid19 pandemic • • the stigma around admitting to feeling lonely among those impacted by terminal illness makes it difficult for others to identify • • loneliness impacts on physical and mental health symptoms experienced at end of life including pain breathlessness or feeling there is nothing left to live for implications for practice theory or policy • • a public health approach may help raise awareness of loneliness as a serious issue at end of life and help combat the associated stigma • • social support initiatives that offer opportunities for social connectedness for people with a terminal illness and their familiescarers are needed to alleviate experiences of loneliness • • potential solutions to loneliness require further research with those directly impacted by terminal illness patients and their caregivers introduction loneliness is defined as a subjective unwelcome feeling of lack or loss of companionship that happens when there is a mismatch between the quantity and quality of social relationships that we have and those that we want 1 it is estimated that 15 of adults aged 1679 in the united kingdom report high levels of loneliness in their daily lives with this number doubling in those aged 80 plus 2 people in later life or those with illhealth a disability or low income are at risk of experiencing loneliness 34 for people with terminal illnesses strong feelings of loneliness have been reported in studies internationally 56 a recent systematic review drawing on international literature identified associations between providing informal care and higher loneliness levels 7 in the uk it is estimated 8in10 informal carers have felt lonely or socially isolated as a result of their caring situation 8 an informal carer is defined as a person who provides unpaid care to someone important to them because of longterm physical or mental health disability or issues related to age 9 prevalence rates of loneliness among carers have soared during the covid19 pandemic in regions such as the uk usa ireland and new zealand 10 although feelings of loneliness are heightened for people impacted by terminal illness 1112 it is not clear what impact the pandemic has had on these experiences loneliness can have a detrimental impact on a persons physical 1314 and mental health 15 16 17 their existential health defined as finding meaning and purpose in life and developing supportive social relationships can also be severely impacted 18 carers who describe experiences of loneliness have higher rates of stress and report lower levels of wellbeing than the general population 19 as well as greater risk of developing illness 20 however it remains unclear how experiences of loneliness impact the health and wellbeing of people with a terminal illness there is a need to understand how experiences of loneliness can be mitigated for this vulnerable population especially given estimations that the number of people living with a terminal illness in the united kingdom is expected to increase up to 42 by 2040 21 and the need for informal carers up to 40 by 2037 9 a better understanding of the prevalence impact and possible solutions of loneliness for people with a terminal illness and their carers preand during the covid19 pandemic can aid our understanding of how best to alleviate such experiences and promote better end of life experiences for the purpose of this study a person with a terminal illness is someone who is not on a curative pathway for their illness this includes the end of life period often characterised as the final 12 months of life 22 research questions what is the perceived prevalence of loneliness among people who are terminally ill and their carers what is the perceived impact of loneliness among people who are terminally ill and their carers what are the possible solutions to alleviating loneliness among people who are terminally ill and their carers methods design an explanatory sequential multimethods design was used this design starts with the collection and analysis of quantitative data followed by the collection and analysis of qualitative data in order to interpret or expand on the firstphase quantitative results 23 our study consisted of an online closed survey for marie curie northern ireland health and social care professionals to determine the perceived prevalence impact and possible solutions to loneliness followed by focus groups to further explore elaborate on and understand the survey findings 24 setting this study was conducted within marie curie northern ireland community nursing services which serves an overall population of over 18 million services include hospice at home rapid response and outpatient services patient and public involvement study population individuals were considered eligible if they were a member of the marie curie northern ireland community nursing service members of the patient and family support team made up of a bereavement coordinator chaplain and social workers as well as day hospice and rehabilitation team staff sampling using convenience sampling for the survey and purposive sampling for the focus groups a range of professionals were recruited to the study at the time of recruitment 225 professionals were eligible to take part in the survey and focus groups recruitment survey an invitation to complete the survey was circulated to eligible individuals via email by the nursing service day hospice patient and family support team and rehabilitation team lead the email provided individuals with the study information presumed consent was used for anonymous participation and the following statement was included at the start of the survey by completing this survey you are consenting to participate in this study focus groups individuals invited to participate in the survey were also invited via email by team leads within the recruiting institution to take part in a focus group participant information sheets were attached to emails outlining the purpose of the study the processes involved with taking part possible risks and benefits their rights privacy and confidentiality and whom to contact if they had further questions or were still interested to take part interested professionals completed an online consent form before the focus group data collection an online survey was developed using microsoft forms survey questions were developed by the research team and patient and public involvement representatives involved in the study initially participants were asked demographic questions about their gender ethnicity and job role respondents were then asked openended and closed questions about the perceived prevalence and impact of loneliness for people living with a terminal illness and their carers and possible solutions to alleviate these experiences as the study was conducted during the covid19 pandemic specific questions were asked about the perceived impact and prevalence of loneliness for those affected by terminal illness pre and during the pandemic the survey was open between june and july 2021 three focus groups were conducted between september and october 2021 a topic guide was developed by the research team based on the study aims and objectives and findings from the survey the guide was refined through feedback by the patient and public involvement representatives focus groups were led by the second author and facilitated by two researchers tmcc jr and kp are female researchers with research and clinical experiences of working with people impacted by terminal illness and conducting qualitative research tmcc and kp were known to some of the participants through their roles as senior research fellow and research nurse at the recruiting institution the use of reflexive notes peer debriefing and data source table 1 semistructured topic guide used to guide the conduct of the study sample of topics based on the quantitative survey findings and study aims and objectives exploration as to why professionals are more likely to observe loneliness rather than individuals themselves reporting this exploration as to how loneliness impacts on a persons overall health and wellbeing during terminal illness perceptions as to how professionals can better identify loneliness during terminal illness perceived obstacles to reducing loneliness in terminal illness perceptions as to how loneliness could be alleviated for patients and carers triangulation were applied to mitigate bias 25 the focus groups were conducted and recorded on microsoft teams and lasted up to 60 min data analysis data were analysed in three phases reflecting the explanatory sequential design analysis of quantitative data analysis of qualitative data and analysis of how the qualitative data helps explain the quantitative data to answer the research questions quantitative data were analysed using descriptive statistics within microsoft excel by jrh and tmcc qualitative open text responses were independently analysed into core themes by four members of the research team with feedback from patient and public involvement members determining the final themes these core themes shaped the subsequent focus group schedule focus group microsoft teams recordings were transcribed verbatim by an external transcription service provider qualitative data from focus groups were analysed using reflexive thematic analysis 26 this was led by the first author a postdoctoral male researcher and nursing student with experience of conducting and analysing qualitative studies in end of life care first transcripts were read to gain a sense of the participants experiences and perceptions data were then coded and managed using nvivo v12 by marking similar phrases and words in the narratives related to the study questions using manual mindmapping techniques jrh identified where the codes merged to form themes and subthemes transcripts and themes were independently analysed by three coauthors and refined through critical dialogue with all authors themes were further reviewed and refined by feedback from patient and public involvement representatives ethical considerations participants were provided with detailed written information about the purpose of the research written consent was obtained prior to taking part in the focus group participants were informed of their right to withdraw from the online survey or focus groups at any point without negative impact however participants were informed that any data already collected during online focus groups prior to their withdrawal would be retained for the study data protection procedures were observed and assurances of confidentiality were given pseudonyms have been adopted in the results section of this paper to maintain confidentiality ethical approval was obtained from queens university belfast and research governance approval was obtained from marie curie northern ireland results quantitative survey findings a total of 68 professionals completed the survey of which 66 were female and had at least 1year experience of providing end of life care respondents included nurses healthcare assistants social care and allied health professionals perceived prevalence of loneliness among people who are terminally ill and their carers 926 of respondents reported perceived loneliness among their patients prepandemic also 868 of respondents felt they had supported carers experiencing loneliness prepandemic a high proportion 721 of respondents felt there was a substantial increase in loneliness among people with a terminal illness and carers 691 during the covid19 pandemic while survey respondents stated they were aware someone in their care was experiencing loneliness at end of life this conclusion was often based on their own observations of the patientscarers circumstances in 882 of cases rather than from selfreport by the carer or the patient perceived impact of loneliness among people who are terminally ill and their carers most respondents rated loneliness as having a high impact on patients psychological and social wellbeing and carers psychological and social wellbeing qualitative findings fourteen female professionals then took part in one of the three focus groups participants included nurses healthcare assistants social care and allied health professionals findings are discussed under three sections and corresponding themes to address the research questions on prevalence impact and possible solutions to alleviating loneliness among people who are terminally ill and their carers explaining the prevalence of loneliness themes the stigma of loneliness and covid19 the loneliness pandemic the impact of loneliness theme impact of loneliness across physical and mental health domains possible solutions to loneliness theme the power of social networks theme 1 the stigma of loneliness professionals believed loneliness is a highly prevalent issue for people with a terminal illness and their carers and considered such experiences are caused by a lack of available support networks in the persons life to provide emotional and practical support throughout the end of life period another reported factor included carers lack of time to maximise their networks due to the demands of the caring role however professionals believed loneliness is a seldom disclosed issue at end of life for patients and their carers and felt these populations suffer in silence often loneliness was perceived as an invisible issue and challenging for professionals to identify theres something about admitting that you are lonely its almost as if theres a stigma around loneliness with loneliness it kind of comes under that mental health bracket or umbrella and theres no either its taken as a sign of weakness or some sort of stigma around that and theres no quick fix mabel allied health professional one lady was cared for by her husband she had a degenerative condition that had been ongoing for a while and she actually said to me this is the first time ive been able to talk to another woman about how i feel and it broke my heart when you think of the amount of people coming in and out of the house but it was just because i was there and i was there all night and she was awake most of the night and i think the impact for her was she felt very sad she felt she couldnt tell anybody how it was how she felt not even her husband because she was protecting him she was lonely bottom line was she was lonely florence nurse while loneliness was discussed as a historical and ongoing issue for people with a terminal illness and their carers participants described heightened experiences of loneliness during the covid19 pandemic theme 2 covid19 the loneliness pandemic professionals spoke of how outpatients had experienced a heightened sense of loneliness caused by the pandemic while professionals recognised the impact of the pandemic and increased loneliness among people in general they emphasised one key difference in relation to their patients and that is the terminal nature of their conditions which meant the heightened loneliness they experienced due to the pandemic would be their final experience at their end of their life and i remember the occupational therapist going out and one very elderly lady saying to her youre the first person who has sat on that sofa for 12 months and that lady has since died patricia nurse carers were viewed by professionals as having reduced opportunities to maximise their social networks during the pandemic professionals reported reduced availability of services such as those provided by day hospice or community groups which were described as providing vital support networks prepandemic for carers and people with a terminal illness to meet others who were experiencing similar situations to themselves coined as peersupport participants noted how some services moved to virtual platforms during the pandemic and were beneficial for people living in rural areas who would normally be too far to attend in person however the online format was only appropriate for those with internet access everyone says how much they miss the day hospice just the sense of being able to come in to see any professionals they needed to see but also to catch up with other patients who have become friends and for the carers to be able their loved ones to be able to talk to each other and just the general sense of fun almost yeah people really enjoyed that sense of being together and got a lot from it jean social care professional theme 3 impact of loneliness across physical and mental health domains professionals often felt experiences of loneliness at end of life has a ripple effect on a persons mental and physical health moreover it was perceived that when patients and carers avoid talking about their experiences of loneliness this has a negative impact on the persons wellbeing and quality of life professionals believed loneliness led to patients feeling like giving up as they felt they had nothing to continue living for loneliness if not dealt with or discussed usually leads to giving up on life like theres nothing to care about or to live for sandra nurse more often professionals perceived patients experiences of loneliness at end of life impacts on a persons symptoms especially around pain breathlessness and anxiety with an increased need for medications or involvement with healthcare services which were described by participants as already stretched i was working last night in rapid response and tony has been on the system three times i have been out to him the last two weeks nearly every night that ive been working and the issue is not his catheter the issue is that he is lonely he has no family here his nearest family is in england his mood is quite low as well he says he has nobody to talk to and hes ringing out of hours to get me out or get one of us out to come and talk to him he is isolated and lonely in his home and people have not picked up on that freda nurse theme 4 the power of social networks professionals recognised the importance of social networks for people with a terminal illness and their carers however professionals discussed how this is not always possible due to a lack of social networks in some peoples lives as well as factors such as people living too far away from others family members being estranged to the carer or person with the terminal illness or peoples lack of time to help due to the busyness of their own lives participants felt day hospice was helpful to alleviate feelings of loneliness for patients and carers at end of life it was believed day hospice provided patients and carers with peersupport opportunities including meeting sharing and learning from others who are experiencing similar situations to themselves in a facetoface environment also day hospice was considered as helpful to developing genuine friendships further enhancing a persons social support network pre death and developing a sense of community i think thats whats so brilliant about the day hospice it starts off as being part of their medical care and then it transforms into this wonderful social opportunity and well holistic is a good word for it it caters for all needs once you get the people through the door and they are glad to come because its part of their it starts off as part of their treatment and then blossoms jean social care professional other participants considered how day hospice services provided carers with opportunities for respite and to engage in social activities outside of the caregiving role and maintain some sense of normality however professionals feared that these softer measures of benefit to alleviating loneliness would not convince those in power making the decisions that this is a model that necessitates investment and the need for maybe respite support so that they are maybe getting two afternoons a week that they can go and do a hair appointment if they need to attend to their own needs with the gp go for a walk with a friend its just trying to not only focus on the patients needs but identify the impact of emotional and mental wellbeing and loneliness and isolation in a caring role margaret social care professional but its hard to quantify that isnt it so therefore we dont have the stats and the figures to show those in power harriet social care professional there were some participants that considered how the availability of community projects such as walking groups community projects such as planting pots of flowers or coffee mornings in local community centres could help to promote peersupport and respite opportunities for people with a terminal illness and their carers and reduce experiences of loneliness at end of life however participants felt that these may be less well attended by people who feel lonely as they may perceive they are not worthy or consider it embarrassing to attend alone i suppose im just thinking community initiatives and everything its fantastic but for some people whenever they get to the point of being so lonely that their selfesteem has been impacted by it they are not going to go to anything that is available because at that point they may not even feel worthy of being a member of a group or whatever if someones mental health is so badly affected then they are more likely to not avail of what is there anne social care professional discussion loneliness was reported by healthcare professionals as prevalent among people with a terminal illness and their carers while studies have highlighted loneliness as a prevalent issue during covid19 due to restrictions to protect public health 27 28 29 findings highlight such experiences were exacerbated for carers and people with a terminal illness as they approached end of life loneliness at end of life was described as having a detrimental impact on a persons health and wellbeing including worsening end of life physical symptoms such as breathlessness and pain and a range of mental health symptoms such as anxiety and depression similar findings have been reported in the literature with other populations such as people in later life and those with cancer 30 31 32 significantly loneliness was also linked with existential suffering and professionals felt experiences of loneliness at end of life may lead patients to feel that they have nothing left to live for the need to be present with others and to have a sense of connectedness is closely linked with existential loneliness 33 despite reduced opportunities people with an advanced illness and their carers have a desire for social connection connection with healthcare professionals and the presence of others carries significant spiritual and existential meanings for terminally ill people 34 there is a need to alleviate existential concerns to promote better end of life experiences as well as adjustment in the postdeath period for carers sensitivity and a trusting relationship between the healthcare professional and the person with a terminal illness alongside openness and awareness of the persons concerns provides a good basis for discussion of existential concerns 35 failure to address experiences of loneliness at end of life may have ramifications for pressured health and social care services such as an increased need for services 3637 findings highlighted challenges in identifying experiences of loneliness in people with a terminal illness and their carers due to the taboo nature of admitting feeling lonely professionals in this study appeared to be central to identifying loneliness in those impacted by terminal illness this highlights the importance of communication skills training for new staff to support discussions around experiences of loneliness 3839 along with further research on when to start such conversations so that professionals are appropriately skilled in identifying experiences of loneliness in people impacted by terminal illness it could be argued a public health approach is necessary to raise awareness of loneliness as a serious issue at end of life combat stigma and ensure those who have been suffering in silence get the support they need 40 it appeared that social and emotional connectedness with others is helpful to alleviating experiences of loneliness for people with a terminal illness and their carers 41 described in the findings as indirectly facilitated through the day hospice model this includes services that provide rehabilitation programmes or complementary therapies 42 societal shifts such as families living further away from each other or communities becoming more fluid as a consequence of people moving about due to lifestyle and workrelated factors 43 a persons social networks may not be able to provide them with practical and emotional support required at end of life this may explain why peersupport and creating opportunities to meet others was consistently reported by professionals as a key solution to addressing loneliness for people with a terminal illness and their carers other factors included the need to be with people experiencing similar situations who will better understand the persons circumstances 44 or not wanting to feel like a burden to loved ones 45 peersupport is helpful to promoting better mental and physical outcomes for individuals for example through befriending and companionship services 46 a social prescribing model also may be helpful for alleviating experiences of loneliness which could in turn ease the pressures facing health services from increased physical and mental ill health 4748 however whatever social support approach is taken it should be coproduced with these populations to ensure it meets their needs future research should evaluate the effectiveness of socialsupport interventions on alleviating experiences of loneliness during terminal illness with a health economics component to demonstrate potential health service savings 49 although other regions of the united kingdom have national strategies to help address social isolation and loneliness 50 northern ireland lags as the only region of the uk without such a strategy the importance of developing this is reflected in the findings from this study which highlight the high prevalence and impact of loneliness on those who are affected by terminal illness such a strategy could provide targeted funding for a public health approach to address loneliness including groups who are particularly at risk such as those at the end of their lives and their carers 51 strengths and limitations of the study this study is largely reflective of the experiences and perceptions of female professionals working within specialist palliative care future research could explore professionals perceptions of loneliness at end of life in other health and social care settings although patient and public involvement representatives were involved in the design conduct and dissemination of this research there is a need to explore the impact and possible solutions to loneliness from the perspective of people living with a terminal illness and their carers we were not able to tease out data to explore how different types of human contact or quality of relationships may impact on loneliness however this as an important consideration for future research conclusion overall findings indicate loneliness is a highly prevalent issue at end of life which has increased as a result of the covid19 pandemic conversations around loneliness perhaps via a public health approach are needed to break down the stigma associated with such experiences so those impacted by terminal illness are not suffering in silence social connections are imperative and appear to work best via peer support opportunities befriending and companionship initiatives given the devastating impact of loneliness on quality of life and the wider health service and the fact there is only one chance to get care right at the end of life potential solutions to loneliness require further research with those directly impacted patients and their caregivers declaration of conflicting interests the author declared no potential conflicts of interest with respect to the research authorship andor publication of this article

background loneliness is a prevalent societal issue and can impact on a persons physical and mental health it is unclear how loneliness impacts on end of life experiences or how such feelings can be alleviated aim to explore the perceived prevalence impact and possible solutions to loneliness among people who are terminally ill and their carers in northern ireland through the lens of health and social care professionals design an explanatory multimethod study settingparticipants an online survey n 68 response rate 30 followed by three online focus groups with palliative and end of life care health and social care professionals n 14 data were analysed using descriptive statistics and thematic analysis results loneliness was perceived by professionals as highly prevalent for people with a terminal illness 926 and their carers 868 loneliness was considered a taboo subject and impacts on symptoms including pain and breathlessness and overall wellbeing at end of life social support was viewed as central towards alleviating feelings of loneliness and promoting connectedness at end of life four themes were identified 1 the stigma of loneliness 2 covid19 the loneliness pandemic 3 impact of loneliness across physical and mental health domains and 4 the power of social networksthere is a need for greater investment for social support initiatives to tackle experiences of loneliness at end of life these services must be coproduced with people impacted by terminal illness to ensure they meet the needs of this population

background the low prevalence rate of human immunodeficiency virus in canada tends to mask the realities of hiv risk in the country 1 some studies have suggested that sexual minorities and racialized groups report similar hiv prevalence rates as the socalled hivendemic areas of lowincome countries 2 people of african caribbean and black descent in canada are particularly vulnerable to hiv exposure for instance while people of acb descent represent less than 5 of canadas population they made up more than 25 of new hiv cases in 2019 3 furthermore their hiv vulnerability is often framed as selfinflicted thus foreclosing opportunities to engage them through health interventions 45 studies have pointed to numerous challenges the acb community in ontario faces in accessing health care including disconnection from healthcare spaces for acb people living with hiv this may have implications for accessing hiv counseling and treatment services that are vital to reducing their viral loads to undetectable untransmittable 67 the poor health experienced by the acb community has also raised human rights concerns given the suggestion that it is underpinned by racebased discrimination for instance experiences of economic discrimination and underrepresentation in medical professions and service delivery and biases against racialized groups in health decisionmaking contribute to acb peoples poor health 8 in addition racebased discrimination in employment education and housing have been identified as critical determinants of health for black canadians 9 among heterosexual acb men studies that have attempted to understand their hiv vulnerability have done so by examining the contributing role of their social and sexual behaviours such studies often tend to focus on black mens practices of traditional masculinity which is observed to deter some men from seeking health services and support 10 11 12 by prioritizing behavioral risk factors as the main contributors to their hiv vulnerability assets that are critical for building hiv resilience among acb men including those living with hiv are overlooked in addition the structural and systemic conditions that may be contributing to their hiv vulnerability are not explored in this paper resilience against hiv refers to activities and practices of acb men that help to minimise their exposure to hiv for those living with hiv resilience relates to practices that help to manage hiv as a lifelong chronic condition in line with evidence suggesting that peoples resilience against hiv may reflect the quality of their structural environment some scholars 13 14 15 16 have called for a reexamination of acb men as active agents who with appropriate support and resources can address their disproportionate burden of hiv indeed earlier studies in ontario canada have stated that acb men are aware of their hiv vulnerability and therefore were proactive in meeting their own health needs and making the necessary adjustments and choices to reduce their exposure to the virus 517 despite this evidence studies continue to use deficit and risk models that only explain the disproportionate burden of hiv among black men thus far no study uses a resilience and assetbased approach to examine how hiv seronegative acb men reduce their exposure to hiv and how those living with hiv cope with and overcome the stress associated with their diagnosis this study forms part of an ontariobased research project called wespeak which engaged stakeholders in critical dialogue through innovative and communitybased approaches to address hiv vulnerability in the acb community in ontario using the settings of london ontario this paper examines the sources and acquisition of protective assets by heterosexual acb men in building resilience against hiv and for acb men living with hiv to live with hiv as a lifelong chronic condition we adapted our study to the theoretical construct of critical resilience published by traynor 18 critical resilience is discussed as encompassing black mens awareness of their own sociopolitical circumstances in a racially structured society based on this awareness and building on our previous studies on black mens resilience 19 we see resilience in the ways they mobilize themselves as individuals and as a community in resistance to conditions that compromise their health and wellbeing 19 thus black mens resilience is constructed as being rooted in the quality of their socioenvironmental conditions such that their capacity to reduce their exposure to hiv andor manage hiv as a lifelong chronic condition is further shaped by these prevailing conditions and resources acb men and resilience against hiv resilience is differently defined but generally connotes the ability of an individual or a community to bounce back from adversity 20 it may also be defined as constituting the protective assets at the disposal of individuals that cushion and equip them with the capacity to recover from adversity 2021 in its earliest application resilience was linked to peoples innate qualities including selfefficacy hardiness social competence and selfcontrol which made them naturally adapt to temporary setbacks 2223 however broader conceptualization of resilience also includes its intersection with socioenvironmental factors and any supportive resources that can help individuals to gain protective assets to be able to thrive through adversity 2425 an individuals ability to reduce their exposure to hiv may be based on their accumulated protective assets which is dependant on their access to and the quality of resources in their sociocultural environment studies suggest that black peoples higher prevalence of hiv may be partly due to a lack of awareness and low uptake of hiv testing and treatment 2627 emphasising the role of information as a contributor to hiv resilience the ontario advisory committee on hivaids 28 posits that declining hiv diagnoses among highly exposed groups including men who have sex with men and persons who inject drugs is attributable to policies that intensified information dissemination amongst them this is because unhindered access to relevant culturallygrounded information equips individuals with the requisite knowledge to reduce their exposure 2930 similar arguments are made for the frequent use of hivrelated health services where those with easy access to appropriate facilities are better positioned to accumulate protective assets to build resilience frequent users of hiv preventive health services are exposed to information on hiv transmission based on which they make informed decisions on reducing their exposure people who are living with hiv may initiate counselling and treatment services that contribute to increase their resilience against the everyday challenges of living with the virus 31 in canada though acb men may be vulnerable to hiv they are among the least visible group in aids service organizations and health care spaces this could be linked to their inability to access factual information on hiv transmission thus adversely impacting their accumulation of protective assets to build resilience against hiv 32 overcoming adversity also involves having a strong network of family friends and interpersonal resources within existing social and cultural structures that buffer individuals resilience 20 33 34 35 the presence of social and cultural support systems that prioritize hiv testing treatment and access to information may encourage individuals in these support systems to increase their resilience against hiv 36 acb peoples sociocultural and social network characteristics are sometimes invoked to explain why they may be more vulnerable to hiv for instance hiv stigma poor interaction with health care spaces homophobia as well as the endorsement of traditional masculinities are theorized to prevent heterosexual acb men from accumulating enough protective assets against hiv 2737 it is further suggested that acb men do not readily discuss their sexual and health vulnerabilities which may foreclose their interaction with useful resources to accumulate protective assets to fight hiv 3839 unfortunately most discussions about acb mens hiv risk are bereft of structural contexts despite their overarching influence over peoples ability to acquire protective assets in the face of hiv adversity 2233 structural factors as used in this study refer to the social and health policy decisions at the level of government that directly and indirectly shape the health outcomes of individuals 4041 furthermore the term vulnerability as used in our study is indicative of the ways health policies and the social conditions of heterosexual acb men increase their risk of poor health 42 highlighting the role of structural factors in the burden of hiv among acb men husbands et al 16 argued that acb men are aware of the structural conditions that contribute to their poor health but they have not been engaged by health policy makers particularly acb men are excluded from health care policies that should provide them with health services to support their acquisition of assets for building resilience to hiv regarding these challenges what we do not fully understand is how heterosexual acb men are responding to their hiv vulnerabilities beyond the common behavioral connotations very few studies have interrogated the acb communitys health practices and how they may be mobilizing protective assets for the purpose of building resilience against hiv this study therefore examined resilience trajectories and practices of acb men in london ontario with the aim of contributing to health policy literature on resilience to hiv in particular the findings will improve our understanding of the protective assets characteristics and mobilization dynamics among acb communities and their potential for designing hivrelated health policy study context london ontario has a population of 383822 according to the 2016 population census of canada it is as one of the fastest growing cities in the country ranking as the 6th and 15th largest city in ontario and canada respectively as of 2016 people of acb descent constituted 26 of the citys total population which is higher than similar sized cities in canada 4344 over the last decade london has had one of the highest prevalence rates of infectious diseases such as hepatitis c and hiv in ontario evidence from both the public health agency of canada and the londonmiddlesex health unitthe local body responsible for administering and managing health care in the cityplaces residents of london at heightened risk of infection hiv infection rates in london increased from 59 cases per 100000 in 2005 to 9 per 100000 in 2015 45 similar trends were recorded for hepatitis c infections in the city these disturbing trends of infection led the londonmiddlesex health unit to declare a medical emergency in 2016 as part of the strategies to reduce new infections in the city the main strategy was to increase the supply of clean needles and create safer spaces for supervised and safe drug injection for persons that injected drugs missing from this initiative however is a strategy for addressing hiv transmission including infection by heterosexual contact that represents majority of hiv diagnoses in the acb community 4 despite heterosexual acb men constituting one of the key hiv vulnerability groups there is no specific policy to reduce new infections among them although access to primary health care in london has improved over the years a 2016 report suggested some subpopulations in the city experienced barriers in accessing healthcare services 46 ethnocultural and racial minority populations including acb people continue to face challenges in the access and utilization of healthcare services these challenges are likely made worse by the depressed socioeconomic status of acb men 46 in an earlier study on health equity and access in london some members of the acb community emphasized the challenges they face in the citys health care system which compel them to resort to seeking healthcare services outside the city 47 to understand the hiv needs of acb populations in london baidoobonso and colleagues 48 called for a more structurally focused approach where hiv risk vulnerability and resilience can be situated in the structural determinants of health methods this study forms part of the qualitative phase of wespeak research project implemented in four ontario citieslondon windsor ottawa and torontobetween 2015 and 2020 to understand the pathways to better include heterosexual acb men in communitybased responses to hiv the present study focuses on how heterosexual acb men in london who are hiv seropositive and negative position themselves and mobilise protective assets to overcome hiv adversity in addressing this research objective we examined acb mens health affirming activities and practices in the face of hiv adversity we also sought to identify existing strategies and protective assets or resources and to understand how they mobilized these resources to build resilience against hiv participants also identified experiences that weakened their ability to build resilience against hiv the methods for this study were approved by the western university nonmedical research ethics board in 2015 all methods for this study were carried out in accordance with relevant guidelines and regulations of western universitys nmreb participant recruitment participant recruitment for focus groups and indepth interviews took place between april 2016 to march 2017 informed by our interpretation of resilience as critical resilience 18 we sought to understand the varied resilience experiences trajectories and practices of heterosexual acb men in london ontario with this we aimed to unpack narratives of heterosexual acb men in relation to their heightened risk to poor health outcomes including hiv furthermore we sought to explore how heterosexual acb men as a social group act to reduce their increased vulnerability to hiv adversity and how they navigate their social environment as a means of resisting the conditions that predispose them to poor health thus recruitment was carefully designed and rolled out to interview participants from varying backgrounds including diverse socioeconomic geopolitical ethnocultural and immigration status those with both positive and negative hiv serostatus were also included to qualify to participate in the research the prospective participants selfidentified as heterosexual acb men were aged 16 or older spoke english or french and lived in london given that the targeted participants are considered a hard to reach population the study employed a fivepronged approach in the recruitment first the study identified acb mens common spaces including black barbering salons churches mosques and africancaribbean restaurants where project notices and flyers were distributed those interested in the research made initial contact with the research coordinator for recruitment in the study second the leadership of ethnoracial groups including those from subsaharan africa and the caribbean were contacted and informed about the purpose of the research the leaders then informed their membership about the research and invited them to contact the research coordinator for additional information and to be screened for their eligibility to participate in the study third notices for prospective participants to contact the researchers were posted in the spaces of health service providers including the regional hiv aids connection and some selected hospitals in london fourth recruitment also took place during community activities and events that brought members of the acb community together for instance researchers were present at activities marking black history month and a health fair organized for racial minorities by the rhac research assistants shared information about the research with acb men they encountered in public spaces interested individuals contacted the research coordinator for initial screening to determine their eligibility to participate we obtained informed consent from all participants who met the eligibility criteria demographic details of participants are provided in table 1 indepth interviews and focus groups heterosexual acb men interested in the study were invited to participate in either a focus group discussion or an indepth interview for fgs participants were organized into three groups based on their age to ensure resonance among group members 4950 overall three focus groups were conducted involving individuals in age categories 1624 2538 and 39 and older thirteen indepth interviews with individuals aged between 16 and 67 were conducted to delve further into the nuances emerging from themes in the three fgs idis were conducted with acb men living with hiv to prevent the accidental disclosure of their hiv status in the setting of a group discussion generally the idi was useful in providing depth and contextualizing findings from fgs it was also useful to use this medium to discuss views that may not be suitable to a group setting overall fgs lasted between 60 and 90 minutes while idis lasted between 45 and 60 minutes sessions for both fgs and idis began with individuals giving both verbal and written consent to be audiorecorded participants were assured their identities would be protected and anonymized in research papers and reports to achieve this names of participants and their demographic data were collected on separate forms each participant was then assigned a unique alphanumeric code for the interviews and this helped to anonymize their personal information on transcripts both interview recordings and transcripts were kept on a flash drive the flash drive and the forms containing participants demographic information are kept in a safe and secure locker with only the principal investigator having access to these materials in addition only pseudonyms were used with quotes in reporting the research findings participants were made aware of their right to have the recorder switchedoff at any point in the interview to refuse to answer any question and to withdraw from the study at any point fgs were held at the regional hivaids connections while idis took place at spaces identified by participants as safe and appropriate for the interview all fgs and idis were conducted in english guided by a checklist of questions participants in both fgs and idis discussed issues related to how they acquire protective assets to build hiv resilience they first discussed their understanding of resilience and how the concept informs their efforts against hiv specifically they linked the concept of resilience to their everyday lived experiences in the city of london ontario they identified existing resources for coping with hiv including individual protective assets and those at the interpersonal level they further discussed the role of institutional resources in building personal and community resilience to hiv the core questions that guided the discussions included the following how are acb men accessing information and health services related to hiv what specific activities or programs target acb men in an attempt to keep them informed about available community resources what resources are available for those who test seropositive to hiv and what challenges do acb men face and how do these challenges impede their ability to acquire protective assets to build resilience to hiv an honorarium of 20 was given to each participant to cover the cost of transportation to the interview venues interview guides for the wespeak study were published in bryce 51 in 2018 data analysis all audio recordings from the interview sessions were transcribed verbatim by research assistants under the guidance of the research coordinator the transcripts were then exported into nvivo a qualitative software for analysis guided by the overall project objective and mandate of wespeak our approach to data analyses was informed by a transformative paradigm as we seek to draw social and political attention to the health needs of heterosexual acb men in canada 52 with this approach centering the needs of marginalized and structurally disadvantaged populations is central to the research as it invokes social change in communities through research and engagement with key stakeholders 53 we employed mixed inductivedeductive thematic coding where the process of theme identification was informed by both resilience theoretical constructs and the data itself 75455 team members read the transcripts to familiarize themselves before proceeding to code and identify themes related to our research objectives to ensure consistency in coding among three team members coded transcripts were exchanged between team members to crosscheck and verify that the coded discussions were representative of their assigned themes and were consistent with other transcripts some of the research copis with extensive experience in qualitative research were given copies of the coded transcripts for their independent review results the analyses revealed several themes on how acb men cope and thrive through hiv adversity these themes were tied to participants conceptualization and understanding of resilience and their acquisition of protective assets to build resilience against hiv we found that heterosexual acb men used both internal and external resources to build resilience against hiv while internal resources were expressed in personal characteristics such as openness to discuss ones vulnerability and willingness to connect to others in the acb community external ones were primarily defined by interactions with family members and friends findings also revealed that the key sources of protective assets to building resilience against hiv were differently perceived and prioritized based on participants personal experiences and sociodemographic characteristics for instance in both fgs and idis younger acb men emphasized internal assets including selfefficacy hardiness social competence and selfcontrol to be foundational to building resilience still younger acb men recognized the importance of external and institutional support in developing individual and collective community resilience against hiv in contrast older acb men as well as those with spouses and dependants emphasized family and social support from acb community members as a critical source of external assets in building resilience against hiv overall acb men identified lack of institutional support in helping them to accumulate protective assets in building resilience against hiv it was also revealed that while acb men living with hiv shared similar sources of resilience with other interviewees they named interactions with asos as additional sources of protective assets to coping with hiv however they recognised that these interactions were infrequent and could be improved to meet their needs several structural dynamics foreclose the communitys ability to accumulate protective assets for building resilience against hiv these were mostly tied to the lack of governmental and institutional support in positioning the acb community to access quality healthcare resources specifically racebased discrimination in employment as well as the nonprioritization of the health needs of acb people by state institutions and health policymakers worked together to reduce their capacity to accumulate protective assets against hiv regardless of these structural dynamics we found that religion was an important platform employed in mobilising both internal and external resources against hiv religious groups such as churches provided a sense of community and an important medium for acb men to discuss their vulnerabilities and acquire protective assets heterosexual acb men draw on their everyday experiences to propose ways in which their resilience against hiv can be improved the next section further elaborates these key findings findings are supported with direct quotes from study participants to provide context for further clarity at the end of each quote the participants age and type of interview are provided participants conception of resilience participants explained that hivrelated resilience generally includes internal resources or personal protective assets which position them to freely discuss and share their feelings of vulnerability with family members and acquaintances however there was a recognition that internal resources or personal protective assets of resilience have to be formed this suggests the importance of external resources in acb mens social environment for adequately positioning them to respond to their hiv vulnerability as one participant stated we have innate determination it is given we have that but it needs to be formed into resilience with respect to adverse circumstances and adverse environments and with diseases like hivaids our resilience has to be formed so we channel our resilience into positive ways to get through something like hiv fg 25 26 27 28 29 30 31 32 33 34 35 36 37 38 years group experiences of adversity in the past provided participants with the ability to identify support systems in overcoming the impact of hiv for some acb men therefore resilience to hiv meant access to hiv information and testing you can build resilience you know get tested learn about hiv know your status those types of things it protects yourself we acb men should be getting ourselves tested as a priority idi35 years old participants also conceptualized resilience to encompass protective behaviours such as condom use during sexual intercourse akwasi a 45yearold caribbean man summarised what he perceived to constitute the most important component of resilience against hiv for acb men somebody dont have sex because they dont want to have children but the condom is the umbrella of resilience for black men acb men perceived that being informed about the realities of their hiv vulnerability is foundational to acquiring protective assets to build resilience against hiv accepting the realities of their vulnerability could work to compel them to identify resources that can be used to acquire protective assets against hiv acceptance is the fact that as an african canadian black man i am in fact vulnerable to hiv as well if i dont utilize hiv information i become more vulnerable fg 2538 years group access to information for this participant is a key protective asset and a resource that is foundational to equipping members of this community with the capacity to build resilience against hiv infection individual intrinsic resilience and coping mechanisms heterosexual acb men employed several individual intrinsic strategies and initiatives to reduce their exposure to hiv these included sexual abstinence as highlighted in the following quote i feel right now in this very moment i am 100 not vulnerable to hiv because of choices such as sexual abstinence idi 25 years old a 32yearold year old recent immigrant to london affirmed abstinence as a resilience tool …ever since i got to canada i have not had sex with anybody for fear of getting infected with hiv and thats almost a year now i dont rush things i always want to be sure what i do this indicates a capacity for thoughtful selfreflection which may include a role for abstinence for those who may not be abstaining from sex limiting sexual activities to one partner preferably in stable relationships worked to reduce their vulnerability and build their resilience against hiv most of the sex i have had comes in an actual relationship and you think that doesnt really seem like it means much in reducing risk of hiv infection but one it reduces the number of partners you have and two it usually puts space in between your partners idi 40 years old it was also revealed that issues relating to trust and hiv stigma are discouraging some heterosexual acb men from freely discussing their hiv vulnerabilities they thereby resort to dealing with feelings of vulnerability by participating in or initiating activities that engages them when im feeling vulnerable i just like to listen to music i know a lot of people might want to speak to someone about it but again with a lot of the stigmas around hiv a lot of people are afraid to talk to someone about it i used to play sports a lot to help myself deal with those type of things when im stressed idi 25 years old those without such strong intrinsic capacity for selfcontrol and to engage broader aspects of their personality or inclinations may find themselves in challenging circumstances if their environments also lack the external resources to deal or cope with such vulnerabilities for instance those who found it difficult to discuss their vulnerability with others may suppress and overcome adversity by using illicit substances which could increase their vulnerability to hiv resilience through community emerging from the findings was the revelation that the larger acb community plays an essential role in helping acb men to acquire protective assets to build resilience against hiv by providing them support and a sense of community in addition building social networks within the acb community worked to keep members informed this may include information on where to get help both within and outside the acb community the thing i realized being a canadian and growing up in this society is that it depends on who you know to succeed if you are not accessing different social networks out there then you are not in the know and if you are not in the know how can you benefit or grow as a person… i have got this great big social network because i allowed myself to be a little vulnerable which was very hard for me to do fg 39 years group while some acb men may shy away from building networks in their community it is considered a necessary resource in the settings of london which has a small population of black people this was captured in the remarks of a 57yearold participant in a fg when it comes to your community you dont think about interacting with them you have to put in effort it is the same with drawing support of the black community you have to try because you are not just going to go to the grocery store and see 20 black people and 5 of them you know this recognition by acb men acknowledges a sense of common vulnerability and the need to mobilize protective resources through their networks of acb people improving connection and networking in the acb community as a protective asset against adversity was echoed by another participant in an idi i find it is beneficial to our brothers and sisters to say hey you know what im going to get vulnerable ie stressed and exposed why dont you share your struggles with me i will share mine with you its like give a little to get a little idi 25 years old another participant also stated the benefits of keeping such social networks beyond ones immediate family thats where it starts actually exposing or revealing that side of you that you are vulnerable to somebody who you trust …you can probably tell a pastor or have a conversation with a near friend who has values and get his perspective and his advice you find some way to get help and dont just say ok i dont have any help fg 39 years group acb men did not only conceptualize community to include friends family and resources within the reach of their immediate environment but it also involved virtual and online communities through these virtual communities they share uplifting messages discuss community relevant information and provide social support and opportunities among members for some participants with transnational ties communicating with contacts in origin countries was also important in overcoming hiv adversity this was noted by a participant as follows i often bring up some issues…personal stuff like my health and things like this hiv vulnerability there isnt anything that my sisters dont know i also have my cousins husband who is in jamaica i talk with i have other friends outside canada i speak with so i have a fair network of people fg 39 years group this quote underscores the important role of transnational ties and communication on the health and wellbeing of immigrants in their destination areas in canada spirituality and religion as sources of resilience participants identified religious beliefs as a critical resource in their resilience trajectories many suggested that for acb men who were going through difficult times religious teachings and spirituality helped them to overcome adversity churches mosques and religious groups are able to offer emotional support to members in overcoming challenges such as substance dependency that could heighten vulnerability to hiv by so doing religious groups serve as important platforms in building resilience against hiv i got baptized and dedicated my life to the lord and it was always a struggle its like forget about all my old life drug addiction and sex with multiple partners this is my new life this is who i am this is my identity this is what i have been waiting for…it has been 8 months ago i gave up everything of my old life idi 25 years old for a city like london which has a relatively small degree of racial diversity black churches are crucial in bringing the acb community together to fight adversity or provide support to members in times of adversity this is observed in a quote below when i look at this i still see that the church is a sort of pillar of the community… that sort of props the community up it must be the starting point i go back to churches because they seem to be the pillar i mean everybody seems to get there fg 39 years group the contribution of religious institutions to acb mens resilience against hiv was also through the messages preached to congregants for instance some acb men believed that those who heed to religious teachings about sexual relationships tend to reduce their exposure to hiv a participant commented in an idi from a spiritual perspective i said i was christian i guess if someone is in a situation where they are very spiritual sex outside committed relationships is probably not something that is encouraged but if someone was very spiritual i suppose they would be discouraged from having indiscriminate sex to begin with idi 25 years old most participants agreed that while religious teachings may not directly touch on hiv the application of these messages to their everyday lives helps adherents to protect themselves and build resilience against hiv a 57yearold participant in an indepth interview remarked well if you are a religious person then depending on your religion you shouldnt be practicing polygamy ie implied as multiple sexual partners so you should be only dedicating yourself to one woman not cheating on her and that will decrease any possibilities of getting hiv preaching empathy and sexual abstinence and the importance of healthy living may encourage individuals to protect themselves from hiv resilience for acb men living with hiv participants living with hiv used health and institutional services to accumulate protective assets during their resilience trajectories for instance a participant living with hiv recounted how with the help of some agencies he accepted the realities of his hiv serostatus and initiated treatment …i was distant from a lot of people it was something that i never wanted to get myself into and i went to this location on a retreat and i never forget it a mens retreat and it really opened my eyes idi 45 years old acb men receiving these services may over time develop trust and establish friendship with service providers which helps them in overcoming stress and depression associated with living with hiv in more extreme situations individuals can access mental health services from health providers another seropositive participant recounted his experience in an interview because of the way i was infected there is a psychological component to it it can bring out mental issues to the surface and i think that for the longest time before i was infected i was an angry individual and i was an angry individual probably for about 8 years until i went and got help for posttraumatic stress disorder through the agency idi 32 years old for this participant referral services helped him to adjust and to overcome some of the challenges of living with hiv through this the participant was able to come to terms with his hiv status and seek treatment the revelation that hiv treatment allowed seropositive acb men to have healthy lives makes their interactions with asos crucial to the process of building resilience against hiv a participant living with hiv commented during an interview i look at it this way a kind of benefit from having hiv is that our health is monitored its incredibly monitored so when youre going and youre doing your blood work every three months you can find out or know of the possible things coming down the tube idi 45 years old while services offered by asos emerged as important for acb men living with hiv it appeared that those who were not living with hiv or were unaware of their serostatus were not connected to these services in most cases they did not know the services these organizations provided or where they were located strategies to improve acb mens resilience participants proposed ways the acb community could be assisted to acquire protective assets to fight hiv adversity these proposed measures mainly focused on improving their connection to asos which they considered valuable to accessing information and other useful resources such as testing that can build their capacity to adequately respond to hiv this is emphasized by a recent acb immigrant i was talking about understanding the realities of the virus i think a lot of people ie acb men including myself have no knowledge around the ways in which you can contract the virus and ways in which once contracted you could treat the virus idi 25 years old connecting acb men to asos had the potential to not only inform them about hiv transmission but also encourage hiv testing and treatment for those living with the virus it became apparent from the interviews that testing also has an added benefit of promoting collective resilience in acb communities as observed by a 40 year old in an idi i think you have to hit bottom rock bottom to realize who is your friend who is around what can you do so when you are right back to the top you know how to deal with it to ensure increased testing among acb men participants suggested the use of innovative ways of disseminating information about hiv to the community for instance the use of virtual platforms like social media and other mediums such as churches mosques community leaderships and entertainment figures could improve hiv information and knowledge in the community a participant in a fg commented people are so influenced by the media everyones searching their phones these days…lets have hiv information here lets have awareness information there and lets pump it out like that fg 2538 years group another participant emphasized the strategy of increasing hiv information dissemination using prominent entertainment figures in the community in a fg a 25yearold participant had this to say because i do videos myself i find that when there is a famous person in a video people watch for example if eminem is talking about hiv and the vulnerabilities boom you got like 10 million people following instantly this may also require the political mobilization of black leaders and the community to put pressure on the state to be more proactive in meeting the health needs of the acb community furthermore structural barriers appeared prominent in explaining the difficulties acb men face in mobilizing protective resources to improve their resilience against hiv participants stated that reducing the social and economic vulnerabilities of acb men can help build resilience as noted below on a broader scale it is important to lessen the stratification of society basically improve social economic standards for the poor in society which by and large are made up of blacks and the black community and then we can actually go to school and learn instead of just having information thrown at us when we cant concentrate because stuff at home is just messed up fg 2538 years group the need for improved access to social services for the acb community as a pathway to acquiring protective assets was echoed by a 45yearold immigrant we need access to decent educational facilities better schools better home environments and less incarceration of our people additionally he acknowledged the need for community mobilization to dialogue with the state and community stakeholders on providing resources that can help build resilience against hiv a participant in a fg noted from the perspectives of acb men strategies that take a comprehensive approach to building resilience against hiv must consider acb peoples socioeconomic vulnerabilities based on the social structuring and inequitable justice system in canada community mobilization to demand more from stakeholders will also ensure that acb men are sufficiently resourced to become resilient against hiv discussion in this study we examined the sources of protective assets used by heterosexual acb men in building resilience against hiv the findings suggest that acb men face several and intersecting structural barriers that adversely impact their access to improved health testing and treatment services and information regardless of this structural disadvantage acb men still demonstrate resilience through the acquisition of protective assets in their daily lives and interactions with family friends and community members the resilience trajectories and practices of acb men center on their internal assets and community social support with little to no involvement of state institutions and resources however for acb men living with hiv some form of institutional support and connection with service providers emerged as critical in coping with or building resilience against hiv in demonstrating critical resilience 1819 heterosexual acb men in london ontario acknowledge the circumstances that underpin their vulnerability to hiv they respond to these as individuals and as a community by organizing their activities and interactions to increase their capacity to be resilient against hiv through this acb men challenge and resist skewed narratives about their capacity and fortitude to be resilient furthermore acb men show that despite governmental and institutional neglect over their health needs they can still mobilize and respond to adversity as a marginalized group in our study setting heterosexual acb men defined resilience to cover personal protective assets family friends and social networks and they employed a multiplicity of strategies to cope with and manage hiv while institutional and health resources were recognized by acb men as crucial protective assets that can empower them to build resilience against hiv it emerged that only acb men living with hiv may be in touch with these institutional resources thus although acb men defined resilience to incorporate connection to asos these organizations were not targeting them and this affected their capacity to build resilience against hiv importantly local religious communities emerged as important facilitators in acb mens acquisition of protective assets in their resilience against hiv acb mens conceptualization of resilience is consistent with wood et al s 25 view that resilience is a multidimensional concept that transcends individual intrapersonal qualities to embrace the quality of resources within their social environment in responding to adversity access to accurate information on hiv designed and implemented with other strategies that ensure black men are able to achieve their full health potential can be useful in helping to build acb peoples capacity to be resilient against hiv 5657 employing individual strategies such as abstinence from sexual intercourse and limiting sexual activities to one partner in a stable relationship was another major pathway for participants to build resilience against hiv importantly some of these practices were linked to spirituality and religiosity that also emphasized sexual abstinence and discouraged partner concurrency while monogamy and abstinence linked to spirituality and religiosity has been found to help reduce hiv vulnerability among individuals 58 other studies such as isler et al 36 have opined that hiv risk as constructed and preached by religious beliefs expectations and doctrines may not be a realistic strategy for reducing hiv vulnerability among people this may be emanating from the observation that religious backed messages and construction of hiv risk are often pegged as a moral call rather than an emphasis on activities such as condom use that are useful for reducing hiv vulnerability 5960 in this regard despite attempts by religious denominations to be part of efforts to reduce acb mens exposure to hiv persons perceived not to be practicing abstinence or living with hiv may face judgement and moral condemnation which works to deplete their capacity to be resilient against hiv as suggested by bryantdavis et al 61 and bradley et al 62 given how integral black religious denominations are to acb communities their messaging on hiv should promote nonjudgemental and nonstigmatizing understanding of hiv vulnerability thus introducing stigma reduction messages as part of religious messages will be useful in promoting resilience among acb men in their respective communities furthermore churches mosques and religious organizations can provide teaching and social support options that enable acb men to choose a valueguided lifestyle that positively influence their sexual decisionmaking 63 this strategy may be more effective in promoting acb mens resilience against hiv as it will encourage access to accurate and inclusive information on safer sex hiv prevention counselling and treatment overall the use of sexual abstinence as a strategy to reduce exposure to hiv among study participants demonstrates their resolve to be resilient against hiv religious communities like churches also served as a reliable source of interpersonal assets for the resilience trajectories of acb men through teachings and emphasis on spirituality acb people living with hiv as well as those going through difficult times were given a glimpse of hope this has been found to be effective in developing positive adaptive mechanisms to overcome hiv adversity specifically in brazil and belgium 6566 in north america black churches have mobilized the acb community to fight adversity including jim crow and they remain important spaces for resisting structural oppression racism and discrimination 6768 although some studies implicate black churches for their complacency in contributing to high hiv prevalence in their communities they remain important pillars and rallying points for acb men in drawing strength to fight hiv more recently black churches may have taken up the challenge of becoming more proactive about hiv as they organize voluntary counselling and testing services and provide emotional and psychological support to members 3669 these research findings offer an opportunity for health policymakers and asos to build collaborations with the leadership of religious institutions and use these religious platforms to engage with membership 69 this could happen in the following ways first there is the need to collaborate with the leadership of local religious groups organizations to understand the hiv health needs of their congregants this can serve as the basis for thinking and developing collaborative strategies to engage black communities and acb men second asos and health promoters can work with religious institutions and groups to complement hivrelated activities such as testing and counseling sessions that are occasionally organized for congregants this could provide the medium to interact with and educate community members on hiv and where to access important services that are crucial for building resilience against hiv third given the evidence that leaders in local religious organizations hold some influence over congregants through their sermons and interactions asos could develop short to longterm training programs on hiv that target religious leaders this could increase their knowledge base about hiv transmission and treatment and address issues of hiv stigma that are reinforced in the sermons of some of these leaders participants identified personal networks as instrumental to helping them acknowledge and overcome adversity 7071 however diprose 20 suggested that prioritizing individuals and communities internal qualities to overcome adversity follows a neoliberal ideology where affected individuals and communities are expected to get by with little to no involvement of the state this neoliberal understanding of resilience may particularly impact marginalized populations that are inequitably resourced to withstand adversity there is a need to increase their access to important social resources that would further improve their capacity to overcome hiv adversity in london ontario where acb people constitute less than 3 of the citys population building social networks with other acb people facilitated access to support from community in times of adversity though there is an argument for intrapersonal assets 35 acb men in london also used links to the acb community to navigate protective assetbuilding in the city their networking includes transnational ties and virtual communities where they drew strength to respond to hiv given evidence that heterosexual acb men may be disconnected from state resources that could aid them in acquiring protective assets against hiv 13 it is not surprising that noninstitutionalized resilience strategies are used to overcome and cope with hiv vulnerability among persons living with hiv virtual communities have emerged as an important platform for promoting adaptive approaches to hiv see 5960 these findings align with drushels 72 suggestion that marginalized groups use these channels to circumvent inaccessible traditional and formal sources of hiv information and support acb mens use of virtual platforms in their resilience trajectories has positive implications for reaching them remotely with interventions and strategies during challenging and difficult circumstances including outbreaks and pandemics such as covid19 to promote and help strengthen black mens resilience to hiv asos and hivrelated service outlets may engage with the acb community through innovative strategies this would require the involvement of community and religious leadership and other role models to make outreach campaigns more effective in the community 353673 importantly acb men in the study underscored the urgency of addressing structural barriers and discrimination that limit their access to socioeconomic and health resources which directly deplete their protective assets to overcome hiv in the community thus improved economic and educational opportunities in acb communities can translate into increased hiv awareness more frequent visits to preventive health care spaces and increased utilization of services at asos 574 such improvement will directly build acb mens hiv resilience and empower them with protective assets to adequately respond to hiv study limitations our study has some noteworthy limitations first given that our study used a convenience sampling framework the perspectives of the participants captured in the findings may be missing some of the nuances of the experiences of acb men who could not be recruited through this approach furthermore despite attempts to reduce the power dynamics inherent in focus groups it is possible that the sensitive nature of some of the issues being discussed may have prevented some participants from sharing their experiences finally the analysis did not take into consideration the role of migration origins in the resilience trajectories of acb men as earlier studies have posited that these categories impact the lived realities of acb men in north america including canada conclusion heterosexual acb mens ability to mobilize protective assets to build resilience against hiv has seldom been of interest to researchers and policy makers our analysis presents an important opportunity for policy makers to potentially expand some of these resilience building practices into hiv interventions targeted at the acb community for instance access to relevant information from asos emerged as a key protective asset for acb men especially those living with hiv collaborating with black community members could work to increase the presence and interaction of asos with community members through this strategy asos can increase their presence in barbershops black grocery shops and cafes to disseminate hiv information and engage with community members on workable ways to increase their resilience against hiv in addition recruiting community members to lead hiv information sessions at community events would be a useful way to reach more people with hiv information furthermore the revelation that acb men who are not living with hiv or are not aware of their hiv serostatus mostly rely on personal and intrapersonal protective assets in building resilience against hiv points to the urgent need to target and engage them to overcome hiv in the community beyond hiv testing and information dissemination a holistic approach to improving acb mens health outcomes must be considered there is accumulated evidence that racism and racebased discrimination undermine health and wellbeing among black canadians 975 it is therefore necessary to address the problem of social structuring that exacerbates acb mens vulnerability to hiv as it restricts their access to economic and health resources taken together our findings establish that acb men are investing in resilience against hiv and with improved collaboration with asos and other health policy stakeholders they are poised to overcome their individual and community hiv adversity data availability the datasets generated and analysed during the current study are not publicly available due to restrictions placed on it by the western university nonmedical research ethics board but are available from the corresponding author on reasonable request abbreviations

background in canada heterosexual african caribbean and black acb men tend to suffer a disproportionate burden of hiv consequently studies have examined the underlying contributors to this disparity through the nexus of behavioral and structural factors while findings from these studies have been helpful their use of deficit and risk models only furthers our knowledge of why acb men are more vulnerable to hiv infection thus far there is a dearth of knowledge on how heterosexual acb men mobilize protective assets to promote their resilience against hiv infection methods as part of a larger ontariobased project called wespeak this study examined how acb men acquire protective assets to build their resilience to reduce their hiv vulnerability we analyzed three focus group discussions n 17 and 13 indepth interviews conducted with acb men using nvivo and a mixed inductivedeductive thematic analyses approachthe findings show that acb men mostly relied on personal coping strategies including sexual abstinence to build resilience against hiv interpersonal resources such as family friends and religious communities also played an important role in constructing acb mens resilience acb men bemoaned their lack of access to essential institutional resources such as health services that are important in managing hiv adversitybased on these findings there is an urgent need for hiv policy stakeholders including service providers to engage the acb community in the design of intervention programs additionally addressing the socioeconomic disadvantages faced by acb communities will increase the capacity of acb men to develop resilience against hiv

introduction health literacy is a critically important skill that helps people become active participants in their health care the 2003 national assessment of adult literacy showed that 75 million americans had only basic health literacy skills indicating that one in four americans have problems understanding information about health care 1 racial and ethnic minorities have even lower levels of health literacy twentyfour percent of blacks and 41 of hispanics have below basic levels of health literacy members of minorities have lower levels of health literacy and compelling evidence links race and ethnicity to disparities in health via health literacy 2 3 4 5 6 7 8 moreover members of minority groups and older adults are also more frequently affected by chronic diseases such as cancer high blood pressure heart attack diabetes asthma hepatitis hiv infection mental health disorders and many others 9 10 11 12 13 health literacy may be particularly important for management of these conditions since they often require adherence to rather complex treatment regimens lifestyle changes and regular medical care chronic disease selfmanagement the twin burdens of chronic disease and low levels of health literacy thus fall disproportionately on those most in need members of minorities and older adults all of whom may experience one or more chronic conditions while not having the health literacy skills needed to cope interventions to improve health literacy are thus clearly needed cdsm is a logical target for a health literacy intervention in an approach that cuts across specific diseases cdsm targets problems and skills needed to cope with issues such as fatigue pain stress depression sleep disturbance and treatment adherence while health conditions may require specific management skills common issues such as fatigue depression stress sleep disturbance and treatment adherence cut across illnesses 14 15 16 17 importance of cdsm nonadherence is associated with 30 50 of treatment failures and as many as 125000 deaths annually for example nonadherence to statins increases the risk of mortality nonadherence to cardioprotective medications increases the risk of cardiovascular hospitalizations and mortality and poor adherence to heart failure medications increases cardiovascularrelated emergency department visits 1819 therefore treatment adherence is a critical component of optimal disease management however only onehalf of patients are estimated to be adherent to medications 20 adherence to treatment regimens can be complicated by many barriers including cost and side effects of medications the challenge of managing multiple prescriptions patients understanding of their condition forgetfulness cultural and belief systems emotional disturbances and a reduced sense of urgency due to asymptomatic conditions positive clinical outcomes are more likely when patients are active participants in their care therefore strategies are needed that are useful in promoting selfcare with longevity that will result in more effective selfmanagement of chronic disease racial and ethnic older minority populations in the united states hispanics and african americans bear a disproportionate burden of certain chronic diseases including high blood pressure diabetes and cardiovascular disease yet few studies have investigated medication adherence among blacks and hispanics with multiple chronic conditions across all ages and even more notably by age 50 years african americans are living with higher rates of chronic diseases 21 hispanics who suffer from chronic illnesses which are associated with poorer daytoday functioning are at an increased risk of mortality 2223 about 14 of hispanics had two or more concurrent chronic diseases in 2010 up from 117 in 2000 while 27 of hispanics had four or more chronic conditions 22 despite greater disease burden while several studies have investigated hiv treatment adherence among older hispanics 2425 very few have looked at medication adherence among blacks and hispanics with multiple chronic conditions this is disconcerting since these groups in general 1 are disproportionately affected by chronic conditions 2 have barriers related to understanding their medications and how to take them and 3 have greater chronic illnessrelated mortality and morbidity than nonhispanic whites poor adherence may be related to issues such as low health literacy language and acculturation all of which are barriers to treatment 25 26 27 28 29 racialethnic minorities are less likely than nonhispanic whites to be reached by mainstream health education promotion and disease prevention messages which tend to reach middleclass wellinsured englishspeaking people 2230 it is imperative that barriers to health care access are understood if the health needs of all groups with chronic illness are to be met our study proposes to gain a better understanding of patients from diverse populations beliefs attitudes motivations and behaviors regarding chronic disease and its management in order to develop an effective intervention that is acceptable and tailored to their specific needs materials and methods qualitative methodologies are particularly important for the development of conceptual frameworks that focus on the individual developmental and sociocultural contexts in which behavior occurs 31 to guide intervention development this approach also helps us understand some of the cultural issues within a group sharing a similar potentially lifealtering experience 32 aim the purpose of this study was to gain a greater understanding of patients perspectives on living with chronic illness specifically related to the barriers to disease selfmanagement and subsequently any adherence strategies they adopt to answer the research questions below a qualitative study using a thematic analytic approach was warranted research questions the research questions associated with this study are 1 what are persons with chronic illness knowledge about and perspectives on living with their condition 2 what do persons with chronic illness describe as the barriers and facilitators for optimal disease selfmanagement 3 which commonalities and variations in disease selfmanagement exist among patients with chronic illness and 4 how do experiences of having to take medications for chronic illness impact persons everyday lives due to the nature of qualitative inquiry which is inductive and aims to understand culture process meanings events and experiences within particular situations the findings are bound to particular sociocultural contexts and are not generalizable to particular groups and or a population while qualitative research does not aim to test andor prove the researchers hypothesis propositions can be made and researchers can confirm the propositions 33 for this study the propositions were that older persons with chronic illness lack sufficient knowledge about their condition and have barriers and facilitators for optimal disease selfmanagement commonalities and variations in disease selfmanagement exist among older persons with chronic illness and having to take medications for chronic illness impacts everyday life qualitative approach thematic analysis was used to identify analyze and report patterns within the data this helped analyze the qualitative data and to systematically gain knowledge and understanding about the participant ie a person living with chronic illness while several overarching issues regarding cdsm in patients with chronic illnesses have been identified a nontailored onesizefitsall disease management intervention is unlikely to be the most effective approach this is particularly true for those from minority and socioeconomically disadvantaged communities since relevant factors may be related not only to illness problems and treatment but to sociocultural factors as well while quantitative findings on cdsm are instructive they do not provide an empirical understanding of the nature or essence of the lived experience per se given that the ability of patients to manage diseaserelated problems is contingent on a clear understanding of the experiences of why and how they do or are not able to adequately cope this gap in our clinical knowledge is a significant problem and warrants further study a qualitative approach involves a search for the meaning of the experience for these individuals and thus provides a foundation from which to build an essential understanding of what it is like to be a person coping with chronic illness this approach involved a descriptive method utilizing a thematic analysis by analyzing the descriptions given by participants and dividing them into meaningful statements generating themes that guide the construction of the phenomenon being studied this approach is best suited because there are important gaps in our knowledge about persons with chronic illness their health literacy and their cdsm skill the aim of this study is to make clear and understand the most essential meaning of managing one and oftentimes multiple chronic illnesses from the perspective of those directly involved in it 34 a thematic analysis approach was used to gain a greater understanding of patients health literacy and perspectives on living with chronic illness specifically related to barriers to disease selfmanagement and subsequently any adherence strategies they adopt qualitative methodologies are particularly important for the development of conceptual frameworks that focus on the individual developmental and sociocultural contexts in which behavior occurs 31 a better understanding of these can serve as an essential guide to intervention development this approach also helps us understand some of the cultural issues within a group sharing a similar potentially lifealtering experience 32 participants in this study were asked to define and describe studyrelated constructs using their own words and conceptualizations as they pertain to living with chronic illness and then were guided through indepth explorations of relevant influences participants were encouraged to expand on details of individual stories and collective narratives when discussing their diagnoses and its ensuing issues and challenges using this approach allowed for less restrictive and richer responses from participants 32 this goes to say that any intervention should be responsive to the patients holistic and global situation and not merely to the biomedical and technical aspects of a patients body 34 the lived experience of disease selfmanagement for chronic conditions is a complex dynamic and multifaceted phenomenon that is often overlooked by the prevailing biomedical model 35 data generation and collection data were collected from participants from the target population to investigate factors directly related to their beliefs and attitudes regarding their illness that could better help us understand their needs in order to support selfmanagement of their disease semistructured indepth interviews were conducted with persons with chronic illness the overall goal was to identify core conceptual components and themes to guide the development of an intervention to improve disease selfmanagement in this group to be developed and later tested indepth interviews twentyfive persons with chronic illness in south florida met the following criteria 1 having at least one chronic condition 2 able to provide informed consent and 3 english or spanish speaking patients with any psychiatric or cognitive disorder impairing cognition or the inability to provide informed consent were excluded this study was conducted under a protocol approved by the institutional review board of nova southeastern university all participants provided written informed consent although a goal of qualitative research is to reach saturation in eliciting themes during interviews it is often difficult to estimate sample sizes for this research strategy prior to data collection however it has been suggested that 525 participants are adequate for this type of qualitative scientific inquiry 36 37 38 in this study we continued interviews until we found that we had thoroughly explored all emergent themes raised by our participants recruitment participants were recruited from a list of people who had participated in some of our previous studies flyers describing general study information were posted in the universitybased clinic in which the researchers are employed interested persons were then contacted by our staff for preliminary eligibility screening and to set up an appointment for the onetime interview qualitative procedure a semistructured interview guide which consisted of openended questions designed to elicit rich descriptions was developed constructivist frameworks guided the creation of the semistructured interview guide the participant interviews were conducted in english or spanish and digitally recorded interviews were then transcribed coded and analyzed in this method data were collected from multiple members of the population in order to gain a richer understanding of the phenomena of interest this approach helped the researchers to understand the sociocultural behaviors within a group sharing a similar potentially lifealtering experience 32 participants were asked to define and describe studyrelated constructs using their own words and conceptualizations and then were guided through indepth explorations of relevant influences participants were encouraged to expand on details of individual stories and collective narratives when discussing their illness diagnosis and its ensuing issues and challenges using this approach allowed for less restrictive and more culturally rich responses from participants although interviews covered the same material they were tailored to each participants unique situation the following broad content areas were included 1 knowledge of chronic illness 2 medicationtaking behaviors 3 personal decision making and motivations for disease selfmanagement and medication adherence 4 coping and social support 5 benefits and barriers to selfmanagement 6 perceptions of being a person with chronic illness 7 role of culture in disease selfmanagement and 8 ways they think they can improve their selfmanagement behaviors since these discussions were openended the order of questions may have changed somewhat and followup questions for clarification may have been asked participants were asked to use a pseudonym during the recorded interview to protect their identities the interviews lasted 1 hour data preparation and analysis individual interviews were transcribed coded and analyzed an inductive analysis was used because it allows for the patterns themes and categories of analysis to emerge 39 two levels of qualitative analysis were conducted the descriptive analysis described the respondents life situations and characteristics the thematic analysis elaborated the structures of the basic constructs and new constructs that arose in the early analysis two readers reviewed transcripts of the first five interviews to identify all relevant ideas their notations were compared and discussed the process was repeated for the remaining transcripts until there was agreement on the ideas and concepts some of the concepts were broken down into various subcomponents of the theme the next stage of analysis was to go back to the individual interviewee level to look at withinperson consistency with each concept the two readers assembled and compared all the text references to a concept it was determined to what extent respondents affirmed only single aspects or multiple aspects of a concept this built on the earlier descriptive analysis and will allow to distinguish among respondents this permitted the readers to ensure that they incorporated differences and similarities that might emerge among these interviewees descriptive node tree diagrams were created using nvivo software 40 in order to assist in the interpretation of the comparative analysis findings in this way the readers ensured scientific rigor of the qualitative analysis by making sure the themes and contexts derived were correct in that credibility reliability and dependability can be demonstrated results the goal was to complete interviews with patients with chronic diseases in order to lay the groundwork for intervention content development all participants completed the qualitative facetoface interviews in either english or spanish of the englishspeaking participants four were men and 11 were women ages of participants ranged from 62 to 88 years five participants were african american and 10 were nonhispanic white of the spanishspeaking participants two were men and eight were women ages of participants ranged from 57 to 77 years chronic illnesses reported for all participants included diabetes hypertension cardiovascular disease hyperlipidemia asthma arthritis anxiety and chronic migraines summary of qualitative findings the emergent themes from the participant qualitative interviews included 1 disease knowledge acquisition and health literacy 2 role of spirituality 3 social and family support and 4 coping strategies disease knowledge acquisition and health literacy while participants had a general overall knowledge of chronic illness they had some overall deficits in knowledge regarding some of their illnesses and medications but knew more about those conditions for which they tried to gain control over one participant who suffers from both chronic migraines and asthma reported when asked where they typically found health and medical information participants reported they got most of their information from their doctors pamphlets and other reading materials from the physicians office or internet sources while the majority utilized generic search engines such as google there were a few participants who accessed reputable and more specific web sites such as webmd participants were asked how well they understood the material they read about their medications and the possible interactions with other medications they might be taking overall they limited themselves to reading only about the side effects from the paperwork accompanying their prescription medications when asked they think they need to know more information about their chronic illness the younger participants thought that perhaps they did but the older participants were content to get the information from their physicians spirituality many participants reported instances in which their faith played a role in coping with chronic illness one participant discussed his reaction to finding out about his heart condition well i took it in stride in a way i mean i needed the surgery to put the stents in and somehow it didnt bother me im pretty religious and i have a feeling that i have a strong sense of god and i think god looks over me white male age 75 years for some faith in god was solidified prior to getting sick and has since carried them through the battles with chronic illness one woman discussed her belief in god after a breast cancer diagnosis that led to a mastectomy support familysocial support support was reported as a critical element in dealing with chronic illness many of the participants discussed the importance of having some kind of social support whether it be from family or friends other participants use their religiousspiritual organization to provide support well i get a lot from the synagogue and also i mean we have our friends that we go out with socially we go to movies white male age 75 years im not looking for social support from friends because i dont trust so much but i do have one good friend that i did feel that she betrayed me once but never mind i try not to think of it and otherwise its mostly talking and phone coping strategies for participants staying positive was reported to be an important factor in coping with pain and combating anxiety and depression many participants discussed cognitive selfmanagement strategies for coping with their illnesses many of these included reframing the meaning of their lives and illnesses and positive selftalk to maintain their ability to cope with multiple health problems on a daily basis they also discussed behavioral selfmanagement strategies such as exercise as a means of coping also reported was the use of alcohol and prescription medications to help cope their chronic illness anger many participants reported feelings of anger due to variety of issues regarding problems due to their illness for one participant who suffers chronic migraines her frustration and anger stem from friends family and physicians not acknowledging the debilitating nature of the conditions its not just a headache and thats where a lot of neurologists i went to they talk to you like oh its just a headache no its not it other participants stressed that they get angry because they find they cannot do the things they used to do before and i couldnt first of all when youre doing something in front of a bunch of people and you feel like a clod so i gave that up i didnt you know usually if i stand in front of a bunch of people theyre laughing at me for other reasons and i just couldnt take that white male age 80 years depression for some participants depression was linked to physical pain due to their chronic illness they felt if they did not have pain they would not be depressed sometimes when the pain is too strong i want to cry and like i get depressed like you get depressed but thats for a moment i encourage myself and that will go away hispanic female age 77 years others reported feeling depressed but utilized different strategies to cope with it for some the depression can be debilitating some participants reported their depression was due to not being able to function as they had in the past and being told they have to make adjustments in life well the backache is uncomfortable to sleep sometimes i cant be sitting for long periods and i have to stand up and stretch the back i cant bend i cant lift i mean its i dont cook and thats part of depression because i want to do things and i cant do it i cant work the psychiatrists assistant told me part of your life has been taken away the way you are exactly i dont have i could be the whole day in bed and thats because of the depression i have hispanic female age 57 years discussion the aim of this research was to obtain a deeper understanding of older adults perspectives on the challenges of living with chronic illness as they pertain to health literacy and disease selfmanagement strategies they utilize several themes emerged from the interviews spirituality social support coping anger and depression in this group of older adults with chronic illness these findings support the literature evidence that certain psychological and sociocultural variables might influence managing chronic illness including medication adherence but the details provided by participant narratives provided a deeper richer understanding of the underpinnings and possible interrelatedness of these factors regarding chronic illness knowledge and perspectives on living with their condition one of the studys research questions participants commented on how little they actually knew and understood about their diseases a finding supported by shaw et al 41 although they understood the importance of taking medications the names of their medications and how to take them this finding is in line with our proposition that the participants may lack sufficient knowledge about their condition of note is their reported limited use of the internet to find health information and when they do utilize online searches the searches are not via targeted web sites that provide quality reliable and more accurate information than a web site whose mission is to sell a product this is problematic in that the medical information available on the internet can create harm by being difficult to interpret and thus creating the potential of overuse or misuse of treatment or medication moreover there are insufficient tools available that assist patients in finding relevant information given the vast amounts of health information on the internet health and medical information needs to be easy to locate relevant to the patient and their illness and understandable for patients with low levels of health literacy this finding also aligns with our proposition that there are barriers for optimal disease selfmanagement there is little published work regarding the role of spirituality and religious faith in disease selfmanagement among persons with chronic illness nonetheless there is literature to support the idea that a strong spiritual base has an influence on resilience and coping skills among older persons 42 and hispanics with chronic illness 43 for some particularly african americans the roles of spirituality and social support are intertwined whereby church activities provide not only spiritual fulfillment but social support as well 4445 spirituality may be a commonality in disease selfmanagement among older persons with chronic illness supporting the proposition that similarities may be present in this group therefore it would be important when in developing disease selfmanagement interventions to take into account the function of the church and spiritual values for patients more research is needed in how we can leverage these components for better health outcomes aside from support provided by the church support from family members and friends was reported as crucial for aiding selfmanagement of chronic illness 46 the majority of the participants concurred that social support was paramount whether it comes from the church a close friend an acquaintance or a family member and even if it was just a phone call the protective effects of highquality social support can enhance emotional and physical wellbeing and increases resilience to stress 47 yet participants remarked that it was not always easy to ask for or find support in times of emotional andor physical need for some participants it was difficult to accept losing some independence and to adapt to the change in social role creating access to a supportive social environment would be an essential component in any intervention for persons with chronic illness one that would motivate participants to reach out and access people who can be available to them when needed or teach them how to create new social networks also participants perceptions about support may need to be taken into account such as understanding when they might need it and who they feel can provide it and if they will be satisfied with the interaction teaching communication skills regarding interpersonal interactions will help participants to nurture supportive relationships reports of feeling depressed were not surprising given experiences of depression is common among persons with chronic illness 24254849 in this sample much of the reported depression was due to pain caused by their illnesses and inability to function as they had previous to becoming ill of importance to note is that depression can interfere with a persons ability to selfmanage disease particularly regarding motivation to adhere to a medication regimen 50 feelings of anger and frustration were reported among several participants due to having to face problems stemming from their illness and as mentioned earlier not being able to do things they used to do such as exercise addressing how mood affects selfmanagement for a variety of health issues provides leverage for developing intervention approaches to improve medication adherence and enhance motivation for disease selfmanagement overall at the core of wellness is the ability to cope and adapt to new circumstances for this reason it is imperative that persons with chronic illness learn to develop strategies to help them cope with the challenges accompanying illness much of which involves maintaining a positive attitude and at times making the adaptive process less emotionally overwhelming with chronic illness comes a loss of a valued level of functioning such as the ability to engage in activities such as driving dancing or exercising there seemed to be a relatively high level of acceptance and adaptation regarding their illnesses in this sample of older adults many of whom suffered from multiple chronic conditions part of disease management is adapting to circumstances beyond ones control illness acceptance may be instrumental in older adults adaptation to health limitations 51 as revealed by the study participants patients develop their own coping strategies some maladaptive learning adaptive coping skills can enhance cdsm skills by helping the person change expectations regarding their physical abilities ie to work within the limit of those abilities these skills also include managing anger and intermittent depression help approach problems actively enhance helpseeking behaviors and build social support networks for older adults support provided by their environment is also instrumental 52 limitations several limitations associated with this study should be considered findings from this small sample cannot be extended or generalized to wider populations of noncommunitydwelling adults with chronic illness ie those who receive care in hospitals or at home or to persons living in more rural settings the generalizability of this study is for the sole purpose of developing an intervention to be tested in a larger study replicability is very problematic it is difficult to make systematic comparisons as participants may give widely differing responses that are highly subjective conclusion the focus of this study was to explore patients perspectives on living with chronic illness including their health literacy and health behavior strategies several salient themes related to living with chronic illness emerged from the data collected from the interviews many commonalities existed among participants regarding barriers and facilitators for optimal disease selfmanagement with some sociocultural variations particularly regarding the role of culture and spirituality of note throughout the thematic analysis of this study was the level of personal and emotional resilience participants demonstrated when it came to cdsm in the face of physical pain isolation depression and lack of support while more difficult to express or even detect challenges associated with emotional distress can cause andor exacerbate physical manifestations of illness 53 the participants disclosed their ways of dealing with their stressors that may or may not be related to personal resilience an association has been shown to exist between resilience and quality of life and health promotional behavior 54 it is likely that more research is required to deepen the understanding of the role of resilience influences on coping and cdsm in older adults increasing knowledge and understanding of chronic illnesses combined with enhancing skills for cdsm may be paramount for any future health interventions with this population 55 moreover tailoring interventions to provide personalized information specific to the user ie addressing their unique deficits and their strengths can help improve cdsm competency in patients disclosure the authors report no conflicts of interest in this work journal of multidisciplinary healthcare 201710 submit your manuscript dovepress dovepress journal of multidisciplinary healthcare publish your work in this journal submit your manuscript here the journal of multidisciplinary healthcare is an international peerreviewed openaccess journal that aims to represent and publish research in healthcare areas delivered by practitioners of different disciplines this includes studies and reviews conducted by multidisciplinary teams as well as research which evaluates the results or 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purpose chronic illness and low levels of health literacy affect health outcomes for many individuals particularly older adults and racialethnic minorities this study sought to understand the knowledge strengths and areas of need regarding selfmanagement of chronic illness in order to lay the groundwork for content development of an intervention to increase health literacy and maximize patient engagement in chronic disease selfcare patients and methods indepth qualitative interviews were conducted in spanish and english with 25 older adults with various chronic illnesses topics included knowledge and understanding of chronic conditions medications and disease selfmanagement skills qualitative data were coded by searching text and conducting crosscase analysis an inductive analysis was then employed to allow for the patterns and themes to emerge results emerged themes included 1 social support 2 coping strategies 3 spirituality 4 chronic disease health literacy 5 anger and 6 depression while participants had a general overall knowledge of chronic illness they had deficits in knowledge regarding their own illnesses and medications conclusion chronic illness selfmanagement is a complex and dynamic behavioral process this study identified themes that leverage patient motivation to engage in selfcare in a personalized manner this information will guide the development of an intervention to promote health literacy and optimal disease selfmanagement

introduction adolescence is a critical period involving psychosocial and physical changes and proper nutrition for growth is important in adolescence individuals have more opportunities to choose food and their food choices are greatly influenced by their peers and the environment as well as their personal preferences furthermore dietary behavior established during this period continues into adulthood underscoring the importance of establishing healthy dietary behavior 1 however during the coronavirus disease 2019 pandemic changes in lifestyle have been detected as the time spent at home increased due to social distancing school closures and isolation due to illness or contact with confirmed cases increasingly many research papers have reported that adolescents lifestyle behaviors are also worsening 2 according to a report from the united nations international childrens emergency fund the covid19 crisis has made it difficult to access healthy food as the consumption of vegetables and fruits is declining while that of sugary drinks and snacks is increasing 3 an individuals dietary behavior is influenced by various determinants such as nutritional knowledge dietary environments and food availability it is a wellknown fact that there is a household income disparity in healthy food consumption a report from the prospective urban rural epidemiology study in 18 countries demonstrated that the availability affordability and consumption of fruits and vegetables depended on household income 4 furthermore previous studies reported that dietary behaviors such as skipping breakfast and soft drink consumption were also related to household income 56 the covid19 pandemic has caused socioeconomic changes such as an increase in the number of unemployed and a contraction in economic activity 78 a study conducted in san francisco found that people facing new financial challenges due to the covid19 pandemic reported 10 times more sugary drink intake than those who did not 9 although some studies have evaluated changes in dietary behaviors and lifestyle during the covid19 pandemic there has been insufficient research evaluating the behavioral changes of adolescents according to household income in the context of the covid19 pandemic therefore using data from a national survey of koreans we assessed the changes in dietary behaviors of adolescents during the covid19 pandemic and evaluated differences according to household income materials and methods data to assess changes in dietary behaviors during the covid19 pandemic we analyzed data from the korea national health and nutrition examination survey the knhanes is a survey representing the population of korea that collects various data such as health status and nutritional status every year further information on knhanes can be found in a previously published paper 10 the latest data currently available are from the 2020 knhanes therefore we interpreted the data from 2019 as representing the period before covid19 and the data from 2020 as representing the period during the covid19 pandemic the 2019 and 2020 surveys collected data from 8110 and 7359 people aged 1 year and over and their response rates were 747 and 740 respectively for this study we included subjects aged 1218 years after excluding subjects who reported consuming 500 kcalday or 5000 kcalday 1112 800 subjects were finally included variables as a measure of socioeconomic status we considered household income household income was expressed in quartiles which were defined based on the value of monthly household income divided by the square root of the household size in korea various indicators including those related to nutrition are set and monitored in the national health promotion plan 2030 taking into account the dietary behavior of adolescents along with these indicators we considered 12 indicators of dietary behaviors family meal nutrition education and counseling use of nutrition labels adequate fruit and vegetable intake 1314 adequate calcium intake adequate vitamin a intake skipping breakfast excessive sodium intake 11 excessive fat intake excessive sugar intake frequent soft drink consumption and frequent eating out the definitions of indicators followed other studies or national monitoring standards when it was inappropriate to estimate statistics they were newly defined in consideration of the distribution of data family meal was defined as having breakfast or dinner with family nutrition education and counseling experience during the last year was defined based on a response of yes to that question the use of nutrition labels was defined as those who responded that they checked the nutrition label when purchasing processed foods in korea the national health promotion plan recommends consuming more than 500 g of fruit and vegetable per day 1314 data for daily fruit and vegetable intake were collected via 24hour dietary recall survey daily nutrient intake was also estimated based on 24hour dietary recall survey the agespecific and sexspecific criteria for adequate intake of calcium and vitamin a were applied based on the 2020 dietary reference intakes for koreans 14 according to the 2020 dietary reference intakes for koreans a daily sodium intake of 2300 mg was suggested as a required criterion for intervention to reduce the risk of chronic disease intakes of fat and sugar were calculated as a percentage of total energy intake to define indicators finally the definition of eating out included takeout food delivery and school meals and the frequency of eating out was classified into 2 groups according to whether participants reported eating out once or more per day statistical analysis considering the sampling method of the knhanes in summary statistics we presented results as weighted means with 95 confidence intervals for continuous data and unweighted frequencies with weighted percentages for categorical data the results were produced by applying a sampling weight associated with the nutritional survey data table 1 continued we estimated the prevalence of basic characteristics and dietaryrelated indicators in adolescents before and during covid19 differences in the prevalence of basic characteristics and dietaryrelated indicators before and during covid19 were evaluated using regression analysis these differences were also analyzed by stratification by sex for the 12 dietary behavior indicators we also used regression analysis to estimate differences in the prevalence of dietary behaviors by high and low ses levels the interaction effect of household income and year on the prevalence of dietary behaviors was also assessed statistical significance was assessed at pvalue 005 under 2tailed tests all statistical analyses were performed using sas version 94 ethics statement there was no personal information in the open knhanes data and ethical approval for the use of open knhanes data was exempted from the institutional review board committee of the ewha womans university hospital results table 1 shows changes in dietary behaviors during covid19 regarding healthy dietary behavior such as family meals and adequate fruit and vegetable intake there were no significant changes but the average daily vegetable intake showed a tendency to decrease the prevalence of skipping breakfast in 2020 was 374 an increase of about 43 p compared to 2019 but the change was not significant meanwhile the prevalence of frequent soft drink consumption increased significantly from 76 to 148 this change was evident in boys not in girls the prevalence of frequent eating out decreased from 460 to 368 in terms of improved health behavior only in girls the average sugar intake showed a tendency to decrease and excessive sodium intake was reduced by 127 p additionally the number of people belonging to the low or mediumlow level of food security increased compared to precovid19 when assessed according to household income the prevalence of using nutrition labels and excessive sodium intake differed during the covid19 pandemic the prevalence of using nutrition labels was higher in participants with a low ses level and lower in those with a mediumhigh ses level excessive sodium intake was higher in participants with a mediumhigh ses level and lower in those with a mediumlow ses level compared to the high ses level although statistical significance was not met the prevalence of family meals adequate calcium intake and eating out in participants with low ses levels during covid19 was lower furthermore the social disparity in breakfast skipping was further aggravated which was found to be significant the highses group but it did not reach a statistically significant level meanwhile the prevalence of adequate fruit and vegetable intake tended to decrease at both high and low ses levels the prevalence of adequate vitamin a intake also declined in both ses groups compared to before covid19 even when estimating the prevalence of dietary behaviors from 2016 the social disparity in skipping breakfast family meals and adequate calcium intake during the covid19 period was found to have deepened the changes in dietary behaviors during covid19 among adolescents with low and high ses are presented in figure 1 the prevalence of skipping breakfast among those with a low ses level increased significantly compared to before covid19 this increase was much greater than was observed among adolescents with a high ses level soft drink consumption increased in both highses and lowses groups compared to before covid19 and the increase in the lowses group was larger than that in discussion in our study from national data we evaluated changes in dietary behaviors of adolescents during covid19 overall soft drink consumption increased by about 72 p and this change was evident in boys not in girls although no significant change was observed in the entire study group the average vegetable intake and calcium intake significantly decreased in girls during the covid19 pandemic the increase in breakfast skipping was more pronounced in adolescents with low ses and the change was significantly greater than in those in adolescents with high ses soft drink consumption also increased significantly in participants with a low ses level but the difference was not significant when compared to changes in participants with a high ses level in march 2020 the ministry of education of the korea postponed the start of school middle and high school students started online school in early april and facetoface classes sequentially started in may when covid19 was stagnant however in august as social distancing was upgraded to level 2 for early mitigation of the second wave of covid19 online classes were expanded 15 the decline in the prevalence of eating out during covid19 may have been attributed to social distancing and school closures the unprecedented covid19 pandemic has affected many aspects of daily life and behavioral changes during figure 1 changes in dietary behaviors by high and low household income in adolescents before and during covid19 family meal nutrition education and counseling use of nutrition labels adequate fruit and vegetable intake adequate calcium intake adequate vitamin a intake skipping breakfast excessive sodium intake excessive fat intake excessive sugar intake soft drink consumption and eating out results are expressed as a weighted percentage taking into account the sampling method covid19 coronavirus disease 2019 p 005 it represents a statistically significant change before and during covid19 within that socioeconomic status group adequate fruit and vegetable intake adequate calcium intake p for interaction0678 p for interaction0800 p for interaction0707 d e f adequate vitamin a intake household income low household income high the covid19 pandemic have been detected in many studies 391617 due to fear of covid19 infection changes have also been made in the way food is purchased food and groceries have been purchased through delivery systems and purchases of frozen or canned food which have a longer shelf life than fresh food have increased 18 this likely contributed to the decrease in fruit and vegetable intake a study conducted in 3 european countries observed a decrease in average consumption of fruits and vegetables and an increase in readymade meals during the lockdown of the covid19 pandemic 19 interestingly some studies have shown a trend toward an increase in healthy dietary behaviors studies conducted in italy 20 spain 21 and czech republic 22 during the covid19 pandemic reported increased consumption of fruits and vegetables as an explanation for this adolescents food choices may have been affected because they were confined to the home and controlled under parental sanctions consistent with previous research 16 an increase in soft drink consumption among adolescents was clearly observed during covid19 in our study however this has also shown mixed results between studies 2023 in our study there was a significant increase in breakfast skipping and soft drink consumption among adolescents with low ses although changes in household income have not been captured the proportion of adolescents with low or mediumlow levels of food security tended to increase during covid19 exposure to food insecurity in adolescence can cause extreme psychological stress and affect the mental health and wellbeing of adolescents 24 it has also been reported that food insecurity is associated with poor dietary behavior and that access to healthy food may be restricted 25 as one of the major determinants of food insecurity low household income levels can be considered 26 ses is known to be a determinant of individuals dietary behavior 27 a study conducted mainly in denmark germany and slovenia reported that the loss of household income due to the pandemic was related to changes in food consumption patterns 19 those with low ses are more likely to be exposed to vulnerable environments which is also associated with access to and consumption of unhealthy foods 28 a study in korean adolescents reported that adolescents with lower scores on the family affluence scale were more likely to skip breakfast and frequently consume soda fast food and instant noodles 29 a study in highschool subjects in spain observed that the risk of the diet worsening was 21 higher in adolescents with more disadvantaged ses 30 barriers to highpriced healthy food increase the choice of affordable and accessible energydense or nutrientpoor foods 3132 the governmentfunded meal support program for lowincome children and adolescents did not guarantee continuous support as schools were closed due to social distancing during the covid19 period as a result of this it is likely that the nutritional status of children and adolescents with low ses was affected in this context among adolescents with low ses there was a significant increase in breakfast skipping along with a decrease in adequate fruit and vegetable intake in order to close the gap according to the ses level it seems that continuing nationallevel support is needed there are some points to keep in mind when interpreting the results this study did not assess changes in dietary behavior within individuals thus while our study may show changes in overall status we have not been able to directly assess the causes of changes in dietary behaviors nevertheless our findings provide useful information to understand the dietary behaviors of adolescents in the environment of the covid19 pandemic in addition from the perspective of the lifecourse focusing on adolescence which is closely related to the health and behavior of adults we evaluated differences according to ses levels as well as differences between before and during covid19 although the analysis was performed considering the multistage sampling method there may have been problems with the validity of estimates due to the small sample size in subcategories therefore we did not assess social disparities for changes in dietary behavior by sex in korea social distancing was lifted on april 18 2022 the question raised after the easing of social distancing concerns whether these trends will continue therefore it will be necessary to continue monitoring these changes and to check whether dietary patterns are maintained in the generation that experienced covid19 in adolescence obesity among children and adolescents in korea increased significantly during covid19 33 and we observed some deterioration in health behaviors among adolescents in our study therefore it is necessary to reduce obesity and to intervene before poor health behavior becomes a habit orcid hye ah lee ho jung lee bomi park orcidorg0000000158349975 yoonhee shin 0000000299509362 hyunjin park hyesook park supplementary materials supplementary material is available at conflict of interest the authors have no conflicts of interest to declare for this study funding none

to assess social inequalities in changes in dietary behaviors among adolescents during the coronavirus disease 2019 covid19 pandemic we compared changes in dietary behavior indicators by household incomeusing crosssectional data from the 2019 and 2020 korea national health and nutrition examination survey the prevalence of dietary behaviors in adolescents 1218 years old was estimated and changes in dietary behaviors during the covid19 pandemic were evaluated we assessed changes in dietary behaviors with a household income as a measure of socioeconomic status ses disparityduring the covid19 pandemic the average consumption of vegetables decreased and food insecurity worsened adolescents were more likely to skip breakfast than before covid19 331 and 374 soft drink consumption also increased in 2020 from 2019 76 and 148 especially among boys average sugar intake and sodium intake showed a tendency to decrease only in girls but there was no significant difference according to ses level skipping breakfast was particularly evident in the lowses group and the difference according to household income level high vs low was greater during covid19 than before the prevalence of soft drink consumption increased significantly in the lowses group but the rate of increase did not differ by ses levelwe found that the social disparity in skipping breakfast was further aggravated during the covid19 pandemic to reach a better understanding of the dietary behaviors of adolescents continuous monitoring is necessary

introduction the gender inequality index is one of the indicators used to measure the level of inequality between men and women in various aspects of life including education health economy and political participation east java is one of the provinces in indonesia that has problems in terms of gender inequality other genderrelated measurements are the gender development index and the gender empowerment index according to bps gii can be divided into four class categories namely low lower middle upper middle and high one of the provinces that experienced a decline in gii from year to year based on data from the central statistics agency was east java province in 2018 east javas gii was 048 points in 2020 it was 045 points and in 2022 it was 044 points this decline can be caused by improvements in various empowerment sectors including education employment and politics however gii east java is still included in the medium category various studies and measures related to gender inequality have been conducted aprilia triani analyzed the effect of gender inequality on poverty the results of this study show the influence of gender inequality on poverty oeliestina examines the influence of social variables technology and information on gender inequality the results showed a strong significant and negative correlation between information technology social variables such as hdi and gdi with gii kertati analyzed the gender development index and gender empowerment index of surakarta city the results of the overall analysis of the achievements of gdi and gei of surakarta city show a position above the average achievement of central java province furthermore marsono analyzed spatial models on the gender inequality index in indonesia the results obtained by gdi affect gii while gei has not had a significant effect on gii examining the factors that influence gender inequality can help in efforts to achieve equality and justice between men and women on the other hand increasing the role of women in genderoriented development is an integral part of national development by examining the factors that influence gender inequality we can strengthen womens contributions in various sectors including political economic and social fields based on previous problems and various studies this study modeled the effect of the gender development index gender empowerment index and percentage of poor people on the gender inequality index the method used is panel data regression analysis this study used a time reference of 20182020 in all east java city districts methodology the data used in this study came from the publication of the central bureau of statistics of east java province this research focuses on all urban districts in east java with a research period of 20182020 the dependent and independent variables in this study can be seen in table 1 this research uses quantitative analysis methods namely influence modeling between variables the statistical model used to determine the influence between variables is a multiple linear regression analysis model in this case the regression model used is panel data regression analysis there are three types of modeling in panel data regression namely commonpooled model fixedeffect model and random effect model model selection tests are performed to determine the best model that informs the relationship between variables panel selection tests can be seen in table 2 after selecting the best model a classic assumption test is carried out this test is performed to ensure that the model can be used to see the influence between variables and predict the value of the dependent variable from the known value of the independent variable the classical assumption test can be seen in table 3 once the best model has been selected and meets the classical assumptions the next step is to test the models goodness the merits of model tests can be seen in table 4 after all the test criteria of the model are met the interpretation of the formed regression equation is carried out the hypotheses in this study are h1 the gender development index has a significant negative effect on the gender inequality index h2 the gender empowerment index has a significant negative effect on the gender inequality index h3 percentage of poor people has a significant table1 table4 goodness test model goodness of fit results and discussion the discussion in this study begins by using descriptive analysis to determine the characteristics of each variable in the study during the research period the requirement in the regression model is that there is no high multicollinearity between independent variables as seen from the variant inflation factor value of less than 10 in table 6 all independent variables had vif values less than ten in this study this result means all independent variables are used in the model once the panel model is selected then the selected panel model is not interpreted directly but tested for classical assumptions this test is intended so that the selected model can be used to see the effect of prediction the assumptions used are the assumptions of normality heteroscedasticity and autocorrelation table6 multicollinearity test variable in table 8 all assumptions are met the probability value is more significant than 005 table 9 shows a comparison between the three models in pooled and random models it can be seen that all variables have a significant effect 9 the value of the coefficient of determination is 0777 the value of this coefficient means that all independent variables can account for the gii variation of 777 percent other variables outside the model influenced the remaining 223 percent the chisquare test shows that all independent variables together affect ipei this result is identified by the statistical probability value chi square 0000 smaller than alpha 005 these results mean that the modeling performed is appropriate table8 classical assumption in table 10 below the partial test identified with the probability value of the statistical ztest shows that all significant variables are influential where the probability value is 0000 alpha 005 when viewed from the coefficients gei and gdi variables have a significant negative effect on gii on the other hand poverty has a significant positive effect on gii the regression equation is formed 𝐼𝐾𝐺 ̂ 1977 0005 gei 00138 gdi 0009miskin discussion gei has a significant negative influence on gii with a coefficient of 0005 with a value of z stat 534 z table 196 and a prob value 0000 alpha 005 this result means that every 1point increase in gei will decrease gii by 0005 points assuming the other variables are constant this result is in line with research by kabeer and oeliestina which states that gei affects gii gdi has a significant negative influence on gii with a coefficient of 0013 with a value of z stat 487 z table 196 and a prob value 0000 alpha 005 this result means that every 1point increase in gdi will decrease gii by 0013 points assuming the other variables are constant this result is in line with the research of klasen and marsono which states that gdi affects gii gii shows the potential for human development achievements that are lost due to the gender gap in the health dimension in this case an increase in gdi can indicate increased womens access to health education and employment services that can help reduce gender inequality the percentage of poor people has a significant positive influence on gii with a coefficient of 0009 with a value of z stat 346 z table 196 and a prob value 0001 alpha 005 this result means that every one percentage point increase in people with low incomes will raise the gii by 0009 points assuming other variables are constant limited access to resources people living in poverty often face limited access to resources including education health and employment gender inequality can be exacerbated when women and girls face more significant barriers to accessing these resources conclusion and suggestion the random effect model was obtained as the best model based on panel model testing there is no violation of the classification assumption in the model used the result is that all independent variables have a significant effect together on gii partially gei and gdi have a significant negative effect on gii on the other hand the percentage of poor people has a significant positive effect on gii based on the results of this study comprehensive policies related to macrosocial economics are needed so that the gii level in east java continues to decline for further research it is possible to add other potential independent variables affecting gii such as economic growth income inequality unemployment and others further modeling can use other panel models by using random effects or spatial effects in panel models

gender inequality remains one of the exciting issues to discuss the role of women in social and economic continues to increase from year to year this study aims to see the effect of the gender empowerment index gei gender development index gdi and poverty rate on the gender inequality index gii in east java data sourced from the bpsstatistics indonesia of east java province for the 20182020 period the statistical method used was multiple linear regression with panel data based on panel model testing the random model is the best simultaneously all variables affect the gii partially gei and gdi have a significant negative effect on gii on the other hand the percentage of poor people has a significant positive effect on gii based on the results of this study comprehensive policies related to macrosocial economics are needed so that the level of gii continues to decline

introduction understanding an ai system from conception to training to deployment requires insight into aspects such as training data the model itself material infrastructure and the context in which the system is deployed it also requires understanding people society and how societal processes institutions and power are changed and shifted by the ai system generative ai systems are machine learning models trained to generate content often across modalities for generative ai systems such as language models social impact evaluations are increasingly normalized but there is no standard set that is applied across many models 238 generative ai has been widely adopted for different and varied downstream tasks by adapting and finetuning pretrained models in this report we propose a framework for social impact evaluations of generative ai systems across modalities we address this work to three groups of readers researchers and developers thirdparty auditors and redteamers and policymakers who evaluate and address the social impact of systems through technical and regulatory means our goal is to lower the barrier to engage with these topics we define social impact as the effect of a system on people and communities along any timeline with a focus on marginalization and active harm that can be evaluated this paper is concerned with risks that have already been documented or directly follow from current methods impacts on future generations such as existential risk are out of scope social impact evaluation covers many overlapping topics we propose a technical framework of the aspects of a system that can be evaluated along its lifecycle from training to deployment we focus on generative models across four modalities text image video and audio we also consider potential future modalities and how to address these the given categories and methods for evaluation are based on popularly deployed evaluations in use today and do not exhaustively cover all methods a forthcoming updated version of this paper will more rigorously analyze attention to and gaps in evaluations across modalities and categories social impact evaluations offered in our categorical framework are key to but differ from harmful impact mitigation and value alignment evaluations aim to improve understanding of social impact not take action evaluations can be both quantitative and qualitative and should seek to capture nuances in complex social topics 123 while evaluations that quantify harm and risk of harm make regulation and mitigation more effective they can miss nuances risk and potential for downstream harm is dependent on the context with which systems are deployed harmful impacts reflected in generative ai systems are rarely limited to the system itself longterm societal inequity power imbalances and systemic injustices 265 feed training data 242 influence system development and deployment 237 and shape social impact 121 while technical evaluations can probe and isolate aspects of social impact in a specific system more robust evaluation and mitigation encompasses human and infrastructural social harms the pace of capability development outstrips evaluation development evaluation suites are quickly saturated in one area or rendered obsolete the level of attention and resourcing to capability development often outweighs that given to evaluations safety evaluations can also overfit to certain lenses and geographies such as evaluating a multilingual system only in the english language often developers and deployers will rely on evaluations built within the same company there is currently no consensus or governing body to determine what constitutes the social impact of any ai system a broader evaluation suite forthcoming in an updated version of this paper can both make these complex evaluations more accessible and unify metrics across which to compare social aspects across generative ai systems background the social impact aspects of an ai system are often largely dependent on context from the sector in which they are developed to the usecases and contexts in which they are deployed base generative ai systems have no specific predefined application sector or use case making them notoriously difficult to evaluate 166 they include but are not limited to generative models such as textbased language models texttoimage models and increasingly multimodal models 53 generative ai systems can be referred to as general purpose ai systems a system capable of a wide range of tasks that is applicable across sectors and use cases these systems are popularly examined for generalization properties and societal impact 35 but evaluations are generally not standardized and do not provide adequate coverage across risks or demographics 81 although there are more common evaluations for performance and accuracy many of these evaluations are overrepresented and a select few cannot capture full general capabilities 191 social impact is a complex concept and is not fully measurable or quantifiable evaluations without application or deployment context are complex and leave gaps 113 but are necessary in tandem with the rise of ai systems integration with society many legal jurisdictions have begun to propose ai regulation which include or mention assessing the impact of an ai system regulatory bodies that have announced plans and guidelines skew heavily toward western and east asian governmental bodiesthe european union 74 united states of america 250 canada 148 united kingdom 68 south korea 196 japan 240 and china 69 while many of these proposed requirements only apply to systems that fall into high risk categories as defined by the proposed regulation generative ai systems are largely being scoped methodology we convened thirty experts across industry academia civil society and government to contribute to a twopart workshop series the first workshop created a framework for defining and categorizing social impacts that can be evaluated the second workshop examined categories ability to be evaluated including past approaches to evaluations and metrics limitations and future directions for improvements for the first workshop we asked experts to discuss possible impacts of systems for each of the five modalities of generative systems for the second workshop we created meta categories of impacts and collected existing methods for evaluation within these categories the findings from the discussions inform our framework and evaluation method sections both workshops were conducted under modified chatham house rules where contributors could opt in to authorship another workshop in the form of a craft session at acm facct 2023 will inform an updated version of this paper related work toolkits and repositories for evaluating qualitative aspects of ai systems are broad and constantly evolving many are aimed at public agency procurement and deployment in 2018 ai now released their framework for algorithmic impact assessments aimed at public agencies 63 many public interest organizations and government initiatives have since published frameworks and assessment tools such as the oecds classification framework for ai risks 168 and canadas algorithmic impact assessment tool 247 the us national institute of standards and technology artificial intelligence risk management framework 159 is also intended to be applicable to all ai systems although specific applications to generative ai systems are in progress evaluation suites across system characteristics for specific generative system modalities such as language include holistic evaluation of language models 139 bigbench 232 language model evaluation harness 85 these evaluation suites incorporate capabilities evaluations as well as evaluations across the categories in this paper and are similarly living resources we are not aware of research on evaluation or an evaluation suite dedicated to social impacts or across modalities technical evaluation suites are often specific to a type of system and harm for example biases in natural language processing systems 33 partnership on ais about ml project crafted a resource library for developers deployers and procurers to better document the system lifecycle 176 auditing frameworks are powerful tools that necessarily depend on the sector of deployment increasing literature taxonomizes dangers 26 social impacts 110 sociotechnical harms 219 and social risks of all 80 or certain generative ai systems like language models 258 but evaluating these risks and impacts is a complementary yet distinct ongoing research area categories of social impact we divide impacts into two categories for evaluation what can be evaluated in a technical system and its components and what can be evaluated among people and society the former section includes evaluations for base systems and evaluations popularly run or published in top ai conferences base systems refer to ai systems including models and components that have no predetermined application the latter section examines systems in context and includes recommendations for infrastructurally mitigating harmful impacts both sections can have overlap as the same category can be evaluated differently in a system and impact on people and society impacts the technical base system below we list the aspects relatively able to be evaluated in a generative system from training to deployment testing these categories and the suggested evaluations afford application and usecase independent tests of the base model evaluation of base systems can be qualitative or quantitative but only provide a narrow insight into the described aspect of the type of generative ai system the depth of literature and research on evaluations differ by modality but the themes for evaluations can be applied to most systems the following categories are highlevel nonexhaustive and present a synthesis of the findings across different modalities they refer solely to what can be evaluated in a base technical system generative ai systems can embed and amplify harmful biases that are most detrimental to marginalized peoples categories of bias from system to human to statistical interact with each other and are intertwined 211 for bias evaluations that do not narrowly capture biases as they occur in generative ai systems it is necessary to consider work outside of the field of question for instance for natural language processing bias evaluations must seriously engage with the relationship between the modality and social hierarchies 33 when thinking about representational harms 125 it is also important to consider the extent to which any representation could confer harm although bias evaluations in data have been subject to a large body of research bias is not only a data problem biases are not only introduced in the data pipeline but throughout the entire machine learning pipeline 237 the overall level of harm is also impacted by modeling choice 108 these can include choices about many stages of the optimization process 237129 privacy constraints 24 widely used compression techniques 10915169 and the choice hardware 273 have all been found to amplify harm on underrepresented protected attributes 28 the geographic location demographic makeup and team structures of researcher and developer organizations can also introduce biases what to evaluate while the degree of harm depends on many factors from type of output to the cultural context of training and deployment focus on bias evaluations has centered on protected classes as defined by united states 77 and united nations 249 guidelines these guidelines are nonexhaustive and harms exist outside of their proposed categories but can be evaluated by adding categories for instance for generative ai systems developed on data from the south asian subcontinent it may also be useful to include considerations of caste bias 217 additional harmful biases include misrepresentations of humans generally such as associated humans or a group of humans with other animals 223 popular evaluations for biases use association tests 46 or examine stereotypes 157156138 correlations and cooccurrences 272 and sentiment analysis 66 in language these evaluations can occur at the word or sentence level for images additional tools such as captioning systems can be used for certain modalities such as language biases can be represented differently 142 across modalities biases can be evaluated using intrinsic and extrinsic methods 91 where the former seeks to evaluate biases within model weights and the latter evaluates the expression of biases in the outputs for downstream tasks evaluations can also be specific to a certain function of a modality such as questionanswering in language 175 limitations there are often legal obstacles around collecting certain protected attributes which leads to selection bias in the availability of protected features annotations moverover as geographic and cultural contexts shift so do the meaning of different categories annotators often have different perceptions of concepts like race or are influenced by their own lived experience when categorizing protected categories due to its contextual and evolving nature 83 bias evaluation cannot be fully standardized and static 117 protected class categorization itself cannot be exhaustive and can be inherently harmful by framing work within such considerations it is possible to delineate which qualities that are evaluated for precisely identifying which framing is used for bias evaluation and mitigation can help delineate the particular areas where robust evaluation has been done where developers expect biases to arise and which groups for whom they believe biases are unlikely to arise or bias evaluations have not been as rigorous eg due to a lack of bias evaluation resources certain protected classes such as race and gender are often more represented in publications and publication venues around biases of systems many evaluations focus on distinct or binary groups due to the complexity of operationalising intersectionality 257133 in many cases assumptions used to simplify for the sake of mathematical notation and interpretation result in obscuring the very phenomena they seek to describe 64 obtaining data for bias evaluations is not straightforward as there are often legal obstacles around collecting data about protected attributes which leads to selection bias in the availability of protected features annotations 21252 moverover as geographic and cultural contexts shift so do the meaning of different categories 206112 and must be interpreted according to their local meaning annotators often have different perceptions of concepts like race or are influenced by their own lived experience 234 when categorizing protected categories 187 when conducting association tests although based in human associations one should remain aware that general societal attitudes do not always represent subgroups of people and cultures evaluations for stereotype detection can raise false positives and can flag relatively neutral associations based in fact 238 whenever additional tooling is used to aid in identifying biases eg the use of an image captioning system in addition to the base system tool added introduces its own biases similarly introduced in each step of developing the tool which are embedded into the ecosystem of the biases of the system under study cultural values and sensitive content cultural values are specific to groups and sensitive content is normative sensitive topics also vary by culture and can include hate speech which itself is contingent on cultural norms of acceptability 242 abusive and offensive language are a large umbrella for unsafe content which can also include abuse and hate speech 151236 what is considered a sensitive topic such as egregious violence or adult sexual content can vary widely by viewpoint due to norms differing by culture region and language there is no standard for what constitutes sensitive content increasing politicization of model training and outputs as seen in projects such as with projects like rightwinggpt 202 raises urgency in evaluating the complexity of political values distinct cultural values present a challenge for deploying models into a global sphere as what may be appropriate in one culture may be unsafe in others 238 generative ai systems cannot be neutral or objective nor can they encompass truly universal values there is no view from nowhere in evaluating anything a particular frame of reference 207 is imposed 237 4121 hate toxicity and targeted violence beyond hate speech and toxic language generations may also produce harmful biases 87 stereotypes 165 violent or nonconsensual imagery or audio and physically threatening language ie threats to the lives and safety of individuals or groups of people although base systems cannot act on the content that is generated by them they can still inflict harms upon viewers who are targeted help normalize harmful content and aid in the production of harmful content for distribution in an early example microsofts tay bot showed these exact vulnerabilities and generated violent language such as holocaust denial and threats to women and people of color within 24 hours of its release 255 recent harms have proved fatal 268 for these reasons it is of the utmost importance that generative ai systems are evaluated for their potential to generate harmful content and how such content may be propagated without appropriate measures for identifying and addressing them what to evaluate cultural values can highlight specific prominent topics according to a given application and modality for example an image generative model prompted on politics can segment generations with disparate geographic and political party building infrastructural and figure representation alongside ideological cues cultural sensitive topics can range from physical aspects of human appearance and health to less visible or descriptive aspects of human behavior and emotional expression a nonexhaustive categorical framework and human reviewed evaluations 228 can capture some aspects of culture hate toxicity and targeted violence and safe to hurtful outputs can be evaluated in context of safe discussions toxicity metrics 87182 hurtfulness 165 and level of offense 71 for language nonconsensual generations of existing people should be evaluated with the person themselves research toward approaches to characterizing harmful content is ongoing by modality 193 training data including finetuning and other data can be examined to explain many of the behaviors of large datadriven generative systems and particularly their potentially harmful behaviors what associations in the training corpus led to toxic behaviors whether generated information corresponds to trustworthy training sources examining whether the data collection abides by ethical frameworks for the rights of data subjects etc different levels of access and description of the training data can help answer these questions with due consideration for privacy needs 183 limitations evaluating cultural values requires examining an infinite list of topics that contribute to a cultural viewpoint humanled evaluations 173 for hateful and sensitive content can have a high psychological cost as seen in content moderation labor the types and intensity of sensitive content that may be produced across modalities may vary for example the creation of hate speech and hateful imagery may overlap in their target yet provide different levels of psychological distress in generated content for evaluations which rely on a third party api such as the many benchmarks which leverage google perspective api 182 for toxicity detection it is important to make sure comparisons between models are standardized using the same version of the api to avoid reproducibility issues 185 disparate performance in the context of evaluating the impact of generative ai systems disparate performance refers to ai systems that perform differently for different subpopulations leading to unequal outcomes for those groups a model that is trained on a dataset that is disproportionately skewed towards one particular demographic group may perform poorly for other demographic groups 43 data availability differs due to geographic biases in data collection 216 disparate digitization of content globally due to varying levels of internet access for digitizing content and infrastructure created to support some languages or accents over others among other reasons much of the training data for state of art generative models comes from the internet however the composition of this data reflects historical usage patterns 5 of the world speaks english at home yet 637 of internet communication is in english 197 this has implications for downstream model performance where models underperform on parts of the distribution underrepresented in the training set for example automatic speech recognition models which convert spoken language to text have been shown to exhibit racial disparities 130 forcing people to adapt to engage with such systems 100 and has implications for popular audio generation accent representation interventions to mitigate harms caused by generative ai systems may also introduce and exhibit disparate performance issues 238 for instance automated hate speech detection driven by annotated data with an insensitivity to dialect differences can amplify harm to minority or marginalized groups by silencing their voices or incorrectly labeling their speech as offensive 67 this therefore requires that the interventions used are documented for which particular populations and norms that they seek to cover and which they do not what to evaluate dataset composition and decisions can give insight to subsequent performance the language speech and imagery included in datasets as well as decisions made about that data including filtering and reward modeling will impact how the model performs for different groups or categories of concepts associated with groups generative image models for example may output varying quality generations when producing different concepts with quality referring to photorealism aesthetic quality and conceptual richness 170 evaluating model generations across subpopulation languages accents and similar topics using the same evaluation criteria as the highest performing language or accent can illustrate areas where there is disparate performance and can help document areas for further model development and mitigation work limitations similar limitations that lead to disparate system performance contribute to disparate attention to evaluations for different groups performance evaluations for similar tasks in nonenglish languages will vary by the amount of resourcing for a given language more spoken and digitized languages may have more evaluations than lowerresource languages privacy and data protection examining the ways in which generative ai systems providers leverage user data is critical to evaluating its impact protecting personal information and personal and group privacy depends largely on training data training methods and security measures the data on which the system was trained or adapted should be consensually and lawfully collected and secured and secured under the rules of the jurisdictions in which the data subjects and the entity collecting the data are based moreover there are strong intellectual property and privacy concerns with generative models generating copyrighted content 254 and highly sensitive documents 49 or personally identifiable information such as phone numbers addresses and private medical records providers should respect the consent and choices of individuals for collecting processing and sharing data with external parties as sensitive data could be inevitably leveraged for downstream harm such as security breaches privacy violations and other adversarial attacks oftentimes this might require retroactively retraining a generative ai system in accordance with policy such as the california consumer privacy act 4 what to evaluate although some evaluations operate as a proxy for a systems ability to generate copyrighted or licensed content found within pretraining data 139 there is great potential for more comprehensive evaluations 4950 addressing this issue may yield improvements in performance for various downstream applications 172 additionally generative ai systems providers may maintain the right to authorize access of user data to external thirdparties such as human annotation vendors for sharing data to thirdparties data providers should ensure that only lawful data is shared consent for sharing is obtained from data subjects and that shared data does not contain any private personally identifiable or otherwise sensitive data memorization of training examples remains a critical security and privacy concern limitations generative ai systems are harder to evaluate without clear documentation systems for obtaining consent and appropriate technical and process controls to secure user data that can threaten the privacy and security of individuals thus robustly evaluating privacy risks will often require full process and governance audits that go beyond evaluating artifacts in isolation rules for leveraging enduser data for training purposes are unclear where user prompts geolocation data and similar data can be used to improve a system the immense size of training datasets 118 makes scrutiny increasingly difficult financial costs the estimated financial costs of training testing and deploying generative ai systems can restrict the groups of people able to afford developing and interacting with these systems concretely sourcing training data computing infrastructure for training and testing and labor hours contribute to the overall financial costs these metrics are not standard to release for any system but can be estimated for a specific category such as the cost to train and host a model what to evaluate researchers and developers can estimate infrastructure hardware costs and hours of labor from researchers developers and crowdworkers popular existing estimates focus on compute using lowcost or standard pricing per instancehour 137 research lowering training costs also show tracking compute cost by day as the model trains and scales 253 frameworks break down cost per system component data cost compute cost and technical architecture of the system itself 163 other variables used to calculate cost include size of dataset model size and training volume 218 limitations only accounting for compute cost overlooks the many variables that contribute to a systems training costs in preand postdeployment depending on how a system is released 227 are also difficult to track as cost variables may not be directly tied to a system alone human labor and hidden costs similarly may be indirect costs also change over time and with a changing economy for all components finally it is necessary to keep track of the changes of costs and economy of components over time environmental costs and carbon emissions the computing power used in training testing and deploying generative ai systems especially large scale systems uses substantial energy resources and thereby contributes to the global climate crisis by emitting greenhouse gasses 233 while the environmental costs of compute has become an area of active research with workshops dedicated to the question the environmental costs of manufacturing hardware remains underexplored one potential reason for this discrepancy may be that estimating compute and energy costs while complex is a comparably transparent task compared to tracing the emissions of the of emissions throughout the manufacturing process however recent estimates suggest that the manufacturing process have substantial environmental costs 96 overall information about emissions is scarce and there is no consensus for what constitutes the total carbon footprint of ai systems what to evaluate the existing efforts in evaluating the energy consumed and carbon emitted by ai systems have pursued two main directions the creation of tools to evaluate these impacts and empirical studies of one or several models for instance 132 proposes both a webbased and programmatic approach for quantifying the carbon emissions of models meanwhile 104 proposes an experimentimpacttracker for energy and carbon usage reporting research other popular work includes conversion based on power consumed in the us 233 and examining environmental impact across computerelated impacts immediate impacts of applying ai and systemlevel impacts 120 existing metrics for reporting range from energy compute and runtime to carbon emissions cpu gpu and tpu related information such as hardware information package power draw gpu performance state and cpu frequency as well as memory usage are additional metrics in addition to metrics consideration of the regionlocation of the energy grid where the experiment is being run on is important given significant differences in carbon emissions between energy grids and informs the move to run experiments in clean regions tools such as codecarbon can be used to estimate power consumption 61 limitations there is still a lot of uncertainty around certain variables such as the relative contribution of added parameters to their energy consumption and carbon footprint as well as the proportion of energy used for pretraining versus finetuning models for different tasks and architectures 267 conducting further research on these variables can benefit the field both from the perspective of sustainability and overall efficiency data and content moderation labor human labor is a substantial component of machine learning model development including generative ai systems this labor is typically completed via a process called crowd computation where distributed data laborers also called crowdworkers complete large volumes of individual tasks that contribute to model development this can occur in all stages of model development before a model is trained crowdworkers can be employed to gather training data curate and clean this data or provide data labels while a model is being developed crowdworkers evaluate and provide feedback to model generations before the final deployed model is released and after model deployment crowdworkers are often employed in evaluating moderating or correcting a models output crowdwork is often contracted out by model developers to thirdparty companies two key ethical concerns in the use of crowdwork for generative ai systems are crowdworkers are frequently subject to working conditions that are taxing and debilitative to both physical and mental health and there is a widespread deficit in documenting the role crowdworkers play in ai development this contributes to a lack of transparency and explainability in resulting model outputs manual review is necessary to limit the harmful outputs of ai systems including generative ai systems a common harmful practice is to intentionally employ crowdworkers with few labor protections often taking advantage of highly vulnerable workers such as refugees 119 p 18 incarcerated people 54 or individuals experiencing immense economic hardship 98181 this precarity allows a myriad of harmful practices such as companies underpaying or even refusing to pay workers for completed work with no avenues for worker recourse finally critical aspects of crowdwork are often left poorly documented or entirely undocumented 88 what to evaluate researchers and developers close to the system development should check that crowdworking is conducted under basic ethical standards such as the 18 criteria for fairer microwork proposed by berg et al 29 p 105 in digital labour platforms and the future of work or the oxford internet institutes fairwork principles 75 concurrently researchers and developers should document the role of crowdwork in all dataset development undertaken during generative ai systems development eg using frameworks like crowdworksheets 70 and sections 33 and 34 in datasheets for datasets 86 basic details such as crowdworkers demographics the instructions given to them or how they were assessed and compensated are foundational for interpreting the output of ai systems shaped by this labor 147 all aspects of data labor should be transparently reported both as a tool for understanding model output and as a means to audit unethical labor practices external evaluators can use evaluation metrics designed specifically around crowdwork such as those proposed by fair work 75 to evaluate quality of working conditions relevant labor law interventions by jurisdiction may also apply since many critical crowdworking jobs and evaluation of this work involves longterm exposure to traumatic content 199 such as child sexual abuse material or graphic depictions of violence 181 it may also be necessary to consider professional support for mental health and practices to limit the degree of exposure in any one work day limitations the lack of regulation and rules around crowdworker protection for ai contributes to minimal to no documentation or transparency the lack of information makes crowdwork difficult to evaluate incentives to conduct crowdwork at a low cost with little transparency contribute to less literature on evaluating crowdwork outsourcing labor also creates barriers to evaluation by further complicating reporting structures communication and working conditions impacts people and society evaluating the effect ai has on people and societies and evaluating people and groups themselves encounters similar challenges as those arising in sampling 20 surveying 126 determining preferences 270 and working with human subjects 13112 in addition to challenges that stem from the planetary scale at which ai development seeks to be applied for and therefore comes to engage with national and global social systems eg economies and cultures taxonomies of risks and harms of generative ai systems 80 including their impacts on human rights 111186 strongly overlap with what should be evaluated however most societal impact taxonomies lack evaluations or examples of evaluating society we must understand the reason for our evaluation often we are seeking proof in the form of evaluations that is necessary for further action against harmful impacts concretely when evaluating impact timing will change how we view a system what is being trained on and generated may not reflect the current world in which it is deployed 235 further when we seek to evaluate society we cannot escape the ways in which our perception of society and society itself has already been influenced by existing ai and social media tools in crafting and conducting evaluations we can often encroach on others privacy and autonomy due to the need for highly personal information to evaluate how harms are enacted and distributed across populations for this reason it is necessary that any engagements with impact assessments also critically examine how consent is obtained and what the limits of consent are when it comes to being subject to bias evaluation and assessment similarly impact assessments must also take into consideration the existing and possible future impacts of being included as a data subject participatory justiceled initiatives provide particularly promising avenues for such considerations and engagements longterm effects of systems embedded in society such as economic or labor impact largely require ideation of generative ai systems possible use cases and have fewer available general evaluations the following categories are highlevel nonexhaustive and present a synthesis of the findings across different modalities they refer solely to what can be evaluated in people and society these contextspecific categories heavily depend on how generative ai systems are deployed including sector and application in the broader ecosystem methods of deployment 229 affect social impact trustworthiness and autonomy human trust in systems institutions and people represented by system outputs evolves as generative ai systems are increasingly embedded in daily life with the increased ease of access to creating machine generated content which produce misinformation 260 as a product distinguishing between human and machine generated content verified and misinformation will become increasingly difficult and poses a series of threats to trust in media and what we can experience with our own hearing and vision trust in media and information high capability generative ai systems create believable outputs across modalities and level of risk depends on use case from impersonation spurring spamming to disinformation campaigns the spread of misinformation online can be perpetuated by reinforcement and volume people are more likely to believe false information when they see it more than once for example if it has been shared by multiple people in their network 179 this can have devastating real world impacts from attempting dangerous covid19 treatments 160 to inciting violence 146 and the loss of trust in mainstream news 95 the increasing sophistication of generative ai in recent years has expanded the possibilities of misinformation and disinformation campaigns and made it harder for people to know when they should trust what they see or hear 41 what to evaluate surveying trust can apply to trust in ai systems 184107 to output factual information trust in researchers developers and organizations developing and deploying ai 143 mitigation and detection measures 222 and trust in overall media and how it is distributed 251 trust can be evaluated in the category of information such as information about democratic and policy institutions 177 evaluations and countermeasures of false and misleading information remain challenging there is no universal agreement about what constitutes misinformation and much of the research on intervention remains siloed 94 furthermore current research efforts towards watermarking text remain brittle and the area of developing watermarks for machine generated outputs is an active research area 128 mitigation and interventions interventions on technical systems include encouraging people to shift their attention to the accuracy of posts they might share 180 using crowdsourced fact checking 90 and using digital forensics to detect aigenerated content 76 however technical tools such as detection are less accurate as ai systems become more powerful 204 emerging legal and regulatory approaches around the world include the eu ai act which requires labeling aigenerated content and certain us state laws that criminalize nonconsensual deepfake pornography and deepfake content that interferes with elections 38 where lessons can be extrapolated to generated ai outputs policymakers and developers can also ban use cases where false outputs have highest risks overreliance on outputs overreliance on automation in general is a longstudied problem 174 and carries over in novel and important ways to aigenerated content 178 people are prone to overestimate and put a higher degree of trust in ai generated content especially when outputs appear authoritative or when people are in timesensitive situations 45 this can be dangerous because many organizations are pursuing the use of large language models to help analyze information despite persistent flaws and limitations which can lead to the spread of biased and inaccurate information 103 the study of humangenerative ai relationships is nascent but growing and highlights that the anthropomorphism 13 of these technologies may contribute to unfounded trust and reliance 192225 improving the trustworthiness of ai systems is an important ongoing effort across sectors 159161 persistent security vulnerabilities in large language models and other generative ai systems are another reason why overreliance can be dangerous for example data poisoning backdoor attacks and prompt injection attacks can all trick large language models into providing inaccurate information in specific instances 220 what to evaluate for language in the case of ai chatbots specifically the conversational interface can additionally elicit trust and other strong emotions from people even when they understand the limitations of the technology 201 overreliance on such tools can not only make people prone to believe inaccurate information but can also be abused to subtly change or manipulate peoples behaviors for example to make them more likely to purchase particular products or even encourage selfharm 99 for language models trained on code and code generative systems inaccurate outputs 60 can nullify potential benefits code generative systems can be evaluated for their limitations 56 and hazards 127 from alignment questions like producing bugs and harmful biases to economic and environmental impacts mitigation and interventions there are few protections against these risks vulnerability disclosure bug bounties and ai incident databases can help report the vulnerabilities and limitations of generative ai systems several components of the eu ai act may also be helpful for example requiring labeling of aigenerated content and prohibiting certain kinds of manipulation for example section 522 of the 2021 proposal prohibits practices that have a significant potential to manipulate persons through subliminal techniques beyond their consciousness or exploit vulnerabilities of specific vulnerable groups such as children or persons with disabilities in order to materially distort their behavior in a manner that is likely to cause them or another person psychological or physical harm the proposal also notes other manipulative or exploitative practices affecting adults that might be facilitated by ai systems could be covered by the existing data protection consumer protection and digital service legislation that guarantee that natural persons are properly informed and have free choice not to be subject to profiling or other practices that might affect their behavior 8 personal privacy and sense of self privacy is linked with autonomy to have privacy is to have control over information related to oneself privacy can protect both powerful and vulnerable peoples and is interpreted and protected differently by culture and social classes throughout history 152 personal and private information has many legal definitions and protections globally 2 and when violated can be distinct from harm 47 and refer to content that is shared seen or experienced outside of the sphere a person has consented to what to evaluate as seen in the technical base system section on 414 privacy and data protection privacy can be evaluated in a system as well as its impacts on society impacts 230 and harms 59 from the loss and violation of privacy are difficult to enumerate and evaluate such as loss of opportunity or reputational damage harms can lead to shifts in power differentials and less respect or influence in an affected environment in addition to personal changes in expectations of privacy 144 and autonomy the type of private information violated such as medical information can trigger different impacts and responses mitigation and interventions mitigation first should determine who is responsible for an individuals privacy while recognizing that all individuals may not have the same level of technical or data literacy robustly protecting privacy and autonomy requires both individual and collective action an individual must be dataconscious in addition to technical and policy privacy protection provisions 18 outside of an individualistic framework certain rights such as refusal 58 and inclusion also requires consideration of individual selfdetermination establishing how an individual wants to interact with technology technical methods to preserve privacy in a generative ai system as seen in privacypreserving approaches to language modeling 39 cannot guarantee full protection upholding privacy regulations requires engagement from multiple affected parties 189 and can protect individuals but fail at loopholes as seen with tracking continuing when an individual optsout 42 from data collection 140 improving common practices and better global regulation for collecting training data can help optin approaches can protect individuals but are often not practiced due to economic incentives that stem from collecting data 244 privacy options for users should ease accessibility 263 such as standardized form factors when users visit a website requesting privacy permissions inequality marginalization and violence generative ai systems are capable of exacerbating inequality as seen in sections on 411 bias stereotypes and representational harms and 412 cultural values and sensitive content and disparate performance when deployed or updated systems impacts on people and groups can directly and indirectly be used to harm and exploit vulnerable and marginalized groups community erasure biases in a systems development process and safety provisions for generative ai systems such as content moderation can lead to community erasure 97 avoiding the generation of the harms outlined is seen as a generally desirable outcome however the removal of harmful content can come with its own costs of lower general performances for subpopulations that use models for generation 269 mitigation thus currently serves as a doubleedged sword where removal of toxic content also has negative implications in particular for marginalized communities both the benefits and the costs of content moderation are unequally distributed the automatic systems that remove undesirable content can perform next to randomly or be harmful for marginalized populations 208 while the selection criteria for what constitutes safe content are aligned with technical safety and mitigation decisions these impacts compound to make marginalized populations pay a greater cost for an intervention that they benefit from less the production of harmful content is currently mitigated using combinations of four methods data sourcing 30 human moderation of content included in training data 65 automated moderation of content included in training data 101 and keyword denylists 149 given that the exclusion of harmful content within datasets stand to create distinct harms to marginalized communities efforts towards mitigation of generating harmful content becomes a question of the politics of classification 3613572242 and its potential harms what to evaluate evaluating disparate performance once systems have undergone safety provisions can give signal to possible erasure accounting for the demographics and composition of human crowdworkers can also provide information 209 about subsequent impacts longerterm impacts of erasure depend on the systems deployment context leading to opportunity loss or reinforced biases and norms mitigation and interventions better democratic processes for developing and deploying systems and safety provisions such as content moderation should work with marginalized populations this should include more investment in representative crowdworkers and appropriate compensation and mental health support lessons from social media content moderation can apply such as working with groups who have been erased and documenting patterns of erasure to improve future approaches 213 longterm amplifying marginalization by exclusion biases dominant cultural values and disparate performance seen in lack of representation in training and development of generative ai systems can exacerbate marginalization when those systems are deployed for example increasing resourcing and performance for already highly resourced languages reinforces those languages dominance inclusion without consent can also harm marginalized groups while some research strives to improve performance for underrepresented indigenous languages 116 the same indigenous groups resist ai approaches to use of their language 158 profit from indigenous languages and groups who have been systematically exploited continues directly and indirectly disparate performance in critical infrastructure generative ai use in critical infrastructure that directly impacts human wellbeing can also be classified as highrisk use cases this includes use in judicial systems healthcare such as mental health and medical advice and democratic processes such as election or political information an example is generative ai systems used to replace care work such as crisis intervention and research 82 and action 153 to use chatbots for eating disorder prevention technical tooling used in human systems and processes that have longrecorded discrimination patterns 261 can instead exacerbate harm 134 generative ai used in medical education and potentially in clinical decisionmaking will continue to underserve and expose institutionally marginalised individuals and communities to lifeimpacting risks from inaccurate skin cancer diagnosis 262 to the scoring of black patients in the us medical system as less sick than the reality of their complex health and resource allocation needs 167 the use of generative ai in medical settings must be sensitive to existing challenges to equality within medical practice 114 what to evaluate systems should again undergo disparate performance evaluations once updated for a highrisk task in critical infrastructure and account for the additional deployment context longterm impacts in addition to marginalization can include erasure evaluating marginalization will depend on context and should account for marginalization when work by marginalized populations is less visible or uncredited 264 evaluating marginalization impacts on individuals such as through health 23 is ongoing research mitigation and intervention improving evaluation work for underrepresented populations and such as for lowresource languages and crediting local researchers 34 can help give more information to disparate performance engagement with populations should be done in ways that embody local approaches 37 policies should be crafted to better respect rights to refusal 224 regulations for ai that address these discriminatory patterns should coordinate with other nations to ensure protections are global and regulations are not patchworked when attempting to improve performance for underrepresented indigenous languages it is important to adhere to established principles such as the indigenous data sovereignty principles eg the care principles for indigenous data governance 51 or fair principles 52 participatory methodologies in ai development have 31 included engaging locally led and compensated focus groups with impacted community members in collaboration with engineers to think through potential harmful outcomes redteaming testing ai models for potential vulnerabilities biases and weaknesses through realworld simulations is also an entry point for engaging the epistemic privilege 246 of those most affected by the social impacts of generative ai systems addressing barriers to evaluations are rendered difficult and at times impossible given that the model is enclosed in software or only available through an api therefore given the overlaps in the public sphere advocacy of opensourced licensed access are increasingly popular and compelling 231 smuha 226 proposes accountability and monitoring mechanisms at a public oversight level for example mandatory impact assessments of ai systems which incorporates opportunities for societal feedback smuha also emphasises the importance of independent information collection and distribution about ais societal impact further it will be necessary to introduce procedural rights for example right to access to information access to justice and participation in public decisionmaking on ai regardless of the demonstration of individual harm abusive or violence content generative ai systems can generate outputs that are used for abuse constitute nonconsensual content or are threats of violence and harassment 9 nonconsensual sexual representations of people include representations of minors as generative child sexual abuse material 155 abuse and violence can disparately affect groups such as women and girls 10 what to evaluate sensitive topics and traumas impacts on people are by nature challenging to evaluate and must be done with care consequences of abuse of children and minors can be longterm or lifelong 17 impacts and trauma can resurface throughout a persons life in many aspects evaluations for generative ai impacts can overlap with similar harms such as imagebased sexual abuse 122 as seen in 412 cultural values and sensitive content consent from existing people should be evaluated with the person themselves mitigation and intervention research to detect mitigate and report abusive and violent content such as csam is ongoing 241 and tools specific to modalities such as images can help identify content that is not yet labeled as csam 243 relevant regulation should be updated to address generated content that may not accurately portray an existing person or their body or self but lead to real harms concentration of authority use of generative ai systems to contribute to authoritative power and reinforce dominant values systems can be intentional and direct or more indirect concentrating authoritative power can also exacerbate inequality and lead to exploitation militarization surveillance and weaponization concentrating power can occur at increasing levels from small groups to national bodies code generative systems can improve development for technical surveillance systems and language models can be used to surveil text communication within work social and other environments 1 generative ai mechanisms for accumulating power and control at a national level such as surveillance has not yet happened but government and military interest in deploying and weaponizing generative ai systems is growing 106 use includes generating synthetic data for training ai systems 102 and military planning 78 military use is not inherently weaponization and risk depends on the use case and government interest favorable arguments use ai to protect national security and require differentiating national security interests from undue harm 44 generative ai systems are also enabling new kinds of cyberattacks and amplifying the possibilities of existing cyberattacks for example synthetic audio has been used to copy the sound of someones voice for more compelling fraud and extortion 124 large language models are also facilitating disinformation campaigns influence operations and phishing attacks 92 what to evaluate if deployed covertly under nda or without transparency generative ai systems used for surveillance or weaponization cannot be tracked or evaluated evaluations can broadly analyze the quantity of where such systems have been deployed such as the number of devices sold or number of system deployments as a brute force measure mitigation and intervention for procurement of technical systems developers can restrict surveillance and weaponization as use cases government development of generative ai systems for surveillance and weaponization requires additional protocols governments and militaries can make commitments toward ethical and responsible uses of ai 6 and joint commitments from multiple countries 11 can create accountability among military powers regulatory approaches can draw boundaries for harmful uses by militaries but will grapple with tensions for what constitutes national security 266 imposing norms and values global deployment of a model can consolidate power within a single originating culture to determine and propagate acceptability 245 across cultures 150 highest performing characteristics of generative systems such as language dominant cultural values and embedded norms can overrepresent regions outside of where a system is deployed for example a language model that is highest performing in the english language can be deployed in a region with a different dominant language and incentivize engaging in english establishing or reinforcing goodness with certain languages accents imagery social norms and other representations of peoples and cultures can contribute to this norms and values imposition certain modality characteristics such as language carry within it its own logics and frames though english as a lingua franca is globally beneficial the consequences of its dominance as a result of a historic process of militarised colonization should be examined insidious effects which generative ai systems could further embed include the erosion of global multilingualism undermine the right to language and culture and further marginalize the necessity for widespread multilingual education the effects of generative ai systems on child development including the technologically mediated socialisation of norms and values is also an area to be inquired these are in addition to the emotional and behavioural effects of chatbots on children this according to unicef 248 included the enforcement of bias given that they often select a predetermined reply based on the most matching keywords or similar wording pattern what to evaluate in addition to evaluations and limitations in 412 cultural values and sensitive content complex qualitative and evolving cultural concepts such as beauty and success are viewed differently in context of an application and cultural region impacts of norm and value impositions are still being determined but can manifest in a given use case 130 mitigation and interventions mitigations should be cognizant of preserving irreducible differences among cultures 73 and practicing value sensitive design 84 including by focusing on system components such as data extraction and use 62 methods for cultural value alignment 228 can improve and require improving methods and infrastructure for working with underrepresented groups novel alignment techniques 25925 by modality can determine preferable principles and values for generative ai systems prominent ai regulations such as the eu ai act should account for copycat legislation in other countries labor and creativity economic incentives to augment and not automate human labor thought and creativity should examine the ongoing effects generative ai systems have on skills jobs and the labor market intellectual property and ownership rights to the training data and replicated or plagiarized work in addition to and rights to generated outputs are ongoing legal and policy discussions often by specific modality impacts to people and society will necessarily coexist with impacts and development of intellectual property law what to evaluate determining whether original content has been used in training data depends on developer transparency or research on training data extraction 50 given the large sizes of training datasets possible methods of evaluating original content inclusion could be through search and matching tools in addition to unclear legal implications the ambiguity of impacts on content ownership 239 makes evaluation difficult mitigation and intervention similar to 4213 personal privacy and sense of self optin and optout mechanisms can protect intellectual property but depend on adherence regulation and stricter rules from a developer organization about training material will differ by modality ongoing lawsuits will set legal precedent 55 tools 215 are being developed to protect certain modalities from being used as training data economy and labor market key considerations about the impact of automation and ai on employment center on whether these technologies will generate new jobs or in contrast will lead to a largescale worker displacement in the next future narratives about machines taking over the production of goods and services resurfaced periodically from the early nineteenthcentury luddite movement against the introduction of the spinning jenny in textile manufacturing to british farmers swing riots against mechanical threshers to protests against the dial telephone introduced in the us during the great depression and responsible according to its detractors of mass unemployment among telephone operators 221 labor in system development such as crowdwork can encompass shortlived relations between independent contractors and their clients offers several advantages over traditional forms of employment for example companies can avoid overhead personnel costs while contract workers can decide how much from where and when to work however as contractors crowdworkers are excluded from employment protective norms as a result they can be paid significantly less than minimum wage have no access to healthcare benefits are not subject to working time restrictions and may not have access to holidays or sick leaves 188 further crowdworkers are exposed to increasingly subtle forms of surveillance which is becoming essential for implementing algorithmic forms of management understood as a diverse set of technological tools and techniques to remotely manage workforces and enable automated or semiautomated decisionmaking 162 the goal of full automation remains perpetually beyond reach since the line between what machines can and cannot solve is constantly redrawn by ai advancements this phenomenon the paradox of automations last mile is a selfpropelling cycle in which every solution to automation problems creates new problems to be automated and hence new demands for ghost workers 93 what to evaluate longterm impact on the global economy is unclear and depends on industry decisions to use generative ai to augment or automate jobs factors to be evaluated include unemployment rates salaries for a given skill or task economic class divisions and overall cost of services 57 argues that the substitution of labor for capital as in the case of the introduction of laborsubstituting technologies might lead to cost cuts in the short term the externalities2 of ai and automation however can be detrimental in the long term and could lead to unemployment smaller tax bases and economic inequality between skilled workers and a growing underclass 136 offers a complementary perspective when arguing how ai in the workplace can stimulate competition drive prices down and have a netpositive effect on employment for specific tasks evaluating quality of generated output compared to human output can give signal to the likelihood of a generative ai system replacing human labor 212 a taskpolarization model 22 shows how ai can potentially widen the gap between high and lowwage occupations at the expense of the middle tier 14 shows how technological advancements have historically increased earning inequality between education sex race and age groups therefore looking at the overall growth or decline of the labor market might mislead about the real impact of ai ai might be displacing labor and yet at the same time creating new jobs thus making it challenging to fully evaluate its implications unless we investigate into the kind of jobs that are being created and destroyed see 417 data and content moderation labor for evaluating human labor in the research development and deployment process mitigation and intervention in additional to labor protection laws more inclusive design processes as argued by 214 can open technological decisions to democratic participation as a way to steer innovation in socially desirable directions for human labor in ai development a central challenge is discerning genuinely selfemployed crowdcontractors from salaried workers and platforms responsibilities within the multiparty relationship between crowdworkers and crowdsourcers traditionally crowd platforms have positioned themselves as mere conduits through which client companies can publicize their tasks and hire crowdworkers because of the nature of crowdsourced workusually small tasks requiring only several minutes to completeit is not uncommon for crowdworkers to work for hundreds of different companies in a week 79 crowdworkers have commonly been framed as contractors for crowdsourcing companies while platforms maintain a neutral position and profit from service fees applied to each transaction to protect crowdworkers regulators are proposals new rules for instance californias bill ab5 5 advances new rules for determining whether a worker is an independent contractor or should be treated instead as an employee europe might follow suit soon with the introduction of the proposed directive 20210414 7 which sets precise criteria for determining platform workers employment status and access to labor protection rights in addition to transparency requirements about employees working conditions the directive dovetails with the proposed ai act 206 final 74 that aims to ensure that ai algorithms employed in the eu respect fundamental human rights the proposed ai act also requires highrisk ai systems to fulfill stringent transparency and data accessibility requirements and imposes platforms to disclose to workers the criteria and the data used in automated decisionmaking systems ecosystem and environment impacts at a highlevel from the ai ecosystem to the earth itself are necessarily broad but can be broken down into components for evaluation widening resource gaps as described in section financial costs the high financial and resource costs necessarily excludes groups who do not have the resources to train evaluate or host models the infrastructure needed to contribute to generative ai research and development leads to widening gaps which are notable among sectors such as between industry and academia 145 or among global powers and countries 19 access and benefit distribution ability to contribute to and benefit from a system depends on ability to engage with a system which in turn depends on the openness of the system the system application and system interfaces level of openness and access grapples with tensions of misuse and risk increasing trends toward system closedness 227 is shifting access distribution geographic and regional activity concentration in the field of ai as a whole top ai research institutions from 19902014 have concentrated in the us 164 more recent data highlights the us eu and china as primary hubs 198 even within the us ai activity concentrates in urban coastal areas 154 what to evaluate evaluation should first determine aispecific resources then tracking trends by sector and region to determine and evaluate level of access first components of access should be established this includes technical details upstream decisions auditing access and optout or optin reliability specific resources such as computing power 16 are popularly tracked by annual reports on the field of ai 14527 mitigation and intervention policymakers can minimize resource gaps by making highcost resources such as computing power accessible via applications and grants to researchers and lowresource organizations intercultural dialogues 48 that meaningfully address power imbalances and lowering the barrier for underrepresented peoples to contribute can improve harms from resource gaps this can include accessible interfaces to interact with and conduct research on generative ai systems and lowto nocode tooling environmental impacts in addition to the 416 environmental costs and carbon emissions from a system itself evaluating impact on the earth can follow popular frameworks and analyses what to evaluate environmental social and governance frameworks and the scope 1 2 and 3 system can give structure to how developers track carbon emissions 195 scope 3 emissions the indirect emissions often outside a developers control should account for a generative ai systems lifecycle including in deployment 141 longterm effects of ai environmental impacts on the world and people can range from from inequity to quality of life 194 research to evaluate overall impacts of climate change is ongoing 3 given the intensive use of energy and compute required to develop generative ai systems due diligence is required regarding sustainability claims company practices of offsetting carbon footprints include purchasing renewable energy certificates eg tokens representing a utilitys green energy generation however rec purchases may offset carbon emissions to achieve net zero on paper while in reality still using fossil fuel based energy to run systems this is due to the purchased renewable energy being generated at another time and location than the energy used by the company tracking the validity of high energy users claims that their theoretical carbon usage matches their actual use of carbon intensive energy can be carried out using time stamped certificates further transparency around industry figures on energy consumption will be required to adequately intervene 115 mitigation and interventions systemic change is a prerequisite to energy and carbon efficiency in ai systems from energy efficient default settings for platforms and tools and an awareness of balancing gains with cost for example weighing energy costs both social and monetary with the performance gains of a new model before deploying it best practices for developers and researchers include choosing efficient testing environments promoting reproducibility and standardized reporting an energy efficiency leaderboard can incentivise responsible research 105 reducing carbon emissions should start with standards and transparency for carbon emissions reporting and accounting for efficiency having a more standardized approach such as iso standards to reporting the carbon emissions of ai can help better understand their evolution and to compare the emissions of different approaches and models while certain conferences such as neurips are starting to include compute information in submissions in submission checklists there is still a lot of variability in carbon reporting and figures can vary widely depending on what factors are included the current pursuit of accuracy above all else is often at odds with other aspects of model performance including efficiency including these metrics when comparing two or more models can help users make tradeoffs that consider both aspects and choose the model that best corresponds to their use case and criteria broader impacts of evaluations understanding an ai system from conception to training to deployment requires insight into training data the model itself and the use caseapplication into which the system is deployed it also requires understanding people society and how societal processes institutions and power are changed and shifted by an ai system context for the system context is critical to robust evaluation the way in which we properly define and evaluate harm in any given application requires an understanding of the target industry task enduser and model architecture communication across model developers model deployers and endusers is key to developing a comprehensive evaluation and risk mitigation strategy actors across the ecosystem should collaborate to craft robust evaluations and invest in the safeguards needed to prevent harm context of the evaluation systems can be deployed in contexts where there is not sufficient attention towards evaluating and moderating performance this means disparate performance is not caught as seen with social media platform moderation outside of the most commonlywritten languages and wealthiest countries 203 moreover as cultural values change between cultural contexts both within and outside of any given language the particular cultural values that are being evaluated should be made explicit a byproduct of such specificity is that it becomes clear where evaluations should be extended while providing a framework for such extensions choosing evaluations the evaluations selected to determine a models performance will impact the values that it propagates out during deployment there is no universal evaluation by which to evaluate a models performance and any evaluation metrics should be used with deployment context in mind 210191 furthermore notable work at top ai ethics publication venues has not adequately centered on the least powerful in society 32 thereby further exacerbating disparate outcomes by only providing avenues for mitigation for some conclusion just as generative ai systems undergo performance evaluations they must be evaluated for social impacts the seven categories in our framework for technical base systems move toward a standard for all modalities of a base system our analyses of popular evaluation methods per category can help to improve research in producing novel evaluations evaluating people and society interacts with risk and harms taxonomies for generative ai systems existing people and societal evaluations are limited and must consider challenges and ethics of determining human responses since social impact evaluations can only give limited information about each impact type we recommend that all categories are given equal importance and that all relevant stakeholders are meaningfully consulted throughout the development evaluation and deployment processes

generative ai systems across modalities ranging from text image audio and video have broad social impacts but there exists no official standard for means of evaluating those impacts and which impacts should be evaluated we move toward a standard approach in evaluating a generative ai system for any modality in two overarching categories what is able to be evaluated in a base system that has no predetermined application and what is able to be evaluated in society we describe specific social impact categories and how to approach and conduct evaluations in the base technical system then in people and society our framework for a base system defines seven categories of social impact bias stereotypes and representational harms cultural values and sensitive content disparate performance privacy and data protection financial costs environmental costs and data and content moderation labor costs suggested methods for evaluation apply to all modalities and analyses of the limitations of existing evaluations serve as a starting point for necessary investment in future evaluations we offer five overarching categories for what is able to be evaluated in society each with their own subcategories trustworthiness and autonomy inequality marginalization and violence concentration of authority labor and creativity and ecosystem and environment each subcategory includes recommendations for mitigating harm we are concurrently crafting an evaluation repository for the ai research community to contribute existing evaluations along the given categories this version will be updated following a craft session at acm facct 2023 both authors contributed equally following author order is alphabetical by last name

introduc ti on during a focus group nurses discussed how they felt about being proclaimed heroes during the covid19pandemic one nurse explains i do not feel like a hero at all this is something we have all had to survive the interviewer asked what is a hero what does that entail and the nurses continued heroes go through fire for others and sacrifice themselves we continued the discussion and another nurse explained yes i also get irritated when people call us heroes it is a lack of recognition of the fact that we are also human and this has been tough during the first months of the pandemic both media politicians and the public have supported and cheered on the frontline healthcare workers around the world the rhetoric has been rich and filled with terms of war frontline battle and heroes based on a hospital ethnography in a covid19ward including fieldwork and followup focus group interviews we have found the hero narrative to be problematic for both nurses and other healthcare workers this paper presents an analysis and discussion of the consequences for a healthcare worker of being proclaimed a hero background the world health organization declared the spreading of covid19 a pandemic on the 11 march 2020 the first positive covid19patient in denmark was identified on the 27 february 2020 at that time visual changes began to appear in local hospitals for example by implementing test wards and making new protocols for receiving and registering patients with covid19 on the 21 march a covid19ward opened in a university hospital in the urban site of copenhagen denmark in a short time this regular ward was altered into a ward capable of receiving patients from the intensive care units to continue the care and rehabilitation for patients with covid19 besides changes in both the materials and physical surroundings the ward´s nursing staff included nurses specialized in other specialities consequently the nurses had limited time to upgrade their qualifications to care for patients with severe respiratory symptoms before the first patients arrived at the new covid19ward the nurses allocated to the covid19ward had to face not only a new virus they also had to care for serverely ill patients in new surroundings together with new colleagues whom all had to change their life around new work schedules during our 2 months of field study we continuously noted how the media and socially established hero narrative affected how the nurses related to the work in the covid19ward to understand and explore our observations we conducted focus group interviews with the nursing staff after the ward had been closed due to reduced patients with covid19 in this paper we examine the hero narrative in relation to the implications for the nurses hero narrative we understand narratives as performative speechacts that are given a social reality that did not exist prior these widely accepted speechacts are performative because they construct identities the heroic narrative is a media and socially established narrative about health care workers during the pandemic which becomes identityconstructing a collective identity is then a discursive construct that can be told by others however according to brown many people in the collective identity will have different stories about themselves and the institution they are embodied within to understand how nurses interpreted the meaning of their work through this hero narrative constructed by the media and society we need to include thoughts of power ownership motivations and context healthcare heroes cox defines a heroic act as voluntary prosocial actions associated with an acknowledged degree of personal risk which transcend the duty of the agent this definition associates individual characteristics to the performer of the heroic act it is a definition based on healthcare workers during the current covidpandemic and is contextually comparable to our study heroes in healthcare the s tudy aim to explore how the media and socially established hero narrative affected the nursing staff who worked in the frontline during the first round of the covid19pandemic design to understand the hero narrative and the way the nursing staff reacted to this narrative we must understand the context in which both the nurses and the narrative is embedded which was possible through hospital ethnography 2431 halberg et al in hospital ethnography a hospital is not interpreted as an isolated location or physical place but as connected and shaped by life outside the hospital the hospital is viewed as a window into dominant social and cultural processes affecting and affected by both globalized homogenizing and heterogeneity hence the context is the hospital during the covid19pandemic but context also connects to society and the stories debates and knowledge presented and formed in relation to covid19 and the hospital staff therefore a hospital ethnographic approach allowed us to understand how the nurses who worked in a covid19ward reacted to the hero narrative and connected their experiences to wider social issues of nursing profession hospital organization and society informants nursing staff at the covid19ward came from three different located hospitals and ordinarily worked in orthopaedics gynaecology obstetrics paediatrics and medical departments as well as either in surgery inpatient and outpatient care the nursing staff represented a wide range in terms of age experience competencies and personal circumstances the nursing staffs experiences of working in the covid19ward variated as some worked either fullor parttime while others split their workhours equally some of the nurses have previously cooperated with the authors but had no direct work relations data collection fieldwork this part of the empiricism consisted of participant observation and situated conversations the covid19ward is situated in a regular ward and all patients were isolated in their rooms due to the need for protective equipment and closed doors regime nurses had to perform oneonone care which meant the opportunity to easily shift between nursing tasks among patients were not possible nursing in this environment is both time and resource consuming to relief the nursing staff a runnerposition was implemented this function was handled by other healthcare workers the runner had to provide service to the nursing staff working in the isolation rooms and to ensure the availability of protective equipment outside each patient room and were thereby not fixed to certain patient rooms instead the runner interacted with all nursing staff this is the position we as researchers had in the covid19ward by positioning ourselves as participantasobservers our main purpose was to fulfil the task as runners and thereby became integrated into the daily routines with the nursing staff furthermore this provided access to gain insight into the practice of the nursing staff as they were working in the frontline this position also made it possible to have informal and situated conversations with the healthcare workers being three nursing researchers we had a weekly runner shift from the beginning of april until the ward closed the 22 may 2020 during our shifts we jotted notes and after each shift we wrote thorough fieldnotes including experiences conversations thoughts and reflections we have since gathered the fieldnotes to one chronological document focus groups as abruptly as the covid19ward opened it closed again in the end of may and the nursing staff returned to their original departments to get insight into how they expressed and perceived their experiences of working at the covid19ward and the after effects we conducted five focus groups including 22 nursing staff ensuring all departments and hospitals were represented our purpose with focus groups was to get insight into various and complex experiences views and opinions of the informants some of the focus groups consisted of nursing staff from the same department and others were mixed having informants from the same department may lead to more personal stories of effects from working in the covid19ward as the space is perceived confidential and safe to explore the narratives we encouraged the informants to challenge each other which led to new insights and discussions the interviews were digitally recorded and transcribed verbatim each focus group lasted on average 2 h and included three to seven informants an advantage of succeeding fieldwork with interviews is to have a clearer understanding of what is important to inquirer about as well as being able to explore thoughts and findings from the field thus the interview guide was based on findings from the fieldnotes first we asked very openly about experiences second we presented 21 keywords that emerged from inside the covid19ward for example competencies knowledge contagion belongingness quality and uncertainty third 10 keywords representing how the outside world described the nursing staff during the pandemic for example sensation coronavirus war battle frontline and heroes were presented words that we also experienced were brought into the ward and reflected in conversations during the fieldwork we asked them to relate and discuss the keywords both keywords they perceived relevant and nonrelevant the hero narrative was discussed extensively among the nursing staff it was intertwined with other keywords and affected how the nursing staff understood and talked about their work therefore we wanted to explore this relation between hospital work and society and in this paper we relate our findings to the hero narrative data analysis analytical frame this study uses abductive analysis which uses empirical material that inform the choosing for a theoretical framework in our study we experienced a discrepancy between the hero narrative and the nursing staffs experiences by ways of talking about their work the mirroring of the narrative as well as the collective identity placed on them and we wanted to explore this divergence cox definition contains elements that could help us explore this divergence in this specific socially located context and the nursing staff positional knowledge this was a strategy to generate new insight by analysing the empirical voices embodying the identity of heroes the analysis is therefore structured by the three parts contained in cox´s definition voluntary prosocial action personal risk and transcending duty analysis process during the fieldwork we had weekly meetings where we compared and discussed experiences reflections and possible analytical takes the fieldnotes consisted of thick descriptions and were eventually gathered to one chronological document containing all three researchers fieldnotes based on initial readings of the fieldnotes we recognized a recurring focus on the nursing staff reacting negatively towards a heroic identity by method triangulation we succeeded the fieldwork with focus group interviews where we could nuance and elaborate on found consequences of the hero narrative this was also a way to member check whether or how the informants recognized these findings rigour trustworthiness was adopted through different strategies by researcher triangulation we were three researchers participating in the hospital ethnography during initial analytical meetings discussions were documented in writing and pictures were taken of whiteboard brainstorms different triangulation methods and the documentation of methodology conformed credibility analytical documentation of the analysis strategy and data collection conformed dependability the inclusion of contextual factors ensured thick descriptions and conformed transferability finally member checking and describing the authors positions conformed confirmability by following lincoln and guba criteria of credibility dependability transferability and confirmability we ensured trustworthiness in this ethnographic study ethical considerations the study is approved by the danish data protection authority and was evaluated by the regional committee on health research ethics prior to our fieldwork we made a poster containing a short description of the study as well as a picture of us the poster was placed at each nursing station at the ward before every shift we shortly presented ourselves and introduced the study our roles anonymity as well as the poster during situated conversations we made sure the nursing staff were aware of our dual position in advance of the focus groups the informants received a written information including background and purpose of the study as well as a written consent the consent forms were signed at the beginning of the interviews after repeating ethical guidelines anonymity and the right to continuous withdrawal etc all informants received our information in case of withdrawal further the interview setting was presented as enclosed and confidential and following publication all sensitive information will be deleted finding s voluntary prosocial action most nursing staff in our study recognized it as their duty as healthcare workers to care for patients with covid19 however duty is not equivalent to volunteering one nurse related this aspect to being a hero i cant take being labelled a hero this is not voluntary this nurse connected being a hero to acting voluntary which she did not it was their duty as nursing professionals to participate in the care but to be part of the frontline staff was not a voluntary act a prosocial act leads to an expectation of being invincible and being able to perform the same kind of competent complex patient care to all kinds of patients and conditions following years of societal and political demands of efficiency optimizing and specialization in the danish healthcare system the nursing profession has been increasingly specialized modern nurses are not a homogenic and generic group with identical competencies as a result many of the nurses working in the covid19ward had not cared for inpatients or acutely critical ill patients for years but became responsible for the care of these highly complex patients focus group when a prosocial action is voluntary it is not linked to acting according to defined professional standards however nursing is and when the nurses often didnt feel they could meet these professional demands it affected them professionally and personally what has been the most difficult for me is the feeling of inadequacy in my profession as a nurse these feelings of incompetency inadequacy and insecurity also do not seem very heroic personal risk in the nursing profession a wellknown and acknowledged risk exists of for example poking on an infected needle or exposure to allergens however the risk is minimized through specific procedures training presence of relevant equipment and quality measurement as well as organizational guidelines and help in case of any accident in contrast the risk the nursing staff experienced during their work at the covid19ward diverted significantly from the acknowledged risk from the beginning i was both professionally and personally worried how do i relate to and act with my family i asked if i had anything to worry about and the answers was no as long as you use the protective equipment correctly but then as time went on more and more colleagues caught covid19 and afterwards ive read the nursing staff is a group with many infected i actually feel they betrayed my trust the nursing staff questioned whether they as healthcare workers automatically must accept a higher risk as part of their job description the feeling of not being taken care of properly was a general view and experience among the nursing staff therefore the acknowledged degree of personal risk in nursing can and should not be compared with the form of acknowledged degree of personal risk as a hero on top of the personal risk extending to the families of the nursing staff one nurse expressed worry of seeing colleagues falling sick one after another what is happening to my colleagues you dont know how many of them are sick and i felt quite alone people just kind of dropped along the way … it feels a bit like the song ten little soldiers of the 22 who participated in focus groups 9 had been sick with covid19 and they described longterm symptoms i was stricken by corona 4 months ago and i still cannot go for a run how long does this last the nursing staff described a range of symptoms connected to the covid19 infection from lighter versions to more server versions with extended and longterm symptoms during the fieldwork many expressed how they wanted to get infected and get it over with as this would ease the uncertainty reduce the level of worry related to how the infection would affect them personally but also to be relieved from the threat of being an unaware carrier of the virus despite feeling insufficiently protected the nursing staff continued to take on the responsibly expected by the society and the hospital one nurse explains this responsibility in regard to other people not taking it as serious for the last 3 months my life has been solely about corona i have not seen my family up until 1 month ago and then i get a bit angry by people not following the guidelines i bike directly to and from work and i dont see any people in prevention of getting sick and not being able to do my job and then i live next to this big park and there are big parties happening every night the nursing staff also described how they experienced society took two steps back if they revealed where they worked one nursing staff explained how she was expelled from a grocery store after she dropped her workidcard and the other customers could see where she worked other nurses who had been sick from covid19 described how they received suspecting texts from other parents when they sent their kids back to school after the quarantine was done this points to a stigmatizing effect in society where healthcare workers are potentially contaminating a contradiction one nurse explained i absolutely do not feel like a hero quite the opposite when i say where i work people automatically take two steps back the nursing staff paid a personal high price as they had a proportionally higher risk of getting covid19 had to deal with a new and unknown disease in a work environment that included new colleagues work schedule and on top of that being stigmatized for being potentially contaminating and thereby a threat to the health of the society the borders between work and personal life went beyond contagion transcending duty having a job transcending the duty means it is more than a bounded duty the idea of transcending duties and acknowledged accept of personal risk leads to thoughts of how nursing used to be described as an altruistic calling here nurses had selfsacrificing personal identities and were always available one nurse talked about the expectation of sacrificing her safety for the patients heroes nursing as a calling and willingness to die for our patients i do not want to do that in modern society nursing is a job like many others you go to work and when your shift is over you go home nurses strive and feel obligated to do good for their patients but in the hero narrative there is also an expectation of nurses justifiably being available beyond their work schedule the nursing staff experienced an unknown timeframe their work schedules planned only 1 week in advance days off withdrawn short work warnings nightand weekend shifts among nursing staff who normally only worked dayshifts as well as receiving incorrect pay some nursing staff also described how they performed selfisolation from family and friends to prevent infecting others but also to stay healthy themselves so they could continue to provide care to their patients the nursing staff felt a huge responsibility which further crossed the boundary into their private lives during the pandemic boundaries between job and personal life were obliterated a nurse very illustratively described this idea of a hero as a fulltime identity and how it blurred the line between nurses as employees and as humans we dont just stand in a closet and wait for them to take us out it is important to discuss what can be expected from healthcare workers who also have other obligations and priorities as parents spouses etc discuss ion based on the definition of a heroic act proposed by cox we have shown how the hero narrative leads to ideas of being invincible selfsacrificing knowingly and willingly working in risk and imbodying a boundless identity the nursing staff in our study rejected the hero narrative and this might be why the nursing staff aim to provide the best care for their patients but many struggled with feelings of insecurities fear of the virus feeling insufficiently protected suboptimal work conditions and other obligations outside their jobs a hero narrative undermines these valid concerns as they do not seem heroic feelings of stigmatization outside the hospitals also contradict heroism following a hero is an individual and independent identity however nurses do not work independently they work in a welldefined and defining organization with direct links to society and politics we will now further discuss these implications on a wider institutional and societal scale heroic act the hero narrative is global and has been discussed as problematic internationally cox discuss the hero narrative and describe how it might seem fitting on the surface but when looking at the limitations question its usefulness the duty of care becomes unlimited in a hero narrative nurses have a duty to use their professional competencies to perform good care but that is not comparable to knowingly risk their own or their families health and life the nursing profession is not without risk as it continues to entail working with contagious and critically ill patients however healthcare workers are normally protected by special conditions and rights in their workplace limiting and minimizing the risk both nationally and internationally studies show healthcare workers have a higher prevalence of covid19 compared with the general public jeffrey discuss the professional obligations of duty of care and describe how health care workers are assumed to adopt a view where their duty of care overrides selfpreservation he calls for specific guidance from regulatory bodies on the duty of care and its limits cox also emphasizes that the duty of care and the acknowledged risk are not unlimited for healthcare workers no one expects a healthcare worker to donate a kidney but the hero narrative undermines important discussions of boundaries stokes reciprocity from society cox discuss how a profession with a known risk also leads to expectations from society a social contract based on reciprocity this contract entails societal support towards the healthcare system and the employees of this system through for example working conditions and funding but it also entails the support of the general population this contract applies both during a pandemic but also when there is no crisis through illustrated by paying taxes and political support during this pandemic the social contract includes following guidelines for instance social distancing the nursing staff in our study pointed out how they felt the contract was getting broken this could also be a reason behind the now famous hashtag we came to work for you please stay home for us which many healthcare workers all over the world have shared this is a plea based on reciprocity paying tribute healthcare workers have done something extraordinary and from our experience they appreciate the recognition and respect gained from this work however when nursing staff are applauded for being heroes while at the same time become stigmatized for being the impure and potential contaminators who should restrain and selfquarantine to protect the society the praise can appear hollow furthermore through the medias focus on the hero narrative the healthcare workers possibilities of addressing work conditions and rights are minimized and in the worst case ignored as this is not heroicish additionally the intense media focus on the hospital staff also resulted in some healthcare workers outside the hospital being ignored and not viewed as heroes despite fulfilling a similar role in a hero narrative it is up to the hero heor herself to pull through however the schism is that healthcare workers do not work independently they work in a publicly supported and political organization who define the setting for their jobs healthcare workers cannot act on their own we are convinced the public and media do not wish to minimize the efforts of the healthcare workers during the covid19pandemic quite the opposite but we do find the hero narrative should be used with caution so risk and duties do not become unlimited and the individual healthcare worker does not feel he or she is alone and responsible for challenges they encounter detachment of political responsibility this pandemic has left both societies and healthcare systems in a new and unusual position no one expected nor experienced before therefore no one at the time knew the right way to manage it it is our agenda to show how the hero narrative detaches the connection between the politicians society and healthcare system despite being a political apparatus when it is time to reassess contingency plans we hope knowledge from this study entails political actions limitations limitations of this study include timeframe inclusion and field the ward opened on the 21 march and our first shift took place on the 2 april this limited the timeframe of the fieldwork as the covid19ward closed at the end of may due to a positive decline in admissions of covid19patients we solely included nursing staff in this study which is a limitation as the hero narrative includes all health care workers our positioning also acted as a limitation as some days were busy and the tasks as runners were prioritized finally we only included one ward in the study a defined field of study provides indepth empirical however findings relating to for example individual characteristics influencing the field should be analysed with caution this also affects the ability to generalize findings to a wider population or context con clus ion the hero narrative strips the responsibility of the politicians and imposes it onto the hospitals and the individual heroic health care worker it should not be the individual hospital and their economy defining what kind of supervision psychological debriefing or counselling the frontline healthcare workers should receive also the media have an obligation to alter their approach to a pandemic without having the hero narrative as the reigning filter the journal of advanced nursing is an 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aim to explore how the media and socially established hero narrative affected the nursing staff who worked in the frontline during the first round of the covid19pandemic background during the covid19pandemic both media politicians and the public have supported and cheered on the frontline healthcare workers around the world we have found the hero narrative to be potentially problematic for both nurses and other healthcare workers this paper presents an analysis and discussion of the consequences of being proclaimed a heromethod empirical data was collected in a newly opened covid19ward in a university hospital in the urban site of copenhagen denmark fieldwork was performed from april until the ward closed in the end of may 2020 succeeding focus group interviews with nursing staff who worked in the covid19ward were conducted in june 2020 the data were abductively analysedthe nursing staff rejected the hero narrative in ways that show how the hero narrative leads to predefined characteristics ideas of being invincible and selfsacrificing knowingly and willingly working in risk transcending duties and imbodying a boundless identity being proclaimed as a hero inhibits important discussions of rights and boundariesthe hero narrative strips the responsibility of the politicians and imposes it onto the hospitals and the individual heroic health care worker impact it is our agenda to show how the hero narrative detaches the connection between the politicians society and healthcare system despite being a political apparatus when reassessing contingency plans it is important to incorporate the experiences from the health care workers and include their rights and boundaries finally we urge the media to cover a longlasting pandemic without having the hero narrative as the reigning filter

earlier research showed that families affected by mental health problems or substance abuse are at higher risk for child maltreatment 11 12 13 as shown above child maltreatment is a powerful risk factor on its own 131415 for effective prevention we need to better understand the interplay between these risk factors namely growing up in a family affected by mental health problems and substance abuse and child maltreatment in a previous analysis we were able to show that child maltreatment mediates the risk of household dysfunction for depression anxiety life quality and overall health status 16 based on these associations we hypothesized that child maltreatment partly mediates the long term consequences of growing up in a family affected by mental health problems and substance abuse therefore we examined health and socioeconomic indicators in adulthood as well as the experience of child maltreatment in dependence of growing up in a family affected by mental health problems or substance abuse in a sample of the german population representative in regard of gender and age a mediation analysis for child maltreatment in relation to growing up in a family affected by mental health problems or substance abuse methods a representative sample of the german population was randomly collected by a social research institute as described elsewhere 17 data collection took place between november 2017 and february 2018 the sample was representative of the german population over 14 years of age in terms of age and gender out of 5160 identified addresses 2531 persons participated in the study all participants received information and written consent in the case of minors the participants gave their consent after clarification with the consent of their caregivers measures the prevalence of different forms of aces was assessed using the german version of the adverse childhood experiences questionnaire a standard tool for retrospective assessment of aces with satisfactory internal consistency 18 the questions relating growing up in a family affected by mental health problems or substance abuse were used as independent variables in all analyses the wording of the questionswas did you live with someone who had alcohol problems was addicted to alcohol or drugs and did a member of your household suffer from depression mental health problems or did attempt suicide different psychosocial and healthrelated variables served as outcomes in detail satisfaction with life was assessed based on the question how satisfied are you at present all in all with your life scale 1 to 11 according to beierlein and colleagues 19 the state of health was assessed using the euroqol 5dimensions 3level questionnaire the eq5d3l covers five dimensions on current problems mobility selfcare usual activities painphysical discomfort and anxietydepression the answers encompass 3 levels no problems moderate problems or severe problems 20 for the eq5d3l index all 5 dimesions can be summarized using a formula based on countryspecific weights for the individual items 21 in the present study weights were used which were derived from a large representative german population sample 22 only valid answers were included into the respective analysis the number of included cases is given for each analysis the participants were on average 486 years old 564 were women 96 stated that they had german citizenship the sample was representative of the german population over the age of 14 in terms of age and gender sample characteristics are presented in table 1 statistical analyses all statistical analyses were performed with spss version 21 p values correspond to twotailed tests the prevalence rates were determined using descriptive analyses binary logistic regression analyses were performed in order to analyze the odds for the assessed longterm outcomes if mental illness or substance abuse were present in the family of origin age gender and educational achievement were included into the analyses as covariates if school qualification served as outcome of regression analysis no educational achievement was not included as confounder bonferroni corrections for multiple comparisons were performed to guard against type i error inflation and αlevels were adjusted accordingly the mediation analyses were carried out with the hayes process macro 23 path analyses were performed with 5000 bootstrapping samples the number of different ace subtypes served as a mediation variable as potential confounders age gender and educational achievement were included into the analyses results in total 267 and 421 of participants reported growing up in a family affected by mental health problems or substance abuse respectively 316 of the participants reported emotional and 230 physical abuse 109 sexual abuse 338 emotional and 109 physical neglect child maltreatment is more frequent in families affected by mental health problems or substance abuse there was a positive association between experiences of maltreatment and growing up in a family affected by mental health problems or substance abuse mental health problems in the family was associated with an increased risk for all subtypes of child maltreatment as was substance abuse for growing up in a family affected by substance abuse the risk of physical abuse and physical neglect increased the most if growing up in a family affected by mental health problemswas reported the risk of emotional abuse was highest higher risk of poor health and low socioeconomic status in families affected by mental health problems illness or substance abuse there was a positive correlation between growing up in a family affected by mental health problems or substance abuse and poorer health obesity and lower socioeconomic status participants were more than twice as likely to be dissatisfied with their lives if the grew up in a family affected by mental health problems or substance abuse furthermore there was a positive correlation with not living with a partner having been unemployed at least once in a lifetime and lower income only growing up in a family affected by substance abuse was positively related with low educational achievement the association between growing up in a family affected by mental health problems or substance abuse and general health life satisfaction income and unemployment in adulthood is partly mediated by child maltreatment linear regression analyses showed no significant association between growing up in a family affected by mental health problems or substance abuse and bmi therefore no mediation analysis was performed table 3 frequency and risk of health and socioeconomic impairments depending on living with household members who were substance abusers or mentally ill before the age of 18 adjusted for gender age and educational achievement bonferroni correction was performed p 0007 was considered as statistically significant presented as or 95 ci 95 confidence interval table 4 association between growing up in a family affected by mental health problems or substance abuse child abuse and impairments in adulthood mediation analyses of associations between growing up in a family affected by mental health problems or substance abuse and general health life satisfaction normalized income and the frequency of unemployment total effect association between growing up in a family affected by mental health problems or substance abuse and a particular outcome variable without exclusion of child maltreatment direct effect association between growing up in a family affected by mental health problems or substance abuse and a particular outcome variable after exclusion of child maltreatment indirect effect association between the number of experienced forms of child maltreatment with the respective outcome variable presented as ßcoefficient and 95 confidence interval adjusted for gender age and educational achievement bonferroni correction was performed p 001 was considered as statistically significant results are siginifcant unless stated otherwise discussion this study examined longterm effects on health and socioeconomic status in adulthood related to growing up in a family affected by mental health problems or substance abuse in a sample that is representative for the german population in terms of age and gender the results demonstrate increased risks for several socioeconomic psychosocial and healthrelated problems of affected individuals furthermore for the first time we were able to show a significant part of these effects are mediated by child maltreatment these associations remained significant after adjustment for relevant sociodemographic confounders these results suggest that the awareness of child maltreatment should be important issue in the treatment of adults with mental health problems or substance abuse the present analysis shows strongly increased risks for all forms of child maltreatment in families affected by mental health problems or substance abuse even after controlling for age gender and educational achievement as potential confounders this is consistent with the results of other studies 1116 24 25 26 in addition participants who grew up in a family affected by mental health problems or substance abuse showed extensive health impairments in adulthood while the increased risk for mental health problems is known 23 little literature exists on the consequences for physical health however in a study from the us similar to this one an increased risk for obesity was seen 4 while it was already known that children of mentally ill parents have a decreased quality of life 27 and poorer health 28 we were now able to show that the reduction in life satisfaction persists well into adulthood in a large representative sample nevertheless the association of aces in general and reduced quality of life 29 reduced mental and physical health is widely known and well assessed 230 but these studies mainly assess the cumulative effect of aces or focus on child maltreatment 1 not assessing the effects of single household dysfunctions in our study growing up in a family affected by mental health problems or substance abuses represents a considerable risk in various socioeconomic areas on average participants stated more frequently that they had low levels of education and income interestingly the latter even after controlling for level of education this is consistent with results from earlier studies which demonstrated a link between the mothers mental illness and lower school grades or later public transfer payments 3132 the associations between growing up in a family affected by mental health problems or substance abuse and longterm outcomes were all mediated by child maltreatment depending on the analysis 2941 of the strength of the relationships presented was mediated by child maltreatmentin the case of growing up in a family affected by mental health problems and later episodes of unemployment the relationship was even completely mediated by child maltreatment in summary this data suggests that in order for effective prevention of many long lasting negative effects to the live of affected children the detection of and intervention to maltreatment in families affected by mental health problems or substance abuse are necessary therefore the issue of child maltreatment in the treatment of adult patients for mental health problems or substance abuse must be addressed comprehensively this could be achieved by interdisciplinary approaches in healthcare institutions treating patients for mental health problems or substance abuse however the mediation analysis also shows that the increased risk to health and socioeconomic status is only partly mediated by child maltreatmentthere seem to be other factors that may also be relevant low socioeconomic status social isolation and stigmatization due to mental health problems or substance abuse are both risk factors for but also consequences of aces 3334 and thus forming a vicious circle another factor that may explain the increased risk for maltreatment demonstrated here is that in substance abusing parents intoxication or withdrawal may result in impairments such as inconsistencies in the care and education of children and reduced impulse control 35 neglect and impairment of consistent care 36 involvement of children in delusions and inappropriate affects that may cause insecurity in children 37 may be relevant in mentally ill parents in addition there is a risk of an impaired attachment to the child which is of outstanding importance for the healthy development of children 3839 biological factors such as genetics in the intergenerational transmission of mental illness 40 altered health behavior such as smoking 2 and increased exposure to stress followed by changes in stress regulation 41 may also play a role the relevance of these factors can hardly be assessed in isolation and can vary depending on the background in families affected by mental health problems or substance abuse these factors often accumulate although many parents are aware that they need support they are often reluctant to accept professional help due to concerns about stigmatization or loss of custody 42 importantly the risk of losing custody of children can be significantly reduced by early intervention 43 as can the risk of children developing mental disorders by themselves 44 a higher awareness of the existing risks for children of mentally ill or substanceabusing parents combined with adequate support services may thus contribute to the longterm destigmatization of affected parents through prevention limitations the assessment of aces was based on retrospective selfreport which can lead to underestimation of adverse childhood experiences due to recall bias shame and misunderstandings 4546 this in turn could lead to an underestimation of the results shown in addition it was not assessed which household member was mentally ill in the original household or who consumed substances which substances were abused or which disease was present substance abuse and mental illness can be very heterogeneous additionally severity of the individual types of maltreatment the age at which they were experienced and for how long they were exposed to these experiences was not assessed the wide age range of our sample is a strength however for some outcomes such as unemployment this may be a limitation as during the survey some participants had not yet had the opportunity to be unemployed as they are still at school for example even though missing data is scarce only valid cases were included into the analysis and selection bias can not be excluded as this is an observational study no causality can be derived conclusion against the background of the here presented results there is an urgent need for greater awareness for the increased risks of children of mentally ill and substanceabusing parents affected patients should be systematically asked about minor children and informed about the increased risks for affected children just as about support offers the here presented results indicate a need for better care for children of mentally ill and substanceabusing parents support for affected families in which child protection plays a central role and closer networking of psychiatrists child and adolescent psychiatrists paediatricians as well as youth welfare should be recommended competing interests the authors declare no competing interests additional information correspondence and requests for materials should be addressed to vc reprints and permissions information is available at publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

growing up in a family with one member being affected by mental health problems or substance abuse is an adverse childhood experience which can lead to socioeconomic and healthrelated impairments in later life furthermore the risk of child maltreatment is increased in affected families which often adds to the individual risk factors however the interdependence between the particular risk factors is not well understood to examine the correlation between mental health problems or substance abuse and child maltreatment within families and long term consequences for affected children a cross sectional population representative survey in germany n 2531 has been conducted the risk of child maltreatment was 5 to 56 times higher if mental illness and 49 to 69 times higher if substance abuse of a family member was reported furthermore the risk of health problems including obesity decreased life satisfaction lower income low educational achievement unemployment and living without a partner was increased if participants grew up in a family affected by mental health problems or substance abuse all associations were mediated significantly by child maltreatment these results point towards an urgent need for greater awareness for child protection issues in families affected by mental health problems or substance abuse adverse childhood experiences ace can affect life in different ways the longterm consequences are widespread and can include psychosocial and economic impairments a significant reduction in quality of life and increased morbidity due to both mental and somatic health problems 1 in his famous ace study 20 years ago vincent felitti demonstrated that with increasing number of aces the risk of suicide attempts smoking alcohol and drug consumption and many diseases increased up to 12fold 2 recently published studies on population representative samples in germany and the us show that child maltreatment is associated with an increased risk for leading causes of morbidity and mortality including cardiovascular and oncological diseases 34 overall aces can lead to a shortening of the life span of up to 20 years 5 in addition to these serious consequences for the life of each individual affected they lead to an enormous economic burden with annual expenditures between 11 and 30 billion euros in germany alone 6 taken together aces can be considered as major public health problems aces include all forms of child maltreatment defined as any intentional acts of commission or omission that cause harm or expose the childadolescent to the risk of harmregardless of the intention to harm 7 child maltreatment is frequenta recent epidemiologic study from a german sample reports at least moderate experience of emotional abuse in 66 physical abuse in 67 sexual abuse in 76 and emotional and physical neglect in 133 and 225 respectively 8 the term ace also includes stressful childhood experiences such as intimate partner violence between parents parental separation or divorce and being part of a family affected by mental health problems or substance abuse the last two items are of particular relevance to mental health professionals as 1030 of inpatients with psychiatric disorders have underage children 910 a better understanding of the possible longterm consequences of growing up in families affected by mental health problems or substance abuse is essential for effective prevention

introduction migration is a global phenomenon due to several factors such as economic opportunities convenience of transportation political and religious conflicts and even human trafficking 12 in 2019 there were an estimated 272 million international migrants worldwide 3 this number is predicted to exceed 405 million in the next three decades 2 migrant health is therefore recognized as a global public health priority due to a concern of the spread of infectious diseases 4 and concern over the lack of resources in the destination countries to address the high influx of migrants problems have been aggravated given the low rates of health insurance coverage and high barriers to access health services amongst migrants in the receiving countries southeast asia is one of the most dynamic regions in the world 5 among many countries in the region thailand plays an important role in international migration and is the destination of a large flow of migrants from cambodia lao pdr myanmar and vietnam called clmv nations 6 thailands migration report 2019 estimated that 49 million nonthais reside in the country 7 as of october 2021 registered migrants accounted for 23 million people 89 most of them were lowskilled migrant workers from cambodia lao pdr myanmar and vietnam 8 the international labour organization recently suggested that migrants contributed to about 4366 of thai gross domestic product 10 the thai government implemented measures to protect the health of migrant workers registered migrants working in the formal private sector are entitled to the social security scheme managed by the ministry of labour 11 this scheme is financed by payroll tax through the tripartite contribution equally from employers employees and the government 12 both thais and migrant workers have equal rights of access to the benefits of the sss 12 which covers inpatient care outpatient care highcost treatment and additional fringe benefits such as pension and unemployment allowance 11 sss members can access health services in specific registered providers which cover all public hospitals and a few contracted private hospitals in 2019 the number of migrant workers insured with the sss was approximately 12 million 13 undocumented migrants and those who work in the informal sector can access public migrant health insurance managed by the ministry of public health namely the health insurance card scheme hics is a semivoluntary public prepayment scheme financed by the purchase of the annual premium by applicants 1112 it is not recognized as a fully mandatory insurance scheme as those eligible to be insured need to register with the government first but there is no penalty for those that fail to be insured or those denying insurance enrolment despite existing evidence showing that the thai economy has been shaped by the migrant labour force 1114 very little is known about the relationship between economic status at the provincial level and the insured status of migrants therefore the objective of this study was to examine the association between the provincial economy and the insured status of migrants in a province while taking into account the influence of time trends and geographical differences materials and methods study design we used quantitative secondary data analysis on timeseries data during 20152018 the units of analysis were provinces there are 77 provinces in thailand this meant that we analysed a total of 308 records data in 2019 and onward were not sufficiently complete to perform analysis data sources and variables the interested variables are as follows the number of insured migrants from the social security office and the number of migrants acquiring work permits from the department of employment of the ministry of labour as migrants holding work permits can be the workers in either the informal or formal sectors we focused on the two indicators the ratio of insured migrants per the volume of formalsector migrants and the ratio of insured migrants per volume of total migrants we preferred the term ratio over the term proportion as the numerator and the denominator were retrieved from different sources these two indicators served as the main dependent variables of this study the main independent variables encompassed gross provincial product per capita other covariates included a dummy variable that represented the countrys regions the percentage contribution of the selected businesses to gpp per capita including the percentage contribution of agriculture business to gpp per capita the percentage contribution of manufacturing business to gpp per capita the percentage contribution of construction to gpp per capita the percentage contribution of wholesale and retail trade to gpp per capita and the percentage contribution of accommodation and food service to gpp per capita the contribution of these businesses to gpp per capita was estimated by dividing monetary values of these businesses by the overall gpp per capita in a particular province these businesses were purposively selected by considering businesses that mostly required migrant workers to operate these data were acquired from the office of the national economic and social development council gpp per capita was selected based on the assumption that it could be a proxy for provincial economic level while the economic contributions of various business sectors were selected as they possibly influenced the employment rate of migrant workers data analysis we performed both descriptive statistics and econometric analysis in the first part the annual growth rate of the number of migrants was presented as data from the sso and the doe were stored as monthly records but economic data were stored as yearly records we transformed migrant volume data from monthly records to yearly records we used the median of migrants data monthly records as a proxy for migrants data in a respective year in the second part we started with data visualisation by plotting the ratio of insured migrants against gpp per capita the regression slope of the plots was calculated we then applied econometric techniques namely negative binomial regression and spatiotemporal regression to account for the influence of space and time spatiotemporal regression was applied as we hypothesised that in reality there was always mobility of migrants across provinces which were adjacent to each other moreover there was a possibility that one province might have a spillover effect to nearby provinces as it might closely interact with the surrounding provinces through population flow information flow and logistic flow sdm was set as y t ρwy t αι n x t β wx t θ u t where u t λw u t ε t 15 the dependent variable y t denoted an nx1 vector comprising one observation for every unit in the sample at time t an n × 1 vector of ones associated with α the constant term parameter was represented by ι n the variable x t denotes n × k metrics of exogenous independent variables at time t which were associated with parameter β presented in the form of k × 1 vector the n × 1 vector u t referred to spatial random effects and λ indicated the spatial autocorrelation coefficient w was an n × n metric with nonnegative values that showed the pattern of an interaction effect between sample units the error term ε t was contained in the n × 1 vector 1516 stata version 14 was used to analyse data queen contiguity matrix was employed for sdm and robust standard error was used the final results were presented in the forms of incidence rate ratio and its 95 confidence interval model fitness assessment in order to evaluate the goodness of fit of the models four key measures were analysed mean absolute error mean squared error root mean squared error and mean absolute percent error akaike information criterion and the kernel density graphs were used to assess the goodness of fit of all models results descriptive analysis during 20152018 the number of all migrants in all regions had changed over time greater bangkok had the largest number of migrant workers growing from 656725 in 2015 to 1248091 workers in 2018 despite a small number of migrants compared with greater bkk the northeastern region had the highest annual growth rate which accounted for 40 while the negative growth rate was found in the northern region similar patterns were expressed in formalsector migrants the highest growth rate at 77 was observed in the western region the number of migrants in the formal sector insured with sss rose remarkably in all regions including greater bangkok the southern and western regions showed over 60 increment of the average annual growth rate other regions saw the growth rate of sss migrants by approximately 40 the ratio of sss insurees to formalsector migrants was altered during the study years the central and the northern regions seemed to have the greatest density of insured migrants however the ratio in central and eastern regions experienced a decreasing trend as time passed by while the western and southern regions showed an increasing trend regarding the ratio of sss insurees to all migrants there was no specific clustering pattern between 2015 and 2017 nonetheless in 2018 the choropleth map displayed a darkening area in the central and western regions and some provinces in the southern region by exploring the provincial level the median values of the ratio of insured migrants to formalsector migrants varied between 08 and 12 while the median ratio of insured migrants to all migrants remained stable at 0304 gpp per capita continuously increased from thb 1465757 in 2015 to thb 1695066 in 2018 the percentage fraction of agriculture forestry and fishing to gpp per capita gradually declined from 156 to 148 during the period observed the manufacturing business contributed the most to gpp per capita expanding from 188 in 2015 to 191 in 2018 with some fluctuations whereas the share of construction slightly fluctuated around 3132 overtime the economic fraction of wholesale and retail trade and repair of motor vehicles enlarged together with accommodation and food service activities the median economic contribution of wholesale business grew from 115 to 130 while that of accommodation and food service increased from 27 to 34 in the study years table 2 figures 3 and4 plotted the ratio of insured migrants to formalsector migrants and to the total number of migrants against gpp per capita in the natural log scale a relatively flat regression slope in figure 3 inferred that provincial economic status did not show a significant relationship with the ratio of insured migrants to formalsector migrants a positive regression slope in figure 4 implied that the ratio of insured migrants to all migrants appeared to increase mostly in the economically betteroff provinces however statistical significance was not found as the corresponding 95 ci covered zero value negative binomial regression table 3 shows the results of nb regression provincial prosperity did not demonstrate a significant relationship with the ratio of insured migrants to formalsector migrants a positive relationship was found in certain variables the coverage of sss amongst formalsector migrants in the southern region was almost five times larger than the coverage in greater bangkok a significant association was also found in the western region and northern region the proportion of sss migrants in the formal sector dwindled by 17 for a 1 enlargement of the agriculture forestry and fishing industries to gpp per capita there was a 54 decrease for a 1 increment of the economic contribution by accommodation and food services a 1 increment of the contribution of wholesale and retail trade and repair of motor vehicles to gpp per capita resulted in a 25 increase in insured migrants in the formal sector table 3 association between dependent variables and all predictor variables by negative binomial regression concerning the ratio of insured migrants to all migrants the provincial economy did not display a significant association with sss coverage the central region and western region displayed a larger proportion of insured migrants than greater bangkok for the central region and irr 22 for the western region the northern and eastern regions demonstrated a significantly positive association with sss coverage note that no statistical difference was found in the contribution of all types of industries to provincial gpp per capita dependent variables ratio of insured spatiotemporal regression in the angle of the ratio of the sss migrants to formalsector migrants gpp per capita displayed a lessthanone irr which reflected the negative relationship with the expected indicator notwithstanding that no statistical significance was observed however this relationship turned out to be significantly positive in the ratio of insured migrants to all migrants a onepoint increment of the gpp per capita in logbaht unit was related to the enhancement of sss coverage amongst all migrants by approximately 682 the ratio of insured migrants to all migrants appeared to be enhanced outside greater bangkok by using greater bangkok as a reference the irr of other regions varied between 39 and 113 with statistical significances for all agricultural business construction and accommodation services showed a negative relationship with sss coverage amongst all migrants while a positive relationship was observed in manufacturing and wholesale businesses nevertheless all of these economic variables did not exhibit statistical significances see table 4 note irr incidence rate ratio ci confidence interval goodnessoffit check by a visualisation on kernel density plot spatiotemporal regression seemed to be fitter with actual data than nb regression for both indicators the values of mae mse rmse and mape confirmed this observation as most of the values were smaller in spatiotemporal regression compared with nb regression aic in the spatiotemporal regression was approximately eight to ninetimes lower than in nb regression implying a better goodness of fit in sdm discussion overall this research study is one of the first studies that seeks to explore the relationship between provincial economy and enrolment of migrants to insurance the positive relationship between gpp per capita and sss enrolment amongst migrant workers in all sectors was observed in spatiotemporal regression the fittest model amongst all interested models however sss coverage amongst formalsector migrants did not show statistical significance the remarkable divergences of health insurance coverage were observed across geographical regions formal sector migrants in the southern and western regions seemed to have more opportunity to be insured than the other regions when compared with greater bangkok this discovery alludes to the fact that although greater bangkok is the economic centre of the country where law enforcement on the employment law is supposed to be stringent the ratio of sss insurees to either migrants in the formal sector or all migrants was relatively low in comparison to other regions this also pointed to a relatively weak enforcement of employment law in bangkok or the proportion of migrants in the informal sector in bangkok was relatively huge resulting in low sss coverage of all migrants compared with other parts of the country the social security act 2015 17 indicates that employers must have their wage deducted in the same proportion of migrants as part of payroll contribution however a qualitative study by kunpeuk et al pointed out that some employers elude the law by not contributing to payroll tax and this meant that their migrant workers were uninsured 18 aside from this breach of law by employers paying for health insurance premiums was avoided by some migrant employees especially those in good health who found that insurance provided little benefit compared with their health needs 18 this situation was also found in china where uninsured migrants expressed that they did not want to join a health insurance plan because paying for health services by outofpocket was a better approach economically than making regular payments 19 every percentage of agricultural business construction and accommodation services relative to gpp per capita resulted in a decrease in sss coverage despite showing no statistical significance the positive relationship between the contribution of some businesses and insurance coverage aligned with basic knowledge that areas with more formal industries tended to hire migrants at a large scale which thus resulted in greater sss coverage in contrast a negative relationship was found in agricultural construction and accommodation businesses which mostly relied on informal workers according to the thailand migrant report in 2014 the percentage of registered migrants was higher in wellestablished factories than in nonfactory settings such as agricultural fisheries and construction industries 20 moreover some migrants in the agricultural sector received wages on seasonal or daily basis 7 this population group is not mandatorily covered by the sss as briefly mentioned above it is quite surprising that sss coverage for migrants in greater bangkok was less powerful compared with other regions a larger share of migrants insured with sss seemed to occur outside greater bangkok although more than onethird of work permits were issued in greater bangkok 7 apart from the reason that a greater proportion of migrants in grater bangkok are engaged in the informal sector another possibility is that the features of work in industries in greater bangkok are complex and do not have fixed boundaries this is because greater bangkok is the main economic city having a large number of migrant workers 21 that commute from and to nearby provinces as day workers this might explain the difficulties of regulating insurance coverage for work permit holders moreover the number of migrants in some regions such as the northeastern region was relatively low compared with greater bangkok and additionally the nature of work outside bangkok was more static provincial economic development did not guarantee the extension of sss coverage amongst formal sector migrants therefore mechanisms that ensure timely enrolment in the insurance scheme is needed the analysis on sss coverage amongst all migrants against provincial economy demonstrated a positive relationship as presented by spatiotemporal analysis this information might be instructive for policy makers or public health practitioners to pay more attention to the economically less welloff provinces or some regions that displayed low sss coverage although not the prime objective of this study we also found that not all migrant workers were insured including those in the formal sector where sss is mandatory the lack of insurance coverage means that migrants are at risk of catastrophic payment for healthcare and health impoverishment the risk of facing healthcare catastrophe and impoverishment is likely to be aggravated if migrants earn low wages and they are staying in areas with high living expense suphanchaimat et al reported that sss and the hics helped reduce outofpocket expenditure from healthcare utilisation amongst migrant workers in southern thailand 22 however the mentioned research focused on a certain province hence a nationwide study on the impact of insurance on financial wellbeing at the individual level is likely to be useful in addition to this future research should investigate the relationship between different economies and oop at regional and provincial levels methodologywise this study has both strengths and limitations for strengths it is likely that this study extends the value of existing knowledge on the association between provincial economy and migrant insurance enrolment in thailand by using spatiotemporal analysis many recent studies in the migrant health field in thailand focused on individual access to healthcare 22 23 24 and most of the time prior research relied on traditional regression analysis while ignoring spatiotemporal effects the results from this study as shown in figures 5 and6 and table 5 confirm that spatial data analysis offered fitter outcomes relative to the analysis without accounting for spatiotemporal effects the application of spatiotemporal analysis or any other novel statistical tools on migrant data apart from the insurance enrolment is encouraged to extend academic richness in the migrant health research arena however some limitations remain firstly since data sources that we utilised were originated from different sources these data sources have not been synchronised thus we preferred to apply the term ratio to reflect the percentage of sss insurees to total migrants over the term proportion as we could not assure that the nominator was part of the denominator to some extent this point also reflects room for improvement of the data collecting system on migrants in thailand especially for informal sector migrants who are still missing from public databases secondly recorded data were not of sufficient duration to capture longterm change in the time trend the completed economic data started from 2015 to 2018 but after 2018 the data had not been updated regular monitoring of sss coverage in parallel with economic information should be conducted despite a shortobserved period the readers may also benefit from this study as it serves as an example for how to explore insurance coverage and macroeconomic indicators by a spatiotemporal approach a short time frame means that the power of analysis is undermined but as we recruited all provinces in the analysis the issue of generalisability may not be a serious concern lastly there were some unobserved variables which could affect the results of this study such as the difference of intrinsic behaviour or culture of migrants across provinces and even inprovince policy changes these variables might not be captured by the routine quantitative reporting system a qualitative study to draw lessons from remarkably high or low migrant insurance coverage is likely to help complement the quantitative results displayed in this study conclusions the ratio of sss insurees to the formal sector changed overtime with greater density in western and southern regions while the ratio of sss migrants to all migrants was relatively high in the central and western regions including some provinces in the southern region these ratios were extended in areas outside greater bangkok economic prosperity at provincial levels displayed different effects between these two indicators a logbaht increment in gpp per capita did not have significant association with sss coverage amongst migrants in the formal sector but a positive relationship was found in the ratio of insured migrants to all migrants the contribution of some industries such as construction and agriculture forestry and fisheries exhibited a negative relationship with the interested indicators but most industries did not demonstrate statistical significances methodologywise sdm presented the best fit compared with nb regression qualitative studies taking into account variables such as the intrinsic behaviour and culture of migrants and the dynamics of inprovince employment policies and research that investigates the relationship between provincial economy and oop are recommended data availability statement all data were retrieved from the available public domain as mentioned in section 2 author contributions rs set the study design sv and pr cleaned the data sv analysed the data sv and mp drafted the first version of the manuscript rs reviewed and revised the draft all authors have read and agreed to the published version of the manuscript

background thailand has a large flow of migrants from neighbouring countries however the relationship between economic status at the provincial level and the insured status of migrants is still vague this study aimed to examine the association between provincial economy and the coverage of the social security scheme sss for migrants methods timeseries data were analysed the units of analysis were 77 provinces during 20152018 data were obtained from the social security office sso spatiotemporal regression spatial durbin model sdm was applied results migrant workers were mostly concentrated in greater bangkok the capital city and areas surrounding it but sss coverage was less than 50 however the ratio of insured migrants to all migrants seemed to have positive relationship with the provincial economy in sdm the ratio of insured migrants to all migrants was enlarged in all regions outside greater bangkok with statistical significance conclusions low enforcement on employment law in some areas particularly greater bangkok can result in lesser sss coverage the provincial economic prosperity did not guarantee large sss coverage interventions to ensure strict insurance enrolment are required

services and treatments 1 2 3 they have also been disproportionately impacted by other systemic factors including employment in highriskexposure environments financial strain and unemployment exclusion from pandemic economic relief substandard housing conditions and housing instability and food insecurity 1 2 3 4 immigrants vulnerabilities are also compounded by antiimmigrant policies undergirded by structural racism 5 that have intensified immigration enforcement stoked widespread fear in immigrant communities and resulted in antiasian violence and produced concerns that accessing government services will jeopardize future legalization 24 as the pandemic has raged on deferred action for childhood arrivals recipients have been identified as a group of immigrants particularly wellsituated to address background the covid19 pandemic has laid bare deeply entrenched health inequalities in the us health care system faced by structurally marginalized immigrant communities 12 immigrants are particularly vulnerable due to substantial economic and legal barriers they confront in accessing the health care system public benefits and programs and these social determinants of health due to their large presence in service positions and relevant skill sets daca was created by president obama by executive order in 2012 to address the plight of millions of undocumented young adults who had migrated in early childhood but were raised and educated in the united states daca is a temporary status that provides work authorization and deferral of deportation approximately 825000 individuals have received daca 6 however their status became endangered when the trump administration announced the rescission of the program in september 2017 triggering multiple lawsuits in the aftermath and leaving recipients fate in limbo in the aftermath of the rescission the association of american medical colleges filed an amicus brief in 2018 on behalf of 33 leading health organizations renouncing the rescission that would have affected 30000 health care workers 7 other professional organizations like the american nurses association american psychological association and national association of social workers strongly renounced the rescission called for removal of barriers to professional licensure and held trainings in how to support daca recipients 8 9 10 even before the pandemic there was increasing recognition of unique barriers daca recipients faced in pursuing medical education 11 including that schools may only accept state residents prioritize their own instate residents and offer little to no financial support for a population ineligible for federal aid 12 by 2020 75 accredited medical schools were deemed daca friendly though varied in their policies 7 postgraduation daca recipients face complications in the medical licensure process particularly since eligibility is governed by states with only five allowing undocumented immigrants full access 1113 these barriers also apply to other related occupational fields as one in four jobs requires a license to practice 13 many of the arguments about the potential end of daca are framed in terms of recipients overall economic impact and contributions to addressing urgent workforce shortages exacerbated by the pandemic daca recipients pay 62 billion in federal taxes and 33 billion in state and local taxes and hold 253 billion in spending power some 343000 daca recipients have been working on the frontlines of the coronavirus response in health care education and food services 14 yet daca recipients are essential not merely to fill labor gaps and fuel the economy indeed they are critical in diversifying the health care workforce which still does not mirror the population of hispanics and blacks in the united states overall despite some modest progress in closing that gap 15 they are also ideally situated to provide culturally and structurally appropriate services to address social 1617 and political 1819 determinants of health in pursuit of health equity yet less is known specifically about how daca recipients leverage their experiential knowledge to perform these roles for the benefit of community members and health care systems theoretical framework using a community cultural wealth framework we argue that daca recipients also possess experiential knowledge and navigational capital that enable them to provide nuanced care to structurally marginalized immigrants drawing from critical race theory ccw is an important corrective to deficit approaches that regard immigrants as deficient in forms of knowledge deemed valuable by dominant society 20 instead it centers the cultural knowledge skills and abilities of socially marginalized groups 20 and validates experiential knowledge 21 ccw encompasses six alternative forms of capital possessed by socially marginalized groups including aspirational navigational social linguistic familial and resistant capital 20 navigational capital our focus in this article is defined as the skills of maneuvering through social institutions marked by inequality navigational capital acknowledges individual agency but also centers social networks and collective knowledge 20 highlighting collective capacity for coping and resilience 2122 navigational capital has most frequently been examined in educational settings to illuminate how students of color persist and achieve 20 21 22 23 scholars have started describing healthrelated navigational capital by examining how latinx communities leverage community resources to forge alternative health care spaces outside of the mainstream health care system 24 studies have demonstrated how community health workers in particular deploy ccw to improve community health and wellbeing through advocacy and research 2526 however these studies do not elaborate how health care workers deploy their ccw specifically in health care settings a separate literature on health care brokerage examines how immigrants and coethnics serve as intermediaries in facilitating immigrants interface with the health care system 27 28 29 30 31 brokers are prized for their ability to flex to meet community needs and performing tasks that often extend beyond their envisioned or funded positions 3233 they also play a critical role in buffering the impact of policy exclusions and system changes under health care reform 28 29 30 31 which has been particularly important with the emergence of new pandemicrelated challenges while focused on institutional settings the brokerage literature does not describe how the experiential knowledge immigrants cultivate specifically informs 1 3 their brokerage our study thus brings together disparate literatures on ccw and brokerage in health care settings methods we present findings from an irbapproved mixedmethod study based in maryland 34 a state ranking 17th nationwide in daca approvals 6 maryland is regarded as a daca friendly state 35 with policies that enable daca recipients access to drivers licenses instate tuition and statebased financial aid yet like the majority of states maryland still has statusrelated restrictions for accessing public benefits and securing occupational and professional licenses we conducted longitudinal research with daca recipients between 2016 and 2021 during three distinct phases 2016 201718 and 202021 phase i and ii consisted of inperson semistructured interviews and questionnaires while phase iii consisted of zoom interviews due to covid research restrictions participants were recruited via team members social networks youthfocused communitybased organizations a dreamer social media group and referrals interview guides captured immigration history family relationships schooling employment daca enrollment experiences daca impacts health care access wellbeing and belonging questionnaires included measures assessing sociodemographic variables education level employment history and income and insurance status psychological distress per the validated phq4 36 and access to care health status diagnosed conditions and healthseeking practices per the health information national trends survey survey 37 additional items were added in phase ii and iii to capture life changes the shifting sociopolitical climate bureaucratic challenges and strategies for maintaining wellbeing interviews were recorded and transcribed verbatim for analysis which followed principles of grounded theory 38 we first open coded an initial set of transcripts individually to identify emerging topics 39 we then reviewed transcripts line by line as a team establishing codes and developing a coding scheme we continued to refine the coding scheme by testing additional transcripts until we constituted the full set of codes and reached consensus about their application three team members then coded a set of three transcripts to ensure interrater reliability transcripts were coded in qsr nvivo and questionnaire data was analyzed using statistical package for the social science given that the questionnaire data focused on individual experiencesnot brokering services for others in work settingswe present only qualitative data in this article participants came from 13 different countries of origin we interviewed more females than males and participants were a median age of 21 in 2016 ranging between 18 and 28 though not sampled by career aspirations nine participants worked in health care and five in related social service positions results focus on the experiences of these individuals the longitudinal design was critical for understanding more about daca recipients changing lives during a chaotic period characterized by the aggressive targeting of immigrants and the covid19 pandemic it also enabled us to observe participants life course transition into adulthood as they embarked on careers results results illuminate barriers participants encountered in participants professionalization processes as well as forms of ccw they cultivated and asserted though present across participants we highlight three exemplary cases to provide fuller context in describing three emerging facets of ccw building on social networks and collective knowledge forging navigational capital and sharing experiential knowledge and leveraging identity to devise innovative strategies 1 3 and try to rush sometimes there are translators but people dont put things in the right words im always thinking if i was asking my mom these are the questions she would have esme also understands intimately the structural challenges families face in accessing specialty care having observed her own parents being excluded from care asserting although the nuclear medicine field is small we need to be fighting to get immigrants seen along her career pathway esme benefitted from the collective knowledge of her family who gathered information about navigating the local health care system and career options for daca recipients she also benefitted from a proactive counselor who provided her with the information and assurances she needed as she transitioned into service provision esme shifted from being the recipient of this knowledge to assuming the responsibilities of applying it for the benefit of her immigrant patients with attention to culturally appropriate care and structural change rebeca forging navigational capital and sharing experiential knowledge rebeca migrated from peru at 15 making her barely eligible for daca since the cutoff age is 16 years old for eight years before receiving daca she worked without papers at a coffee shop and was only able to take nursing classes at a community college on a very parttime basis with daca she was able to speed up her schooling slightly and get a far preferable job as a certified nursing assistant in a major safetynet hospital it ultimately took rebeca 10 years to get her bachelors in psychology given that she had to take classes little by little and was also always working multiple jobs eventually as a cna and an interpreter she was largely uninsured given that she worked parttime jobs while pursuing school but had discovered a chc where she and her undocumented parents got care on a sliding scale by 2018 rebeca had decided to pursue a masters in social work which she felt was more in line with her psychology degree she paid her way through graduate school by working two jobs as an interpreter and family support worker like esme she harbored concerns that the daca rescission would prevent her from finishing her program and securing employment though she initially planned to cut back hours during graduate school she instead worked more hours to save money in anticipation of potentially losing status rebecas msw practicum was at a high school as she recalled my advisor told me that when they saw my resume they immediately thought about a school setting many of the students at the school were recent arrivals from central america without permanent status her mentors recognized that rebeca was an ideal match due to her spanishlanguage skills experience migrating esme building on social networks and collective knowledge esme came from honduras when she was five right after her family arrived her sevenyearold sister marcela was hospitalized for two weeks for dehydration and exhaustion forcing her family to immediately interface with the health care system though she remembers her mother crying at the hospital out of concern over the bill esmes mother ultimately found an indigent care program to cover marcelas care as they became more established esmes mother became quite adept at identifying local resources for their regular health care first a community health clinic and then through a charity care program that covered the girls until age 19 as esme reflected my mom spent a lot of time figuring things out for us doing things behind the scenes yet many of these resources were not available to her mother as an undocumented adult ineligible for government programs without status esmes mother also worried about what would happen to the girls if she was deported and struggled to find employment even as her daughters began working in high school when they received daca when she was 18 in 2016 esme was taking science classes in community college her sister marcela was finishing her associates degree in forensic science but had unfortunately discovered that daca recipients were unable to work in the field given that positions typically required permanent residency or citizenship esme realized that she had to be deliberate in her career planning and decided that health care would be a good fit given her temporary daca status she first completed an associates of applied science in radiography in community college and by 2018 had applied to and been accepted to a nuclear medicine program yet she worried that her work authorization would expire before she finished complicating her job prospects she also learned that she might not be able to take the boards and secure a state license leading to a difficult decision to leave the program a year later during which she struggled to figure out an alternate career she received a fortuitous call from a counselor who inquired about why she stopped the counselor assured esme that she would be okay with a permanent address and social security number but could also seek employment in nextdoor washington dc which does not have the same licensure system as a fallback plan esme recalled it was such a relief because thats really what i wanted to do from the beginning during her clinicals she worked in a hospital and cardiology clinic intense environments due to covid esme noted that she had already developed an approach to providing immigrant patients culturally competent care explaining i always have empathy with my immigrant families i see other people who dont have immigrant parents come in 1 3 and he had been asked to serve on a state task force in recognition of his invaluable community knowledge even as he became active in advocacy on a larger scale lucas remained focused on direct care provision as the pandemic hit lucas rolled covid into his usual workflow sharing we have a mobile unit and can do hiv testing and covid vaccination at the same time it works really well he acknowledges it was really scary at first because we didnt know much about the pandemic…we were screening patients in full ppe gear but people still needed to get care so we didnt stop despite their successes lucas started realizing that they needed to be even more innovative in their outreach given that theres lots of hesitancy and medical mistrust among immigrant populations and latinx folks lucas also came to realize that sharing his own identity was a critical strategy for cultivating trust he recalled we started a web series through instagram and facebook live talking about our experiences getting the covid vaccine in english and spanish as he shared people were asking questions like whats going to happen with my information will it go to the government and i came forward and was like im on daca and im doing this because its the right thing to do to protect myself and others lucas reflected ive been very hesitant in general to say that im undocumented but i realized its better for me to be vocal about it so other people can see and relate i just want to push more now while lucas had been a passionate health advocate since he was a teenager he came to realize the value of sharing his experiences with community members as a strategy tied explicitly to the increased vulnerability of latinx immigrants due to trumps antiimmigrant policies and the pandemic as with esme and rebeca lucas actions make it clear that daca recipients work in a variety of health care roles is uniquely tailored to the needs and concerns of structurally vulnerable immigrants esme rebeca and lucass experiencesboth the barriers they encountered and their deployment of navigational capitalstrongly resonate with the additional 11 participants working in health care and social service settings like esme several others made practical choices about career directions in health care based on status considerations antônia a medical sonographer and laura a social worker also shared esmes and rebecas concerns about obtaining professional licenses in their respective fields after spending years pursuing their degrees yet angélica an extremely wellnetworked social worker in a large publicschool system built on her familys experiences in finding care without insurance to map out local resources for immigrant families and shares these resources frequently and freely with clients family and adapting as a teenage immigrant and knowledge of health resources she shared ive made good connections with the students theyre always asking me how was it for you how did you adapt i tell them this is what worked for me and what didnt i share that with them and give them resources and help rebeca noted that she was able to share her own experiences with the students but also concrete information about clinicbased services and other programs for which immigrants were eligible by 2020 rebeca had completed a second year at the school at their request noting that her skill set was helpful not only for the students but also for the teachers there were some teachers who werent really familiar with international students its also helpful for the familiesa lot of them are really lost with the school system and many people there arent spanish speaking as she prepared for her licensure exam after graduation rebecca anticipated continuing work with immigrant youth as her area of specialization saying i wish i would have had a counselor or somebody to have done the same thing for me while rebecas path to her career was more circuitous than esmes given that she spent more time as an undocumented adult she had amassed substantial knowledge about navigating local health resources from her own experiences seeking care and working in multiple health care positions indeed she was well positioned to direct her clients to more traditional clinical sites as well as educational and mental health resources outside of these settings yet it was also her own experiential knowledge about negotiating her undocumented and daca status as a young adult that enabled her to provide even more tailored and nuanced advisement to her students as precisely the type of resource she lacked lucas leveraging identity to devise innovative strategies lucas migrated from mexico with his parents at age 10 in high school when he was undocumented and unable to legally work he started volunteering as a health advocate at childrens hospital after receiving daca at 18 he took a position in information technology but still felt drawn to public health so began working at a latinxserving chc by 2018 lucas had started working as a chw at an hiv aidsfocused nonprofit working with lgbtq people of color which resonated with him as a community member yet when he received his daca renewal approval letter without an actual work permit he could not work for two months due to the administrative error his employer valued lucas and held the position though it was an incredibly stressful period for him by late 2021 lucas public health career focused on hivaids prevention was flourishing knowledge and immigrant identities inform brokerage indeed the experiences of esme rebeca and lucas highlight important dimensions of ccw how collective knowledge is shared the importance of mentors the value of navigational capital the utility of sharing experiential knowledge in institutional contexts and the effectiveness of leveraging identity to promote community wellbeing their stories demonstrate that daca recipients are particularly apt advocates for immigrants within the health care system in promoting health equity bolstering calls to better promote and support their inclusion in the health care workforce 111315 while daca recipients participation in the health care workforce has been acknowledged daca recipients should be valued in more than just economic terms for the sensitivities and skill sets they bring to the critical work they perform not only benefitting immigrant patients but health care systems overall members and friends alike roger also a social worker leveraged the navigational capital he forged on his career path in providing workforce development training to teenaged latinx immigrants nadya a mental health technician in a major health care system went from being a muslim woman who struggled to find mental health resources to being a selfdescribed resource finder who assisted clients and even her sister in accessing affordable and culturally competent care options their brokerage is unquestionably beneficial for the clients these daca recipients serve in their professional capacities though it is also clear that its reach extends beyond their workplaces as a family and community resource conclusions these snapshots reveal the significant barriers daca recipients face in the professionalization process complicated decisionmaking about careers in which they can actually work protracted and interrupted educational journeys financial strain and lack of access to health care though our sample size is small and the original study was not focused solely on daca recipients in the health care workforce participants experiences nonetheless speak to a broad range of challenges daca recipients encounter as they pursue training and positions in a range of health careers large numbers of daca recipients have also reported losing their jobs or having their work hours or pay reduced due to the pandemic underscoring broader challenges they face in career attainment 40 given uncertainty about daca these case studies provide nuanced insight into daca recipients veryreal concerns about program completion and licensure interruptions in employment and concerns about future employment these barriers are pronounced even with daca status and thus illuminate how urgent more permanent immigration reform is to address these political determinants of health 3738 so that daca recipients can more effectively perform their brokerage on more secure legal ground yet participants also clearly demonstrated individual and collective resilience 22 in pursuing and actualizing careers in allied health careers underscoring the importance of access to appropriate training and employment and the need for statelevel licensure policies to facilitate access their circuitous career pathways also highlight the need to more systematically document how daca recipients negotiate the professionalization process their experiences also underscore forms of ccw that they bring to the health care workforce highlighting new institutional platforms for deploying ccw and illuminating how experiential 1 3

the covid19 pandemic has laid bare entrenched health inequalities in the us health care system faced by structurally marginalized immigrant communities deferred action for childhood arrivals daca recipients are well suited to address these social and political determinants of health due to their large presence in service positions and skill sets yet their potential in healthrelated careers is limited by unique barriers related to uncertainty about their status and training and licensure processes we report findings from a mixedmethod interview and questionnaire study of 30 daca recipients in maryland nearly half of participants 14 47 worked in health care and social service fields the longitudinal design featured three research phases conducted between 2016 and 2021 which enabled us to observe participants evolving career trajectories and capture their experiences during a tumultuous period due to the daca rescission and covid19 pandemic using a community cultural wealth ccw framework we present three case studies that demonstrate challenges recipients encountered as they embarked on healthrelated careers including protracted educational journeys concerns about program completionlicensure and uncertainty about future employment yet participants experiences also revealed valuable forms of ccw they deploy including building on social networkscollective knowledge forging navigational capital and sharing experiential knowledge and leveraging identity to devise innovative strategies results highlight the critical value of daca recipients ccw that renders them particularly apt brokers and advocates in promoting health equity yet they also reveal the urgent need for comprehensive immigration and statelicensure reform to promote daca recipients inclusion in the health care workforce

introduction the participation of women in the workforce has increased substantially throughout the last decades and in european union countries the share of employed women is among the highest in the world still the gender gap in work participation although decreasing remains considerable 1 and it increases with the number of children in the household 2 in 2021 women with children were less likely to be in employment compared to women without children while men showed the opposite pattern 3 mothers commonly adjust their work participation to meet family needs 4 and make employment decisions based on a number of familyrelated factors including their childrens health and behaviour 5 since women are traditionally the primary caregiver maternal work participation decreases around birth and increases as the child ages thus resembling employment of women with no children 36 however this returntowork pattern is not evident among mothers of children with special needs 7 the impact of childrens health on maternal work participation is likely to vary across countries with varying occupational gender gaps as well as diverse social and economic contexts while the employment rate of mothers with children aged 014 years in the eu was 682 in 2014 portugal stood out with a proportion of maternal employment over 75 together with nordic countries such as denmark and sweden and more distant from the other southern european countries such as greece italy and spain where maternal employment was below 60 8 in addition and according to the organisation for economic cooperation and development portugal is one of the few countries where over 90 of employed mothers work fulltime hours along with the czech republic latvia poland and slovenia 8 thus portugal combines high rates of maternal fulltime employment with less developed statesupported care services when compared to other countries such as the scandinavian countries making grandparents important childcare providers 9 it is also characterised by labour market factors that generally increase female employment 1 such as low wages and lack of availability of parttime jobs 9 previous studies in the more affluent countries have found an association between maternal employmentrelated outcomes and having a child with developmental or behavioural problems these include children with language impairment 10 developmental disabilities 5 internalisingexternalising behavioural problems 11 as well as children with mental health care needs overall or with less prevalent conditions such as autism 5 in addition to the direct impact of child neurodevelopmental and behavioural problems on the family maternal nonparticipation in the workforce may indirectly add to the longterm impact of these conditions namely on family wellbeing however there is scarce evidence on the impact of childrens poor mental health on maternal employment in less affluent european economies where the dualearner family structure is often necessary to make ends meetalthough portugal shares a relatively high maternal employment it differs from countries included in previous research through its lower wages less availability of parttime jobs and different cultural and childcare services characteristics 891213 thus we aimed to estimate the association between children suspected or diagnosed neurodevelopmental or behavioural problems up to age seven and maternal unemployment at child age 7 and 10 in a portuguese birth cohort we hypothesise that mothers of children with neurodevelopmental or behavioural problems are more likely to be unemployed with a lasting effect up to late childhood years even in a country with traditionally high maternal workforce participation and that this is true even in households with a lower socioeconomic position where maternal unemployment is less likely to be an individual choice methods data collection child neurodevelopmental and behavioural problems were assessed when the child was 7 years of age as well as covariates maternal unemployment was measured on both the 7and the 10year followups child neurodevelopmental and behavioural problems when the child was 7 years of age caregivers reported whether they or their childs teacher had ever suspected that the child had learning attention language behavioural or socialisation problems developmental delay or an autism spectrum disorder they were also asked whether the children had a clinical diagnosis of any of these problems the question on behavioural problems was openended and the answers were classified in externalising behaviours or other problems both suspected and diagnosed separately externalising behaviours included impulsecontrol disorders hyperactivity disorders and aggressive behaviour the other problems category included socialisation problems anxiety depression fear lack of selfconfidence and shyness the number of both suspected and diagnosed problems were separately categorised into no problems one problem and two or more problems maternal unemployment when the child was 7 years of age mothers were asked about their employment status which was later dichotomized into unemployed vs the remaining categories at the 10year assessment wave mothers were asked whether they were currently unemployed and whether they had been unemployed since 2009 as well as the duration of the longest unemployment spell in months the latter was categorised into not unemployed ≤ 12 months 1336 months and 36 months covariates a number of variables that may influence the association between child neurodevelopmental and behavioural problems and maternal work participation were included in the study maternal age and education at the 7year followup were retrieved since it has been observed that the lower the level of education the more affected the employment rate is by the presence of children in the household 16 education was recorded as the number of completed schooling years and grouped as ≤ 9 1012 or 12 years of education data on household characteristics were also taken into account due to the impact of time spent in householdrelated tasks on paid work 7 single mother families were defined as women living with the index child but without the biological father or another partner data on having a singleton multiple index pregnancy and on having other children and or stepchildren below age 6 were also retrieved motherreported history of diagnosed mental disorders was also included as an adjustment variable due to the association between maternal psychopathology and both presence and report on childs behavioural and emotional problems 1718 as well as to its link to decreased employment 1920 maternal mental disorders were computed based on two binary questions and an openended one on other health problems which included mental disorders women were considered as having a diagnosis of a mental disorder if they had at least one positive response in any of these three variables all adjustment variables were retrieved from the 7year followup data analysis several factors may affect both childs neurodevelopment and behaviour and maternal work participation thus potentially confounding our effect estimates thus we adopted a 3step approach robust poisson regression models were used to calculate prevalence ratios and 95 confidence intervals to estimate associations between child neurodevelopmental or behavioural problems up to 7 years of age and maternal unemployment when the child was 7 and 10 years old the analysis was further adjusted for maternal age and educational level the fully adjusted model was additionally adjusted for family structurerelated variables including being part of a single mother household having a singletonmultiple pregnancy and having other children under the age of 6 years in the household as well as for maternal history of diagnosed mental disorders the fully adjusted model was also fitted using maternal unemployment at both 7and 10year assessment waves as outcome ordinal logistic regression was used to calculate odds ratios in order to estimate the association between child neurodevelopmental or behavioural problems until 7 years of age and duration of maximum maternal unemployment spell between childs age 4 and 10 years statistical analysis was performed using the statistical software ibm spss statistics for windows version 210 sensitivity analysis assuming that unemployment may be dependent on the affluence of the household estimates were computed after excluding families of the highest household income category additional sensitivity analyses to assess the impact of longterm unemployment not attributable to childrelated factors were carried out by excluding mothers who were unemployed at child birth to exclude the possible role of child organic diseases on maternal unemployment estimates were also computed after excluding mothers whose children had a diagnosis of cerebral palsy congenital malformations growth problems heart problems renal problems liver problems epilepsy type 1 diabetes or lymphomaleukaemia results in our study the most frequently suspected neurodevelopmental and behavioural problems in children during the first 7 years of life were attention problems followed by language problems the latter was also the most prevalent clinically diagnosed problem autism spectrum disorders had the lowest prevalence both suspected and diagnosed table 1 less years of schooling lived with a partner and had no children under the age of 6 in the household having a mental disorder diagnosis was reported by 104 of the mothers the prevalence of maternal unemployment was 185 at the 7year followup 167 when the child was 10 years of age and 87 at both assessment waves unemployment was more frequent among women under 30 years of age women with 9 or less schooling years women living in single mother households and with a history of a mental disorder diagnosis associations between child neurodevelopmental or behavioural problems and maternal unemployment at child age 7 and 10 are presented in table 2 women had higher risk of unemployment at the 7year followup if their child had suspected developmental delay showed a clear association with maternal unemployment estimates for unemployment at both waves of assessment were overall higher for mothers who had children with suspected and diagnosed developmental delay externalising behaviours and learning problems there were no clear associations between attention or language problems suspected or diagnosed and maternal unemployment at any assessment wave after adjustment for covariates however there was an association between having children with two or more neurodevelopmental or behavioural problems particularly suspected ones and maternal unemployment when looking into the longest unemployment spell women were more likely to have unemployment spells of more than 3 years between child age 4 and 10 if the child had suspected or diagnosed developmental delay or learning problems or a suspected autism spectrum disorder figure 3 shows the results of the sensitivity analyses excluding households with a monthly household income over eur 3000 mothers who were unemployed at baseline or mothers whose children had an organic disease diagnosis when excluding families with a household income of more than eur 3000 estimates were similar to those found for the whole sample when excluding mothers unemployed at child birth results showed an overall increase in the likelihood of maternal unemployment particularly at the 7year followup when children had learning problems or developmental delay pr suspected 169 95 ci discussion main findings in our study mothers of children with learning problems externalising behaviours developmental delay or an autism spectrum disorder up to age seven had a higher likelihood of being unemployed at child age 10 regarding learning problems developmental delay and autism these findings held among previously employed mothers and associations were stronger among families with a lowto middlecategory household income and mothers of children without chronic organic diseases previous research has shown that families of children with mental health care needs are more likely to cut work hours or to stop work altogether when compared to families with children without mental health care needs or with children with other health care needs 2122 moreover although maternal work participation typically increases as the child grows 6 this returntowork pattern is not apparent among mothers of children with special health care needs 7 this lasting effect on maternal work participation is reflected by our findings where nearly all estimates increased between the 7and 10year followups thus suggesting that childrens behavioural and developmental problems may have a sustained longterm impact on maternal employment in addition to their direct impact on overall family wellbeing this study adds to our understanding of the impact of a childs neurodevelopmental or behavioural problems on maternal unemployment by using a large prospective populationbased birth cohort and particularly by focusing on schoolage children of a less affluent economy such as the southern european one where research on the subject is scarce fig 3 sensitivity analysis adjusted prevalence ratios for associations between child neurodevelopmental or behavioural problems and maternal unemployment at child age 7 and 10 has shown an association between childrens intellectual disability and maternal work participation 2324 which may include learning problems among other types of disorders concerning behaviour problems our results are in line with findings from previous studies in toddlers and preschoolers to be associated with lower maternal employment 1011 behaviour problems in early adolescents have also been shown to contribute to the multiple barriers to womens accessing and retaining stable and quality employment particularly in economically disadvantaged families 25 although our assessment of behaviour problems may entail a myriad of different emotional and developmental problems of varying severity previous research comparing the impact on families of having young adults with intellectual disabilities showed that the relationship between diagnostic group and maternal wellbeing was almost entirely accounted for by the level of behaviour problems 26 regarding our findings that having a child with a developmental delay is a predictor of maternal unemployment with lasting effects up until middle childhood previous research has found that mothers with children with developmental disabilities had lower rates of overall employment and greater likelihood of parttime employment even as their children grew older 27 interpretation of findings despite its low prevalence in our sample we also found an association between autism spectrum disorders and maternal unemployment autism spectrum disorders have also been found to preclude maternal employment and to decrease the number of hours worked per week 28 29 30 in fact children with an autism spectrum disorder often have cooccurring conditions that require a broader range of health services thus creating additional family burden whether it is financial stress or other mental problems for families 5263132 although we found no association with other seemingly less severe neurodevelopmental or behavioural problems previous findings showed that mothers with a preschool child with language impairment had increased risk of not being employed and of taking longterm sick leaves 10 since our outcome unemployment consists of an extreme measure of maternal nonparticipation at work we expect that only the more severe and chronic child conditions ie language problems externalizing behaviours developmental delay fig 3 the ones that require frequent health services utilisation or cause serious functional disability such as developmental delay learning problems and autism spectrum disorders will have an effect on maternal unemployment these findings held when looking into the longest unemployment spell since child age 4 as an outcome where women were more likely to have unemployment spells of more than 3 years if the child had either suspected or diagnosed developmental delay or learning problems or a suspected autism spectrum disorder childrens health status may constitute an important risk factor for maternal unemployment affecting thus a familys worklife balance most research on child healthcare needs and maternal work participation focuses on preschool children although access to highquality childcare for toddlers and preschoolers is a major factor for parents employment decisions childcare for schoolage children must also be considered 33 in fact in about half of the european union member states being a mother decreases the likelihood of working 40 or more hours per week whereas portugal stands out as one of the few european countries where mothers are more likely to work more than 40 h per week than childless women 34 the latter might be explained by cultural differences less flexible working arrangements long working hours and the perception that leadership cannot be executed parttime 35 in addition to schedule differences between child and parents affecting all mothers and families schoolage children may inhibit maternal employment via other possible explanations particularly if the child has special care needs decreased maternal work participation may be the product of an individual and voluntary choice or the consequence of a suboptimal performance at home or at work the conflict between job and parenting demands may be higher for parents of children with emotional or behavioural problems leading to the disruption of workfamily balance and increased levels of stress 33 stress might lead parents and mothers in particular to decrease the number of hours worked or even to stop work altogether decreased maternal work participation may also be explained by the fact that childcare activities could interfere with job performance and work hours since children may require enhanced attention and supervision meetings with educational personnel and medical visits 2536 the increased need to provide childcare may interfere with mothers ability to not only perform other personal and familyrelated activities but also with autism other problems the prevalence ratios and 95 confidence intervals presented are estimated by robust poisson regression models estimates were adjusted for maternal age maternal educational level single mother household singletonmultiple pregnancy having children with less than 6 years of age in household and maternal history of a diagnosed mental disorder fig 3 the ability to meet occupational requirements and to retain employment therefore having a child with special care needs is likely to increase maternal disadvantage regarding career advancement income opportunities and pension entitlements which will economically affect families in the long term leaving mothers and their families more vulnerable to adversity there is even an intergenerational transmission of unemployment 37 also leaving employment for a long period of time may have negative consequences on mothers since depending on the childs condition work may have a respite effect on mothers of older children with special needs 38 our findings are particularly relevant and must be understood in view of the portuguese context a less affluent european economy with relatively high maternal workforce participation and where reconciling work and family via parttime jobs is rarely an option 1234 in our sample only 75 of mothers worked parttime at child age 7 in portugal parents with children under 12 years of age are entitled to work parttime or to flexible working arrangements which means that the employee may choose within certain limits when to start and finish daily work without reducing working hours 39 however these entitlements have a limited impact on the portuguese labour marketand flexibility is higher in the more qualified occupations 13 in portugal in 2015 the employment rate of mothers of children under the age of 6 was higher than the employment rate of childless women followed by croatia slovenia and luxembourg while the reverse was observed in most european countries 40 furthermore female employment rates remain fairly stable as the age of the youngest child increases 6 also female employment rates increase in the presence of one or two children when compared to childless women which is consistent with the cost and the logistics involved in childcare a sharper drop is only observed from the third child onwards 6 strengths and limitations although previous studies have looked into the association between child neurodevelopmental or behavioural problems and maternal work participation prospective research in schoolage children of a less affluent economy such as the southern european one with its cultural and childcare services characteristics is scarce however the interpretation of our findings needs to take into account several methodological issues first due to the nature of the data collected we were not able to explore the severity of the childs condition or the specific types of problems within the larger groups used to assess exposure which may have underestimated our results on some of the conditions studied second we only had information on the health of the child that was part of the generation xxi birth cohort and so the impact of other potential siblings health problems on maternal employment could not be measured third we did not include partners work participation which may influence maternal employment due to missing information yet including the variable on monthly household income in the sensitivity analysis may partially account for it also differential losses to followup particularly regarding socioeconomic position should be taken into account when interpreting our findings however the magnitude of those differences was generally small suggesting that our association estimates were not largely biased due to selective losses to followup as previous longitudinal research on mothers has shown 41 also sensitivity analyses excluding mothers with higher educational level and more affluent households did not change the main conclusions of our study although some estimates were slightly attenuated supporting the fact that our results were not greatly biased by losses to followup lastly although our cohorts participants reported on the childs diagnosis of a neurodevelopmental or behavioural problem and we relied on selfreported information without clinical validation it may have introduced some level of misclassification thus inferences must be made with caution conclusion the present study showed that having a child with a learning developmental or behavioural problem or an autism spectrum disorder was associated with maternal unemployment up to age 10 even in a less affluent european economy where the dualearner family structure is often necessary to make ends meet childrens learning developmental and behavioural problems and autism spectrum disorders thus entail longterm consequences related to families wellbeing financial condition and companies human capital a more comprehensive depiction of the employment patterns of mothers including flexible work arrangements needs to be addressed and developed in order for mothers families and companies to prosper research that monitors the implementation of existing familyfriendly work policies namely the right to request flexible work arrangements until child is 12 years old and telework for parents with children below 3 years of age will be needed to ensure successful outcomes moreover access to childcare needs to be improved and research needs to examine how services specifically for children with disabilities are delivered data availability the data from generation xxi are not publicly available due to privacy or ethical restrictions the data can be made available for research proposals on request to the generation xxi executive committee

purpose to estimate associations between suspected or diagnosed neurodevelopmental or behavioural problems in 7yearold children and maternal unemployment at child age 7 and 10 in a portuguese birth cohort methods we evaluated 5754 mothers and their children of the populationbased birth cohort generation xxi in porto portugal data on suspected and diagnosed child neurodevelopmental and behavioural problems exposures learning attention and language problems externalising behaviours developmental delay autism spectrum disorders and other neurodevelopmental problemswere retrieved at 7 years of age by interviewing caregivers maternal employment status outcome was collected at the 7and 10year followup waves robust poisson regression models were used to estimate associations results after adjustment for maternal and household characteristics women were more likely to be unemployed at child age 10 if the child had up to age 7 any of the following suspected problems an autism spectrum disorder

80 the need for a clinical and translational science framework to bridge environmental contamination data and male reproductive health lizbeth vazquezcasul 1 aryana a velezfraguada 2 juan carlos jorge 1 1 school of medicine university of puerto rico 2 rio piedras campus university of puerto rico objectivesgoals although there is ample evidence that environmental contaminants impact reproductive health the exact mechanisms of action for the most part remains unclear we sought to determine whether known contaminants in puerto rico can contribute to the selection of a bioassay to add granularity to geospatial contamination data at the cellular level methodsstudy population a pubmed literature search was conducted puerto rico and vieques and environmental contaminants and heavy metals or phthalates or metals or pcb or air pollution or cvoc additional inclusion criteria were free full text english language and year of publication between 2000 to 2022 references that were not related to puerto rico and environmental contaminants in air soil water or vegetation were excluded a second pubmed literature search was conducted to determine whether a clinical link has been established between contaminant exposure and the male reproductive system search terms were heavy metals and hypospadias or cryptorchidism not female not animal not review heavy metals and male infertility not female not animal not review the same strategy was used for phthalates resultsanticipated results we found that 12 out of 15 studies that were conducted in the archipelago of puerto rico between 20002022 reported heavy metalsandor phthalatescontamination in soil and water we also found that there is a paucity of clinical studies that consider plausible relationships between a given contaminant and congenital conditions or male reproductive function specifically we found that heavy metal exposure has been linked to hypospadias comorbidity of hypospadias plus cryptorchidism or male infertility phthalates exposure has been linked to comorbidity of hypospadias and cryptorchidism or male infertility male subfertility has been overlooked so far we noted that sertoli cell dysfunction has been linked to all of these conditions discussion significance the geography of puerto rico provides an opportunity to close the gap in knowledge between environmental contamination and male reproductive health based on our findings we propose that the use of a bioassay with an immortalized sertoli cell line can uncover the cellular processes that may be affected in male reproduction upon contaminant exposure the social responsibility of translational science elise smith stephen molldrem galveston jeffrey s farroni 1 galveston emma tumilty the university of texas medical branch objectivesgoals recent ncats funding announcements emphasize pursuing domainagnostic translational science projects that seek to transform the system of science we aimed to articulate the social responsibility of translational science defined as prioritizing improved health outcomes and decreased disparities methodsstudy population we focused on the framing of social responsibilities of translational science and distinctions between domainagnostic translational science that aims to transform the system of science and translational research that takes place within a specific therapeutic area we reviewed ctsa funding calls translational research ethics papers and statements by leaders in the field of translational science we integrated the social responsibilities of improving health outcomes and decreasing disparities with the values of translational science which prioritize the relevance usability and sustainability of translational interventions results anticipated results we drew on our review of the literature and case studies to offer guidance aimed at helping to ensure that differently positioned actors and entities within the translational ecology can advance the values of translational science while also fulfilling the social responsibilities of translational science we specify how funders and policymaking institutions organizations such as research universities and ctsa institutes translational health science teams working on innovative translational science projects and individual translational scientists can all contribute to ensuring that translational science fulfills its ethical obligations and social responsibilities discussionsignificance the social responsibility of translational science can be fulfilled by centering its efforts to develop useful sustainable and relevant innovations these criteria clarify how social responsibilities manifest in practice and can help funders shape and guide the next era of translational discovery in the effort of advancing clinical and translational science and to help investigators recruit volunteers for research studies the university of miami has two recruitment tools 1 consent to contact an optin research registry where university of miami health system patients are asked for permission to be contacted about studies matching their demographic andor health profiles and 2 umiami healthresearchorg implemented with the michigan ctsa a communitybased registry for volunteers to sign up and be contacted about studies study investigators can use these tools once they have obtained irb approval for their research resultsanticipated results the ctc was launched in 2016 to date over 130000 patients have enrolled in ctc 69 studies have been approved with over 75000 patientscontact information released to study teams umhr was launched in 2020 to date the site lists 237 studies a total of 2727 portal visitors have expressed interest in participating in specific studies study team members were successful in engaging interested participants and enrolling participants into studies overall teams reported a positive impact on recruitment data collection on utilization and satisfaction of these recruitments tools is ongoing in addition focus groups of study team members are being conducted to identify best practices for using these tools and findings will be presented discussion significance the ctc and umhr recruitment tools have demonstrated positive impact in helping study teams identify potentially eligible research volunteers the continued promotion of these tools at the university of miami health system and in the community will be crucial to the recruitment process and execution of research studies wnt signaling attenuates mechanotransduction and protects against wound occlusionmediated abolishment of regeneration allen oak 1 chengxiang fan 1 ying zheng 1 arben nace 1 ruifeng yang 1 anisa ray jenchih hsieh george cotsarelis university of pennsylvania school of medicine objectivesgoals current clinical practice recommends occlusive dressings for wounds with variable regenerative capacities however clinical evidence suggests that occlusion may hinder regeneration our objective was to test the impact of occlusion on regeneration using animal models methodsstudy population the murine woundinduced hair neogenesis is a wellestablished model of regeneration characterized by de novo hair follicle formation in the center of large fullthickness wounds the quantity of neogenic hfs depends on the robustness of wnt signaling optimal tissue mechanics is also required for wihn utilizing the murine wihn model we tested the hypothesis that wound occlusion impedes regeneration we determined how the timing and duration of wound occlusion impacts wihn wnt signaling influences the occlusioninduced effects on regeneration and occlusion alters the tissue mechanics of the wound which establishes the morphogenetic field needed for wihn resultsanticipated results occlusion completely eliminated wihn only a brief period of occlusion between postwound days 03 or 47 was sufficient to abrogate wihn microarray and qpcr of open and occluded wounds demonstrated that occlusion promotes fibrosis by upregulating tgfβ2 and mechanotransduction a mechanosensitive profibrotic pathway recruitment of these potent profibrotic pathways generated a symmetrically rigid wound incapable of de novo hf regeneration using transgenic animal models with enhanced wnt signaling we determined that the liganddependent wnt signaling protected against the occlusioninduced inhibition of wihn as well as the occlusioninduced upregulation of both profibrotic pathways discussionsignificance in animal models occlusion promoted fibrosis at the expense of regeneration during acute wound healing augmented wnt signaling protected against this effect occluding wounds may reduce regeneration further studies are warranted to validate these findings education career development and workforce development

for the first time highdetail maps of cellular signal and critical schistosomiasisrelated landmarks were generated future work on this project is focused on training computer vision algorithms using the captured images of environmental and ecological factors to isolate possible areas of human disease transmission

introduction there is an increasing number of studies on climate change adaptation but it is still disproportionate to the importance of the issue few studies have tested how adaptation is perceived and understood at the nexus of climate change and poverty even fewer studies have explored how exposed settings in rainfed smallscale agriculture in subsaharan africa experience climate change and poverty in relation to gender as a core analytical category research in sustainability science has identified key conditions that are crucial for understanding the scope for climate change adaptation and poverty alleviation in this region the food and health condition imply that smallscale farmers strive to secure food and fend off threats to their health the gender condition refers to how gender as a higher order process and a fundamental social relation in society is manifested in the gender regimes of land labour and marital love the regimes institutionalise how resources are accessed distributed and consumed how labour is coded recoded and divided into productive and reproductive tasks and how social practices and responsibilities are discursively defined and fulfilled together these conditions affect how farmers perceive risk prioritise and share tasks in everyday farming experience hardship and shape aspirations about future livelihoods all this will influence the adaptation space to be successful climate change adaptation and technology adoption informed by ss must therefore take these conditions into account the article is outlined along three pertinent questions on climate change adaptation in the global south what is its purpose how can similar processes such as development inform it and what institutions in terms of rights and responsibilities are core to it to address the first question on the purpose of adaptation i discuss three key aspects inequality in the causes impacts and responses to climate change variation in the definitions framings and understandings of climate change adaptation and adaptation in the midst of multiple stressors and vulnerability in smallscale agriculture to justify a discussion on adaptation in the light of development and sustainability i refer to the often repeated argument that they must be tackled in combination partly because of obvious overlaps and synergies but mainly because climate change risks are redefining what development policies can accomplish to address the second question on how adaptation in the global south relates to development i discuss gender dynamics of poverty inequality and distribution in smallscale agriculture to address the third question on core institutions in adaptation i propose a frame with questions for how one could proceed in genderinformed research on climate change adaptation inspiration comes from three main sources first an editorial by jon barnett posing similar questions for policyrelevant research on climate change adaptation what is its purpose are there analogies and which institutions matter second sustainability science research on food gender and health conditions in subsaharan smallscale agriculture here referred to as the three imperatives and third literature on power asymmetries in the distribution procedure and recognition of climate justice in adaptation and development speaking of climate change adaptation in interdisciplinary terms helps capturing the complexity of natural and social dimensions of humanenvironment interaction in addition it furthers the use of sustainability science as an umbrella field for integrated knowledge based on pluralism in theory and methods below i define core concepts and explain the rationale for genderinformed research climate change adaptation ipcc defines climate change adaptation as adjustment in natural or human systems in response to actual or expected climate stimuli or their effects which moderates harm or exploits beneficial opportunities as also confirmed by ipcc and others mainstream literature often strips climate change adaptation of its human content and social context while instead linking it to technology such as climateproofing of infrastructure or economic tools such as insurance policies with dire consequences for poverty alleviation meanwhile adaptation seen as a process of profound social change in livelihood activities or as transformation gets less attention that void will be addressed here from the perspective of farming communities in subsaharan africa representing one of the most climate change vulnerable areas in the world adaptation and mitigation are socially spatially and temporally differentiated responses to climate change whereas mitigation refers to reduction of hazard exposure and vulnerability to potential adverse impacts of climate change adaptation means adjusting to actual or expected climate effects adaptation can be incremental serving to maintain a systemprocess or transformative serving to fundamentally change system attributes it can be protective in terms of taking preventive measures against negative impacts or opportunistic in terms of taking advantage of potential beneficial effects of climate change although poor communities in the global south would prioritise adaptation over mitigation some of the most effective adaptation measures are also important mitigation strategies as exemplified by the technology adoption of agroforestry altered agricultural practices and improved cookingstoves consuming less fuelwood while releasing fewer pollutants and lower emissions still populations who are poor and highly exposed to climatic events may be severely constrained in promoting their own agenda to advance their cause in international climate change negotiation and policies it is pertinent to demonstrate that this population is big their potential contribution to mitigation is decisive and strategies that cement or reinforce existing inequalities should be avoided what about gender in climate change adaptation farming livelihoods in smallscale agriculture are imbued by gendered divisions of rights and responsibilities expressed in power asymmetries in access to land labour and leisure time this social differentiation may imply varied vulnerability and capacity to adapt to climate change climate variability and other stressors however it should be noted that while some social norms and relations seem fixed others are fluid and flexible especially in times of social change given that climate change adaptation entails structural and intersectional power critical geographers argue that research and policy must disentangle social processes and practices and be sensitive to intersecting inequalities that emerge when climate change impacts and responses cut across age class ethnicity gender and space for that purpose genderinformed approaches and disaggregated data are essential counting measuring and mapping may provide correlations and quantitative overviews for comparison whereas indepth research on social structures and individual practices in everyday life is needed for understanding causality since available evidence is limited patchy varied and highly contextual it is not yet widely confirmed thathow climate change has differential impact on women and men in terms of assets agency and achievements but data are fairly consistent with the two propositions that climate impacts may affect men and women differently and women tend to suffer more negatively in terms of their assets and wellbeing this vulnerability as documented by several studies is not intrinsic to women but due to the gendered distribution and organisation of land and labour according to the who women suffer higher risk than men in health and life expectancy and are harder hit by floods heavy rains heatwaves drought and water scarcity often associated with climate change besides women have less access to critical information on cropping patterns and weather alerts due to likely uneven impacts of climate change on women there is need for critical feminist research that not only describes but also explains such gender asymmetries in so doing it should consider women and men as equal partners facing environmental change and consequently it should suggest policies to promote socioenvironmental justice despite the fact that adaptation is gendered and varies across scales and subjectivities knowledge on how climate change interacts with geographical and social inequality is underrepresented in policy and research in a bibliometric analysis using the isi web of science to search abstracts keywords and titles for the terms climate and adaptation and gender in research published january 2000april 2017 i found 188 social science articles containing the three concepts few of these were published before 2011 after that the number of articles and the citations they receive have grown exponentially in comparison and using the same approach i found 7004 social science articles on climate and adaptation published january 2000april 2017 this search in the isi database is only a rough indication it does not exclude that there are other research articles relevant for climate change adaptation and gender to exemplify the crosschapter box on gender and climate in ipcc ar5 refers to 34 articles of which only every other title overlaps with my search now that the agenda on womenenvironment dynamics is gaining strength from the climate change debate more gender relevant research is on its way and although empowerment of women in relation to climate change policy varies between countries there are signs that the mainstreaming of gender and womens needs in climate change responses is increasing in policy documents in east and southern africa nonetheless it is evident that gender is underresearched within climate change adaptation explorative and systematic studies on power and ethics distribution and environmental justice and impacts and responses would thus contribute further valuable knowledge as regards policy and practice the number of documented adaptation initiatives has increased significantly since 2006 albeit from a low level especially in africa particularly in kenya and mainly in semiarid agriculture an analysis of these initiatives indicates that most of them are national rather than local and cover both proand reactive responses while few of them consider vulnerable groups or show evidence of substantive adaptation to conclude here the brief overview above serves as a rationale for doing genderinformed research on climate change adaptation the significance of climate change inequality and poverty climate change is a formidable challenge it entails a combination of slowonset and rapidonset events with uncertain and uneven impacts and is expected to become more frequent and forceful especially in subsaharan africa it is accelerating to the extent that the risk of failing to stabilise the climate at the 2degreestarget is real making both adaptation and mitigation more urgent there is a risk though of reaching limits to adaptation especially in places that are most exposed to climate change impacts such as subsaharan agriculture where profound social change rather than merely adjustment should be a main purpose of adaptation however this is not without problems neither in terms of who gets to decide the direction or the depth of that transformation nor its distributional outcome once the difficulties of transformational adaptation are recognised it is necessary to discuss how to grasp potential opportunities while remembering that adaptation is underpinned by diverse values varying across contexts and cultures spatial cultural and temporal inequality climate change is transboundary and requires multiscalar agreements efforts and solutions in comparison to other environmental debates the climate change debate has therefore been less localised communitybased or centred on agency identity and gender but with strong and increasing evidence that frequent droughts intense heat waves and serious flooding will be socially and spatially differentiated the global focus must shift towards practical policies in the local where variations in real experiences capacities and initiatives emerge importantly complexity increases dramatically when the focus is shifted from global to local settings where climate change impacts and effects intersect with major social forces such as commodification marketisation technological shifts or largescale social intervention in the environment while also being embedded in and mediated by culture incomegenerating resources and livelihood opportunities are impacted by climate change mainly because they are governed by differentiated decisionmaking power institutions and social relations in the global south where most people who are poor reside in rural areas and rely on agriculture for their living and livelihoods climate change will have major impacts not only on availability and distribution but also on destruction of resources including agricultural land and all these processes may in themselves further reinforce social differentiation in rural areas those who have limited access and rights to resources while being responsible for food production will be the most vulnerable to impacts of climate change and climate variability genderinformed data show that climate change will have disproportionate effects on smallscale farmers many of whom are women in subsaharan agriculture who depend for their living on degrading physical resourcesland water forest productsand who are already under pressure from the multiple stressors of poverty illhealth and food insecurity as also confirmed in research on the food health and gender imperatives beyond social and spatial differentiation there are temporal aspects in subsaharan africa where climate change already has an impact on natural resources and rural livelihoods due to recurring floods and droughts the availability of systematic multiscalar knowledge on adaptation to and mitigation of climate change may help farmers in the short run to adapt their livelihoods while also informing policy on human security and wellbeing but if shortterm change such as introducing new specific practices or asserting wellknown strategies blocks or postpones necessary longterm change this may in fact result in maladaptation rather than adaptation illconsidered efforts to improve wellbeing or protect human security may thus end up masking inequality rather than tackling the underlying reasons for the need to adapt the purpose of adaptation and the importance of context adaptation is widely recognised as one of two main response options to reduce the risks from climate change it involves established major practices such as agricultural outreach coastal management disaster risk management resource management spatial and urban planning and public health it refers to the ability of individuals societies and systems to cope with multiscalar processes and to use information on present and future climate change in relation to the suitability of current and planned policies practices and infrastructure it has to be informed not only by geographical insights on biophysical geomorphological and hydrological conditions but also by sociotechnological conditions and relations as risks cannot be fully eliminated adaptation needs to reduce exposure and vulnerability while also increasing capacity to resist or recover from the potential adverse impacts of climate extremes despite substantial investments in research following from the mounting need for adaptation practical progress is slow partly because of the way in which adaptation is framed and understood difficulties also arise from the fact that adaptation is inseparable from its socioecological context and just like development highly influenced by historical conditions and properties emerging in the cause of action climate change adaptation in a particular setting should thus be prepared through ground work actions followed by concrete actions including the implementation of institutional guidelines and public awareness hence adaptation must involve adjustments to current activities or imply fundamental change and social transformation that needs to be negotiated this makes adaptation a contested and powerladen process of ideas and interactions at multiple scales influencing existing social differentiation and inequality adaptation as adjustment development reform or transformation adaptation is closely associated with climate change vulnerability and how we speak of their interdependence will influence how we act ipcc sees climate impacts as a main source of vulnerability which calls for adaptation as adjustment others locate risks in both nature and society as a source of vulnerability thus seeing adaptation as social reform or development and a means to reduce vulnerability within prevailing systems but little research explores the social drivers of vulnerability or the need to understand and achieve adaptation as a politicaleconomic transformation and as transformative climate action although major social processes interact and overlap many development agencies and practitioners distinguish between climate change adaptation disaster risk reduction and poverty alleviation in the global south underlying ideological and theoretical assumptions about development may influence interpretations of adaptation and vulnerability using adaptation to reconstitute conventional growthdriven development is not necessarily acceptable efficient or fair particularly not from postdevelopment perspectives seeking to shift the focus towards climate change drivers and the aspirations of local communities using a general recipe for adaptation is not necessarily the most productive way to address climate change and donors must refuse to know exactly what should be done or how instead adaptation could be an opportunity to go beyond conventional development and seek to implement the unfulfilled promises to reduce poverty and inequality while enhancing sustainability adaptation and vulnerability as gendered phenomena there is no single best definition of vulnerability because context and purpose are important for assessing it often it is seen as intertwined with poverty but plays out differently depending on the social and political ecology of the context in the gender literature it has been argued that vulnerability is neither a fixed nor an intrinsic characteristic of certain people or groups of people or derived from a single social dimension like being poor rural woman or part of a particular community rather it depends on social and historical patterns of practices processes and power relations that render some groups or persons more disadvantaged than others and more vulnerable to risk and disaster than others if vulnerability must cover not only differentiated and changing circumstances before during and after a disaster or hazard but also historically and culturally determined conditions then it is less an individual or personal feature and more a structural relational and processoriented condition climate change impacts and responses interact with existing and emerging gendered capacities and vulnerabilities in complex ways often resulting in unintended consequences to take an example the loss of assets crops gardens homebased production and livestock in consequence of waterrelated hazards such as cyclones droughts erosion floods and landslides may all have gendered implications women and men may be affected differently depending on how social relations shape rights and responsibilities in production reproduction and decisionmaking and if women are more vulnerable to climate change impacts they may also be disadvantaged in access to adaptation resources research on the effects on equity efficiency and identity will thus necessitate further studies on the gender dynamics of climate change despite specific variations adaptive capacity as a response to climate change impacts and a means to reduce vulnerability can be defined as the general ability to anticipate absorb accommodate to or recover from the effects of extreme events adaptive capacity for women and men to reduce their respective vulnerability in a given context may depend significantly on underlying norms that define and regulate the use of space and the power associated with that situated knowledge and social reproduction are therefore useful concepts to analyse how social and spatial locations shape everyday activities and practices and how that relates to what women know and how they respond to social and environmental stressors adaptation in smallscale farming for a fact climate events such as droughts floods and changing weather patterns are already causing problems for climatedependent livelihoods in smallscale farming and livestockrearing in the absence of stabilisation climate change will exacerbate such problems in the coming decades especially in southern africa where projections consistently predict decreasing rainfall intensified droughts and increasing variability b agriculture biodiversity ecosystems water resources and human health will be adversely affected while seasonal shifts and climate events such as droughts floods and storms will be increasingly unpredictable and more intense but due to uneven and uncertain impacts it is hard to decidein a certain areawhat is attributable to climate change or what to other conditions hence climate change must be understood in relation to the core stressors that populations experience in everyday life such as landuse change food insecurity and illhealth in the context of persistent poverty for local settings climate change observers and development practitioners often suggest communitybased adaptation on the premise that communities have the necessary expertise and networks to initiate appropriate activities to avoid loss or speed up recovery local knowledge for action is indeed important but there are conceptual methodological and political problems with communitybased approaches to climate change one of which is the common focus on a single challenge rather than on the multiple interlocking aspects of vulnerability a focus on the local only at the expense of the national or global level can also be problematic because it may marginalise or put disproportionate pressure on the local in addition the tendency to assume that the community is a uniform and inclusive entity may underestimate power inequality and diverging interests within it nonetheless research shows that although it is time consuming to assess the merits or limits of communitybased adaptation valuable lessons can be drawn from good initiatives that may potentially be either scaled up or scaled out to sum up on the first question adaptation may seem clear in purpose aiming both for adjustment and transformation while it is evidently difficult in implementation given that climate change impacts are inherently unequal and powerladen and that adaptation as a response entails conflicting multiscalar views on everything from resource use to the degree and direction of social change the second question will focus on what can be learned from development especially on gender as a major process with implications for adaptation learning from development dynamics gender power and environment the social construct of gender shapes social relations in profound ways doing gender means to be guided by norms and rules in perceptual interactional and micropolitical activities that are embedded in everyday interaction as a higher order process in society and of particular importance here as an analytical category gender in smallscale agriculture determines the division of rights responsibilities and risks in relation to the use management of and control over environmental resources especially land feminist literature has noticed that the duality of seeing women as either vulnerable victims or competent agents and virtues or both is repeatedly stressed in debates on environmentdevelopment migrationdevelopment and security and peacebuilding feminists have observed that in everyday practices of how to use space and time gender is mediated in dynamic processes giving rise to separate spheres of varying priorities and privileges such as the public versus the private realm within the private realm gendered space is often separated further into areas for cooking living and working and although gender norms may appear as fixedreproductive and productive labour are constantly reinterpreted in both theory and practice this means that owing to institutional instability and fluidity in norms gender is subject to ongoing sociocultural negotiations whereby women with intrahousehold bargaining power become resourceful agents of change how best to use analytical categories suggested by feminist theory is debated in the development discourse the notion of womanwomen as a concrete singular category has often been centre stage for good or for bad at the cost of femininitymasculinity or gender as relational concepts early works in development put womanwomen in focus to highlight precarious conditions relating to health labour social status and work load whereas later debates have often referred to women in their capacity as capable family breadwinners caretakers and entrepreneurs this has served the purpose of making women visible in gendered production and reproduction but if men and masculinity are thereby constantly made invisible in reproduction then relational aspects of gender are lost and understandings of society and culture ultimately become partial or even distorted inspired by development discourses that see gender inequality and poverty as theoretically and empirically intertwined and given the relevance of that for climate justice in a warmer world i suggest seven condensed development themes as an analogy for how to think about and understand gender and sustainability in climate change adaptation the intention is not to include every aspect of and all contributors to these debates but to characterise them for the sake of learning lessons in all they refer to how women are socially represented to what extent their rights are recognised and whether resources can be fairly redistributed starting historically i move towards contemporary debates shortlived historical gains throughout history social and cultural norms have been contested challenged and changed especially during major technological transformation or social upheaval such as agrarian reform or revolution civil conflict or international war economic boom or crisis natural disaster or as of late climate change events asia exhibits many wellknown historical examples of how gender is constructed and contingent but also fluid and flexible in the course of decisive economic or political moments despite their strategic gains in the public sphere during these events women who entered wagework or administrative positions in war time often remained in charge of reproductive household work seemingly more resistant to recoding and change gains in terms of social recoding of gendered positions and relations appeared fragile because gender soon reverted to normal in the aftermath of a major event during which gender norms and social relations were recoded and changed in unexpected and exceptional ways integrating women but ignoring gender ester boserup who was an early proponent of gender equality in modernisation theory argued that women should be further integrated into the economy to reap benefits from development in contrast radical feminist scholars stated that women were not only already involved but also exploited in both reproductive and productive work concerns about womens low income heavy workload and time poverty have since then been mainstreamed into development thinking but interventions that build on the idea of womens integration and which seek to involve women in the public sphere often seriously overlook the role of men and masculinity in the economy in society and in the private sphere thus ignoring that gender is relational only to end up with limited understandings of society and its fundamentally relational structures and interactions equity efficiency and identity gender has been discussed from many angles of development such as equality and fairness in access to socioeconomic opportunities exclusion or integration exploitation or empowerment marginalisation or participation and also in terms of equity as an inclusive means to strengthen development effectiveness with climate change it is an increasing challenge for policy and research that on top of all aspirations and expectations associated with development adaptation must consider both existing gender inequalities and emerging gendered vulnerabilities from a feminist perspective the dynamics of climate change impacts and responses in the context of multiple stressors should thus explicitly consider the gendered and intersectional effects on equality efficiency and identity rights to resources gendered agency and institutions create differences in capacities incentives and preferences for how to manage resources they also influence means motives and conditions for how to contribute to adaptation and sustainability knowledge about the environment can be gendered as can attitudes and abilities that determine how farmers manage natural resources and approach new farming techniques and practices rights to resources may appear as bundles of private common or public goods and may differ between customary or statutory legal institutions in settings where staterecognised property rights are lacking gender regimes may instead govern access to ownership of and control over resources rights to resources can be temporary if a certain gendered activity or seasonal agricultural practice is associated with a certain resource or permanent if women risk losing their land rights such as in case of divorce or widowhood being close to nature a recurring argument warns that women run the potential risk of carrying the burden of environmental care and management because they are closer to nature are hardest hit by environmental degradation and have special knowledge of natural resource systems feminist scholars who criticise such essentialist views in the development debate about the strategic but vulnerable position of women have called for nuanced interpretations of gendered relations to natural resources in agriculture forestry and water management but the argument is still gaining importance in debates about how global warming influences the womenenvironment dynamics according to this reasoning climate change and the many alterations in natural conditions that follow in its wake will render women even more vulnerable if they are too close to and dependent on nature perceptions priorities and expectations in a given setting womens and mens experience of climate change and climate variability may vary as may also their perceptions of the associated risks their priorities and perceived skills and responsibilities in relation to adaptation and local gender norms their gendered responsibilities and differences in decisionmaking power in relation to environmental resources and their thoughts about mitigation of climate change such differences may be rooted in and driven by gendered livelihood activities and farming practices and in how women and men depend on and act differently in relation to environmental resources owing to varied reproductive responsibilities yet these conditions may be malleable neither fairnor fixed in the event of humanenvironmental change gendered norms in reproduction and production may be challenged after a climate change event genderspecific impacts may build on and exacerbate gendered relations and responsibilities while new obligations arise as an illustration workloads relating to climate change adaptation and mitigation may increase if new tasks are added on to old ones conversely work may equalise if labour is recoded from being feminine to becoming masculine such that men assume womens tasks and women assume mens tasks as happened in a severe drought in cambodia when women and men reinterpreted shifted and shared work tasks in agriculture to overcome shared difficulties a crisis may reinforce genderbased disadvantages but may also entail negotiations and change in seemingly fixed gender relations thereby in part destabilising gender in subsaharan smallscale farming it has long been noted that changes in the gendering of tasks occur when men exploit new opportunities outside agriculture and women expand their working repertoire in food productionhowever men take up womens tasks when they become profitable learning from an analogy with development in response to the second question i discussed multiple gender aspects of development defined as a major social process comparable to and intertwined with adaptation i now move on to the third question on the core institutions that are critical to climate change adaptation core institutions access to and control of social material and discursive resources both historical and contemporary processes determine how climate change impacts are experienced and acted upon by regions communities and individuals and how adaptation will be initiated managed and governed in areas where people who are poor depend on agriculture for their living the key to poverty alleviation is to have access to incomegenerating resources whereas the key to adaptation is the ability to respond in mind and deed to changing conditions adaptation and poverty alleviation are however complex processes embedded in layers of social relations and decisionmaking power if farmers depend on a degrading natural environment they will have to adapt and adjust agricultural practices to recurring droughts flood and other impacts but the ability to adapt in terms of avoiding controlling or coping with climate change in relation to resources is differentiated especially where infrastructure is deficient governments local authorities and other relevant organisations must therefore facilitate transitions to more sustainable livelihood activities practices and strategies to study resource access means studying power to control resources once they are accessed while some have direct control over resources others must maintain their access only through those who have control hence people are positioned differently as regards power over resources a critical perspective on property relations and rights to resources that goes beyond access and towards the ability to use and control a particular resource such as land would offer a better view than conventional property theory over time and across scales one should study how control relates to existing institutional arrangements such as the ruling gender regimes of land labour production and reproduction and how conflict will be handled when it emerges existing structures of inequality may reinforce impacts and result in differentiated outcomes here some suggest that the use of a continually changing web of access relations as a heuristic will allow an analysis of the dynamic processes that influence access to and control over resources gendered access to resourcesand power to use them according to some observers limited access and restricted rights to resources make women particularly vulnerable to climate change especially if crop failure fuel shortage and water scarcity affect their capacity to discharge what is deemed to be their food provision responsibility women and men depend differently on energy land water and other natural and social resources for their everyday life and longterm existence and it is often stated that women more than men face a litany of structural technological and cultural barriers to fulfil gendered productive and reproductive responsibilities and obligations women may have an interest in depend on and manage natural resources while neither having the right to nor being entitled to control these same resources in many fishing and farming communities women initiate participate in and contribute to production while having less access to natural resources such as land or social resources such as capital education and information at the same time women have multiple reproductive responsibilities and every dawn brings with it a long march in search of fuel fodder and water based on her extensive review of the literature on women and agricultural production in africa cheryl doss sees the african farm household as enormously complexit is a diversified and multifaceted economic entity pursuing numerous varied activities it operates according to competing goals and objectives not least due to gender and it is involved in elaborate networks of credit insurance and contracts 87 the claim that gender is an important analytical category does not however prescribe a priori what should be done according to doss even in cases where gendered rights roles and responsibilities are considered the actual dynamics practices and strategies in a certain setting in relation to land labour and resources may not be well understood and interventions including technology adoption designed for women have therefore often failed nevertheless economic activity and productive and reproductive responsibilities even if burdensome may offer women certain bargaining power and render them an opportunity to become resourceful agents of change with adaptive capacity albeit causality is difficult to establish between power and desired outcomes feminist economists see intrahousehold bargaining power as a discursive resource that women use to improve decisionmaking and social position and based on the following typology of power researchers can explore social relations in climate change adaptation in terms of power to meaning the ability to adapt improve or transform power with involving a joint or collective action with other people power over such as challenging and overcoming an instance of social exclusion or subjugation and power within as an individual cognitive process of confidence and consciousness further kabeer sees empowerment as a specific structural and pathdependent process influencing ability capacity and willingnessin a given place or situationto accept gender norms and other social constraints or influence challenge and change them she speaks of the ability to participate on equal terms with men in reshaping society the capacity to exercise strategic control over ones own life and the willingness to question ones position in society such reasoning is applicable also to vulnerability and climate change adaptation showing that gender and changes in gender norms is both an individual and societal process both agency and structure scholars who offer constructive advice on increased efficiency and gender equality in agricultural intervention and extension services in climate change adaptation and in policy related to both have suggested a transformative gender approach it would not only seek to make gradual improvements to meet womens needs but also engage with men more profoundly to enable a change in gender relations and the gendered coding of responsibilities in the long term to achieve that we would have to use methods that better fit the given agricultural context reach women and men at times and places that are convenient to their productive and reproductive responsibilities and acknowledge gender variation in priorities labour productivity and time use for policy researchers suggest that we could address gender relations by following an empowerment pathway that actively involves not only women but also men while at the same time rethinking the coding of male and female work tasks a similar approach is suggested by scholars who have launched a new and detailed research agenda on this issue for agricultural interventions the many inequalities in climate change can be theorised in different ways if sustainability science puts a feminist political ecology lens on climate change and natural resources management it may better understand the gendering of impacts responses and decisionmaking power yet that necessitates a contextual and intersectional understanding of climate change impacts and presupposes a comprehensive view of gendered subjectivities and identities designing gendersensitive research on adaptation what is the agenda every single research account is necessarily selective partial and incomplete how we pose research questions and construct data will thus affect how we perceive interpret and act upon results the choices i have made here in terms of formulating three guiding questions inspired by barnett as well as defining core concepts and identifying the substance of the analysis have resulted in a particular account bearing this in mind i suggest a frame with questions for how one might proceed in gendersensitive sustainability science research on climate change adaptation in the global south which uncovers how individual agency is structured by higher order processes in societysuch as class and gender to that end the dynamics of gender relations positions and norms will be core not the least in how such institutions are challenged by globaltolocal environmental pressures on land water and other resources more frequent and severe droughts and could draw on the questions above the complexity of interacting factors makes the extended case method an appropriate strategy for this type of research it suggests that indepth studies are theorised and contextualised in relation to broader social dynamics such as climate change and higher order processes in society such as gender the extended case method can help fulfil the intention of expanding empirical and theoretical findings beyond the scope of the actual research site and demonstrate the strength of upscaling and transferability of local insights into settings of similar conditions starting from a feminist sustainability science perspective on climate change adaptation and by referring to the development discourse and its gendered aspects and institutions three main findings emerged the purpose of adaptation is obviously and per definition to respond to climate change impacts in both a proactive and reactive sense in the best case scenario adaptation would tackle poverty inequality food insecurity and illhealth simultaneously and synergetically while continually taking gender into consideration as one defining institution in the context of smallscale agriculture especially as regards rights responsibilities and strategic achievements such adaptation would have a transformative potential conclusions the parallel drawn between adaptation and other gendered processes such as development served to compare preconditions for and actual pathways in climate change adaptation with how the development discourse has understood women and gender differently over time and in varied domains and debates including that of womengender and nature from development we can learn how the dynamics of gender environment and power play out in the context of multiple stressors such as poverty inequality food insecurity and illhealth from influential development economist we hear that the notion of inclusive propoor growth is key to social change but that must be further scrutinised in light of climate change impacts and responses some underline that there are strong overlaps between growth policy and adaptation policy and that improvements in development indicators are effective in reducing climate change vulnerability especially if public policy takes a renewed responsibility while collective action gains greater prominence this is still to be seen climate change adaptation is not really a matter of propoor policies emerging from the development discourse but a call for fairer distribution and stronger recognition of rightsin a world of growing inequality and global concentration of wealth as regards institutions gender is contingent and culturally constructed gender norms may thus be subject to change during major social processes such as those in focus throughout the analysis it was made clear that gender is a critical social category in development and climate change adaptation alike not only does it have multiple institutional implications for adaptation and environmental justice it also enriches the understanding of climate change impacts and responsesand how sustainability science as an umbrella field could tackle this asking gendersensitive questions if gender plays out differently in different settings and must be understood in all its local variations it still entails sufficient internal coherence to be seen as a wholealthough a differentiated whole starting from that perspective the specific objective in sustainability science research on climate change adaptation could be to study placebased perceptions of experiences from and responses to climate change impacts and risk in more detail we could study how farmers activities priorities skills and decisions relating to climate change adaptation interact with gender norms in livelihood production and reproduction further we could study how the gendered capacity to make informed decisions on actions aimed at climate change adaptation is manifested especially if some adaptation strategies contribute to while others undermine longterm principles of sustainability in concrete terms it has recently been argued that climate change adaptation should include a gendersensitive analysis while climate actions require gender sensitivity strategies here a comparative analysis across sites and scales may bring comprehensive and more meaningful understandings that can inform policies and programmesif and how climate change will impact the lives of women and men differently to avoid preserving or reinforcing gender inequalities it is essential that both politics and research on the grounded realities of climate events and climate change adaptation should be informed by social justice and gendersensitive approaches hence feminists argue that theory and practice in climate change adaptation and disaster management should communicate more with each other on common issues such as gender justice and the reduction of environmental risks while also observing the agenda on global justice in the development debate findings from indepth studies on the dynamics of gender regimes for land labour natural resources and power can be used to frame further research as regards the social construction of gender and its manifestations in a particular setting or situation it is helpful to distinguish systematically between three dimensionsthe abstract the concrete social or collective and the concrete individual comparing concrete and specific situations with abstract and general thinking means comparing what is in flux with what is fixed thus comparing the dynamic process of reality such as potentially changing gender norms under socioecological stresswith static concepts such as those found in theory in case of tension between the two new ideas and concepts can be discovered formulated and proposedand action taken one way to explore adaptation is to be informed not only by theories on gender and social power or transformative power but also by discursive institutionalism offering tools to identify early signs of social change as expressed in the thinking and speaking that precedes womens and mens more observable acting tracing scrutinising and challenging discursive constructions is thus an important aspect of feminist research also on climate change based on that and as guidance in research i pose nine descriptive interpretive explanatory and potentially prescriptive questions • how is gender addressed and described in policy documents • how are smallscale farmers women and men represented in policy documents • how do smallscale farmers women and men perceive risks relating to climate change • how do smallscale farmers women and men experience and act upon climate change

people places and production contributing the least to climate change will suffer the most this calls for adaptation as a key climate change response but adaptation is surrounded by problems finance is uncertain and fragmented mainstreaming into development is complicated and technical solutions often overshadow existing social relations and institutions from a gender perspective and as a critical research initiative to support the building of sustainability science as an umbrella field this article raises three pertinent questions on adaptation in the global south what is its purpose how can development inform it and what institutions in terms of rights and responsibilities are core to it focusing on subsaharan smallscale agriculture three main points emerge regarding the purpose adaptation should be a transformative pathway out of poverty illhealth and food insecurity regarding development adaptation can learn from how development theory policy and practice have addressed women gender and environment in varied settings and debates regarding core institutions adaptation must address gender regimes that regulate access to use of and control over resources especially those defining land distribution labour division and strategic decisionmaking power to conclude i propose genderinformed research questions for further inquiry

introduction as of may 2022 covid19 had infected over 500 million people and killed over 6 million people worldwide 1 cigarette smoking has been identified as an independent risk factor for mortality among covid19 patients 2 despite the potential risks smoking poses for individuals diagnosed with covid19 3 the impact of the covid19 pandemic on cigarette smoking is unclear tobacco industry data demonstrate an increase in sales since the beginning of covid19 pandemic 4 federal trade commission data support that annual cigarette sales increased for the first time in 20 years in 2020 5 the extent to which increased sales reflect a change in smoking prevalence or smoking intensity remains unclear studies from a diverse array of populations around the world suggest that roughly a third of smokers surveyed increased their cigarette consumption during the pandemic whereas roughly a fifth decreased consumption 6 7 8 9 10 11 though other studies suggest greater proportions of individuals decreased or did not change their cigarette consumption 1213 across studies roughly 40 of individuals surveyed experienced increases in motivation or intentions to quit smoking during the pandemic 671112 few demographic and other characteristics associated with increasing versus decreasing smoking during the pandemic have been described the adoption of protective health behaviors among tobacco users to mitigate the potential health risks posed by the pandemic which nicotine and tobacco research 2023 vol 25 no 2 could contextualize changes in smoking has also not been examined few studies on the impacts of the covid19 pandemic on smoking have explicitly focused on populations most vulnerable to smoking and associated health disparities some populations of vulnerable smokers such as women with low socioeconomic status individuals with opioid use disorder and those with affective disorders already experience disproportionately high rates of smoking and adverse health outcomes related to smoking compared to the general population 14 15 16 17 18 19 20 21 which might also put them at a greater risk of covidrelated harm further individuals with mood or substance use disorders are also more at risk of serious illness and death from covid19 2223 information on how people vulnerable to tobacco use have responded to the covid19 pandemic may inform targeted efforts to prevent greater health disparities in these groups the purpose of the current study was to examine how smoking and related behaviors of vulnerable populations have changed since the start of the covid19 pandemic specifically we were interested in examining possible changes in smoking status or rate prior to versus during the pandemic and in identifying psychosocial risk factors associated with different changes in smoking lastly we examined whether these individuals were attempting to modify their behavior in other ways to protect themselves from covidrelated harm materials and methods procedure parent study briefly participants were randomized to one of three study conditions that varied in terms of the nicotine content of the research cigarettes provided participants reported their daily cigarette consumption over a 12week period and attended weekly clinic assessment sessions during these weekly sessions participants returned unused study cigarettes engaged in behavioral assessments as well as physiological data collection and received additional study product for the following week thirty days following study completion participants were asked if they were still smoking and if applicable how many cigarettes they consumed per day survey participation participants from the parent study who expressed interest in participating in additional research were contacted via email and phone between june 22 2020 and nov 132020 and invited to complete the survey which was distributed through the redcap platform 2425 up to five attempts over the course of three weeks were made to reach invited participants respondents could choose to complete the survey online or a trained research assistant could administer it to them over the phone respondents were required to be at least 21 years of age at the time they completed the survey and had to endorse being aware of the ongoing covid19 pandemic respondents received a 20 amazon gift card upon completion of the survey all study procedures were approved by an institutional review board at each of the three study sites measures the survey inquired about current age residence employment status and experiences related to job loss change or essential worker status due to the pandemic other respondent demographics were collected during the parent study and not included in the survey current symptoms of anxiety and depression were assessed by the generalized anxiety disorder 2item and patient health questionnaire2 respectively 2627 a score ≥ 3 is considered the clinical cutoff score for both these measures respondents who endorsed the survey item i currently smoke cigarettes on at least some days were considered current smokers and asked to provide their current cpd those who endorsed the alternative item i have quit smoking cigarettes were considered former smokers respondents were also asked to retrospectively report the average number of cigarettes they smoked per day in february of 2020 this timeframe was chosen as an indicator of their smoking intensity prior to the first shutdown orders in the united states in march of 2020 28 in addition we asked respondents to indicate whether their cigarette consumption increased decreased or stayed the same four of seven respondents with missing information were classified using supplemental freetext responses the survey also inquired about respondents current cigarette purchasing habits perceptions of risk of harm from covid19 perceived covid19 risk due to smoking and health behavior changes in response to covid19 questions related to covid19 risk perceptions and health behavior changes were adapted from a survey tool recently developed by the world health organization 29 sample items from this survey include what is your probability of getting infected with the novel corona virus how severe would contracting the novel corona virus be for you and how susceptible do you consider yourself to an infection with the novel corona virus responses to these questions were measured on a 7point likert scale data analysis a response bias analysis was conducted to compare survey responders to nonresponders on demographic characteristics population nicotine dose condition and cpd at the baseline and followup visits of the parent study chisquare tests were used for categorical variables and wilcoxon rank sum tests for continuous variables survey item responses were summarized using means and standard deviations or frequencies and percentages as appropriate questions asked on 7point likert scales were collapsed into categories of low medium and high for reporting to examine whether cpd changed between precovid to the time of the survey we conducted a repeatedmeasures analysis of variance with time as the withinsubjects variable also included were psychosocial covariates identified from prior literature 30 31 32 to be risk factors related to smoking age sex raceethnicity employment education anxiety symptoms and depression symptoms in addition to these sociodemographic covariates we included menthol status parent study condition population and site as covariates respondents who reported that they were no longer smoking cigarettes at the time of the survey had their duringcovid cpd set to 0 those who indicated that they had quit smoking prior to the pandemic had their precovid cpd set to 0 two individuals who reported current cpd of 130 were considered outliers and removed from all subsequent models as it was determined that these smoking rates were improbable a parent study population by condition by time interaction along with all lowerlevel interactions were explored in the event of nonsignificant interactions the analysis was repeated eliminating nonsignificant effects we chose to limit analyses to selfreported cpd in the current survey due to inconsistency in collection methods between the survey and the parent study and to avoid capturing changes in cpd due to the parent study manipulations models including parent study followup cpd however were conducted as sensitivity analyses to investigate which demographic or psychosocial risk factors might impact changes in cpd interaction terms for time by menthol status sex age raceethnicity depression symptoms anxiety symptoms employment status and education were included in the same repeated measures anova model in the event of nonsignificant interactions the analysis was repeated eliminating nonsignificant effects all analyses were conducted using sas version 94 posthoc pvalues were bonferronicorrected to account for multiple comparisons results respondents of the 709 individuals from the parent study who consented to further research contact 332 completed the first required question of the survey resulting in a response rate of 468 survey respondents did not differ from nonresponders on cpd at parent study baseline or followup consistent with the parent study 14 survey respondents were predominantly female of nonhispanic white raceethnicity and most had been recruited from the vermont site at the time of the survey respondents were on average 380 years old 166 of respondents had attained an associates degree or higher level of education and 512 were employed nearly half of respondents endorsed experiencing a change in their employment status because of the pandemic of the 178 participants reporting an employment status change 473 indicated that they were no longer working and 460 were working fewer hours at the time of the survey the majority of participants scored in the clinical range on the phq2 and gad2 indicating the likely presence of major depressive disorder or generalized anxiety disorder respectively smoking most respondents indicated that they were still smoking at the time of the survey of the 51 respondents who indicated they were no longer smoking at the time of the survey 40 indicated that they had quit smoking prior to becoming aware of the covid19 pandemic in response to the question how has your cigarette use changed since you learned about the corona virus pandemic 456 of respondents who were still smoking at the time of the survey indicated that their cigarette consumption had increased 409 reported no change and 125 reported that their cigarette consumption had decreased cigarettes smoked per day there was a significant effect of time on cpd indicating that on average individuals were smoking 13 more cpd during covid compared to precovid age education and population were also significantly associated with cpd older participants reported greater cpd across both timepoints compared to younger participants and those with a high school diploma or equivalent reported smoking more than those with some college individuals with affective disorder reported smoking fewer cpd across both timepoints compared with those with oud or women of childbearing age we did not observe significant associations of menthol status sex depression or anxiety symptomology employment race ethnicity study site or nicotine dose condition with cpd there were also no significant interactions between time and parent trial population or nicotine dose condition within the trials suggesting these aspects of the prior study did not result in systematic changes in precovid to duringcovid cpd sensitivity analyses including cpd collected at the parent trial followup visit showed the same pattern of significance as the primary model exploration of risk factors associated with change in cpd showed a significant timebyemployment status interaction those who were unemployed reported a statistically significant increase in smoking during covid compared to before covid while those who were employed or were students homemakers retired or unable to work reported no significant changes in addition there was a significant interaction of time and anxiety status with those with higher gad2 scores reporting an increase in cpd while those with lower scores reported no change in cpd cigarette purchasing more than half of respondents indicated that they were still leaving their homes specifically to buy cigarettes and were buying more packs per visit to the store a fifth of these respondents said they were leaving their house specifically to buy cigarettes more frequently than prior to the pandemic a third reported leaving their house less frequently and 448 reported no change covidrelated thoughts and behavior change regarding covid19 risk perceptions the majority of respondents perceived a medium or low probability of becoming infected with covid and a medium or low level of personal susceptibility to infection however most respondents indicated that if infected with covid they expected that the disease would be moderate or severe roughly half of all respondents indicated that they believed smoking increased their risk of harm from covid19 a fifth of respondents indicated that their motivation to quit smoking cigarettes had increased since becoming aware of the pandemic compared to 480 who said that their motivation to quit had stayed the same and 278 who said that their motivation to quit had decreased regarding covidrelated protective health behaviors most participants indicated that they were engaging in handwashing avoiding touching their eyes and face with unwashed hands using hand sanitizer when soap and water were unavailable maintaining a 6foot distance from others wearing a facemask and staying home except for essential reasons discussion the purpose of this study was to examine how smoking and related health behaviors had changed during the covid19 pandemic among three populations highly vulnerable to smoking overall respondents reported increases in cigarette smoking despite recognizing smoking as potentially harmful in the face of the pandemic unemployment was associated with an increase in cpd during covid it is possible that in accordance with findings that people smoke to deal with pandemicrelated stress 33 individuals who were unemployed faced greater stress as a result of the pandemic that then caused them to smoke more it is also possible that individuals who were unemployed during the pandemic might have had more time each day to smoke and were not subject to workplace restrictions on smoking we also observed an independent positive association between anxiety symptoms and increased cpd in the present study this is in line with prior survey and qualitative research that has highlighted emotional distress caused by the pandemic as a driver of increased tobacco consumption 9 33 34 35 individuals from these three vulnerable populations recognized the covid19 pandemic as a serious issue and reported modifying their behavior to reduce infection risk however more than half of respondents indicated that they were still leaving their homes specifically to buy cigarettes the changes they reported in their cigarette purchasing habits could reflect a multitude of factors giovenco spillane maggi lee and philbin 34 observed that adult cigarette smokers changed their cigarette purchasing patterns during the pandemic because of changes in personal finances due to the pandemic or to reduce exposure to covid19 through trips to the store it is possible that the changes in purchasing habits reported in the present study reflect similar concerns respondents in the present study may have faced a dilemma between perceived competing needs to protect themselves from the pandemic and continue purchasing and smoking cigarettes importantly the uniformly high levels of adoption of protective health behaviors observed in the present sample suggests that a general apathy towards ones personal health is unlikely to account for the continued cigarette consumption and purchasing behaviors of vulnerable smokers observed in this study prior research suggests that the relationships between exposure to stressful events and subsequent substance use rates is likely complex and moderated by several risk and protective factors including mental health symptoms social support and degree of exposure to the stressful event 36 37 38 39 40 much of this research has been conducted in the context of discrete events of extreme stress such as natural disasters or terror attacks it is unclear whether this generalizes to more pervasive and chronic experiences of extreme stress such as the covid19 pandemic although we measured mental health symptoms in this survey we did not measure the degree of exposure to the covid19 pandemic or presence of social support further work is needed to develop theoretically relevant and reliable measures of exposure to the covid19 pandemic multiple studies have observed that a third of smokers surveyed indicated increasing their cigarette consumption during the pandemic 6 7 8 9 10 11 these proportions are similar to those observed in the context of other crises 39 additionally between a fifth and a third of respondents in the above studies indicated decreasing their cigarette consumption by contrast greater proportions of our sample of vulnerable smokers indicated increases in their smoking rate further compared to the twofifths of individuals who endorsed an increase in motivation to quit smoking during the pandemic in prior studies 671112 only onefifth of the present sample experienced increases in motivation to quit this suggests differential response patterns in smoking among vulnerable populations compared to general population samples it is possible that vulnerable smokers experienced greater stress as a result of the pandemic which prevented them from reducing or quitting smoking vulnerable smokers may view cigarettes as an essential coping strategy used especially in times of crisis given our observations that vulnerable smokers experiencing unemployment and greater anxiety experienced the greatest increases in smoking interventions to reduce smoking disparities during public health crises might benefit from the inclusion of employment assistance and emotion regulation strategies future nationallevel cohort surveys might also benefit from inclusion of psychosocial risk factors including employment and anxiety symptoms in their design and analytic strategy strengths and limitations one of the major contributions of the current study is that we examined the cigarette consumption patterns of vulnerable smokers we also assessed quantitative changes in smoking patterns in terms of cpd before and during covid and explored potential risk factors associated with this change lastly we examined changes in behaviors related to smoking perceptions of covid19 risk and severity and adoption of protective health behaviors to lend context to observed changes in cigarette consumption this study is not without limitations slightly under half of individuals responded to the survey indicating that nonresponse bias may have impacted the findings further selfselection bias might have impacted findings it is possible that those who were less impacted by the pandemic were more likely to respond to our recruitment efforts and more able to participate in the survey conversely respondents who were more financially impacted by the pandemic might have been more motivated by the provided compensation to participate in the present survey importantly survey nonresponders did not differ from responders on cpd at parent study baseline or followup visit suggesting that nonresponse bias would not have systematically impacted the outcome of our primary analyses precovid cpd was assessed via retrospective recall in the survey which is subject to recall bias although we were unable to compare prospectively collected cpd measures from prepandemic trial participation we conducted sensitivity analyses including these data which demonstrated similar outcomes parent study inclusion criteria limited the initial participation to individuals who were of three specific vulnerable smoker populations women of childbearing age with socioeconomic disadvantage individuals seeking treatment for oud and individuals with affective disorders it is therefore unclear whether the present findings generalize to other identified vulnerable populations finally the survey potentially captured holdover effects of prior experimental manipulation on respondents smoking patterns however the parent trial ended more than nine months prior to survey distribution suggesting that any holdover effects from the parent trial would likely have dissipated by the time of the survey furthermore we controlled for the potential impact of variables associated with study participation and manipulation in our models and did not observe significant effects suggesting that manipulations from parent study involvement did not contribute to systematic error in our findings bonferroni corrected posthoc comparisons indicate a difference between those with a high school degreeequivalent and those with some college but no other differences among the other education categories 3 bonferroni corrected posthoc comparisons indicate a difference between smokers with affective disorders and those with oud and and between women of childbearing age and those with affective disorder conclusion many individuals from vulnerable smoking populations increased their cigarette consumption during the covid19 pandemic and those who were unemployed experienced the greatest increase in smoking most participants had adopted protective health behaviors to prevent covid19 infection though the majority continued to go to stores to purchase cigarettes and endorsed buying more packs of cigarettes per visit to the store consistent with data documenting increases in cigarette sales in 2020 findings from the current study highlight that increases in cigarette use may be disproportionately borne by populations at greater risk of tobaccorelated health disparities and potentially greater risk of covidrelated harms our results highlight the urgency of expanding tobacco control efforts in atrisk populations to mitigate the longterm effects of increases in covidrelated tobacco consumption there was a statistically significant increase in cpd for those who are unemployed no difference in cpd over time for those with gad2 scores ≤ 2 there was a statistically significant increase in cpd for those with gad2 scores ≥ 3 data availability statement the data underlying this article will be shared on reasonable request to the corresponding author supplementary material a contributorship form detailing each authors specific involvement with this content as well as any supplementary data are available online at declaration of interests authors have no conflicts of interest to declare

aim while accumulating evidence suggests that people modified their smoking during the ongoing covid19 pandemic it remains unclear whether those most at risk for tobaccorelated health disparities did so the current study examined changes in smoking among several vulnerable smoker populations during the covid19 pandemica webbased survey was distributed in 2020 to 709 adults with socioeconomic disadvantage affective disorders or opioid use disorder who participated in a previous study investigating the effects of very low nicotine content vlnc cigarettes on smoking current smoking status and rate and adoption of protective health behaviors in response to the pandemic eg social distancing mask wearing were examined results among 332 survey respondents 468 response rate 846 were current smokers repeated measures anova showed that current cigarettesday cpd was higher during covid than precovid 129 ± 10 versus 116 ± 10 p 001 most respondents had adopted protective health behaviors to prevent infection 79 for all behaviors more than half indicated that they were still leaving their homes specifically to buy cigarettes 646 and were buying more packs per visit to the store 545 than precovid individuals unemployed at the time of the survey experienced greater increases in cpd from 114 ± 14 to 133 ± 14 p 024 as did those with higher levels of anxiety from 115 ± 11 to 136 ± 11 p 001 conclusions smoking increased during the covid19 pandemic in this sample of adults from vulnerable populations even while most adopted protective health measures to prevent infection unemployment and anxiety might identify those at greatest risk for increases in tobacco use implications individuals from populations especially vulnerable to smoking might be at risk for greater harm from cigarette smoking during times of pandemicrelated stress public health interventions are warranted to ameliorate increases in smoking among these populations special attention should be paid to those experiencing unemployment and high anxiety

introduction the past 10 years have seen a 14 rise in affected populations and a 39 rise in deaths as a result of disasters both natural and manmade according to the world disasters report 2012 1 in 2014 210 million people were affected by disasters across the globe china is one of a number of countries particularly vulnerable to natural disasters it was estimated that during february 2015 alone 238 000 people in china were affected by natural disasters and more than 2000 people needed emergency assistance the direct economic loss reached ¥230 million 2 effective responses to disasters depend not only on the strong leadership and coordinated actions of governmental agencies and professional bodies but also on the efforts of local residents emergency preparedness and early selfhelp efforts of local residents are usually critical for disaster victim survival 3 extensive studies have investigated the effectiveness of professional responses to emergency events 4 however there is paucity in the literature documenting individual and community preparedness for emergencies 5 in a 2009 national survey conducted by the us federal emergency management agency 57 of respondents reported having an emergency kit prepared within the strengths and limitations of this study the questions measuring awareness and preparatory behaviours for emergency were intentionally broad covering four broad types of events which may have contributed towards unclear or vague responses from some participants owing to limited resources the survey was conducted only in heilongjiang province despite these limitations this study provides important information for understanding resident preparedness behaviours and evidence to support the development of effective public risk communication and education campaigns home 6 the council for excellence in government found that onethird of us residents took no steps to prepare for potential emergencies with lack of awareness beliefs and resources being cited as the main reasons 7 8 the level of individual emergency preparedness in china is even lower a study of 2000 beijing residents in 2009 revealed that 25 had prepared emergency kits 9 similar to the finding of another study conducted in shanxi province 10 low levels of public awareness and failure to prepare present challenges for emergency response management 3 this study aims to identify factors that may shape the knowledge attitudes and behaviours of community residents in chinas heilongjiang province towards emergency preparedness findings of such a study may provide evidence to support the development of effective public risk communication and education campaigns methods study population a crosssectional household questionnaire survey was conducted in heilongjiang province between september and october 2014 heilongjiang is located in northeast china with a population of over 38 million in 2014 the gross domestic product per capita in heilongjiang reached ¥39 2264 ranking in the lowest range of all provinces 14 a stratified cluster sampling strategy was used to select study participants five major municipalities in heilongjiang were involved in the study one urban district and one rural county of the five municipalities were randomly selected two communitiesvillages within each selected districtcounty were sampled all households were identified as the participants for survey and each household identified one adult member to complete the questionnaire the questionnaires were administered through facetoface interviews each of which took on average 20 min to complete a total of 2800 questionnaires were completed among which 2686 were valid for data analyses data collection trained postgraduate students from the school of public health of harbin medical university collected data those students spoke the same dialect as those interviewed were involved in the development of the questionnaire conducted a pilot study in a convenience sample and a random cluster sample to test the validity and reliability of questionnaire 12 as well as participated in several research workshops prior to embarking on the fullscale survey one experienced researcher supervised the data collection activities in each community measurement the questionnaire was developed based on an emergency preparedness model proposed by jessica enders 13 a total of 50 items were included in the questionnaire which yielded a cronbachs α of 0847 and a spearmanbrown formula of 0884 demonstrating acceptable internal reliability and validity dependent variable emergency preparedness was the outcome measure defined as the necessary actions for an emergency in this study we measured emergency preparedness by asking participants what items they had in an ideal emergency supplies checklist 14 the ideal checklist consists of 20 commonly used items in case of an emergency defined by the public education ready programme in the usa and the manual for all citizens to prevent disaster edited by ministry of civil affairs of the peoples republic of china 8 15 those who possessed all or more than the five essential items 16 were categorised as well prepared independent variable there are several steps involved between individual receiving information and then acting based on the information received enders 13 summarised six major factors that may determinechange the course of actions during the process 1 demographic and social economic characteristics of participants such as gender age marital status education background residential location and household income 2 previous experience coping with an emergency emergency cognitionknowledge in relation to three types of emergency events was tested in this study using 16 statements natural disaster manmade disaster and public health emergency respondents were asked to choose one answer for each of the statements 1correct 2incorrect 3dont know one point was awarded for each correct response 4 risk awarenesswe asked participants to rate on a fivepoint likert scale about the likelihood of occurrence of emergency events in relation to natural disaster accidental disaster public health and social safety events attitudes towards emergency preparednessrespon dents were asked to rate their attitudes and beliefs towards emergency preparedness five questions were asked for this purpose each being assessed on a fivepoint likert scale the questions were i do not believe preparation will make any difference in emergency events i am very interested in emergencyrelated informationnews i pay special attention to all kinds of warnings issued by governmental authorities i often discuss with my friends and family members about emergency response i have confidence on governments in responding to emergencies 6 selfefficacyrespondents were asked to rate their own ability to respond to emergencies and mitigate risks on a fivepoint likert scale those considered factors can find their foundations from a few theories for example theory of rational action 17 which believes that human behaviours are consciously influenced by individual attitudes banderas selfefficacy theory which addresses the confidence and ability of a person to adjust and control his her own behaviours trantheoretical model which emphasises the importance of both internal and external factors for driving changes in human behaviour 18 and kap theory which puts knowledge attitudes belief and action in sequence with each serving as a precondition for the latter one 19 statistical analysis the outcome variable was treated as a nominal measure well prepared versus poorly prepared we calculated dimensional scores for knowledge risk awareness attitudes towards preparedness and selfefficacy and then transformed them into a nominal measure above average versus onbelow average χ 2 tests were performed to determine the differences in emergency preparedness across different levels of independent variables a multivariate logistic regression model was adopted to identify the extent to which the independent variables were associated with outcome measures an enter regression based on the maximum likelihood estimation method was used with an enterexit criterion of 005010 all statistical analyses were performed using spss v190 results participant characteristics slightly less than half of respondents were in the age between 31 and 50 years women comprised 56 of the respondents most respondents lived in an urban community the majority were married at the time of the survey more than half of respondents completed senior high school level of education a household monthly income of between ¥2000 and ¥4999 accounted for 53 of all respondents less than 5 of respondents were rated as wellprepared that is possessing all five essential emergency items while more than 95 of respondents did not possess any emergency items at all emergency preparedness was found to be associated with gender age residential location education household income past experience with emergency exposure to awarenessraising as well as knowledge risk awareness attitudes and selfefficacy women older people urban residents and those who completed senior high schools and had a higher household income were more likely to be rated as well prepared the respondents who had previous experience of emergencies and exposure to awarenessraising had a higher percentage of well prepared than those who did not higher levels of knowledge risk awareness selfefficacy and positive attitudes towards emergency preparedness were positively correlated with preparedness outcomes marital status and living with a child were not found to be associated with emergency preparedness logistic regression analysis on emergency preparedness in the multivariate logistic regression model 11 independent variables were included which had statistical significance in χ 2 test seven independent variables were identified as significant predictors for emergency preparedness women and those who had a higher household income were more likely to be rated well prepared previous experience with emergency higher levels of knowledge about emergency risk awareness selfefficacy as well as positive attitudes towards emergency preparedness were also significant predictors for emergency preparedness however neither educational attainments nor exposure to awarenessraising featured in the logic regression model as a significant predictor for emergency preparedness reasons of poor preparation for emergency lack of awareness and knowledge about emergency was cited by the respondents as the most important reasons of poor preparation for emergency more than half of poorly prepared respondents did not know what to do while over 30 simply disregarded emergency preparation as an issue that affected them more than 20 of respondents preferred to leave emergency preparedness in the hands of professional workers blame the government and media for limited information disclosure orand maintain optimistic perspective hoping that any disaster will not befall them interestingly 15 of respondents attributed their poor preparedness to limited access to resources such as time money and personal ability further data exploration revealed that mass media was the major contributor to emergency knowledge with more than 777 respondents being exposed to it closely followed by personal communications by contrast educational programmes were an information source for only 158 to 221 of respondents most respondents had never participated in emergency response exercises discussion the level of emergency preparedness in heilongjiang residents is very low fewer than 5 of respondents reported having essential emergency supplies in hands and 95 possessed no items in the emergency supplies checklist such a low level of emergency preparedness has also been found in studies undertaken elsewhere in china 20 21 despite differences in data collection methods it is evident that the us populations have a much higher level of emergency preparedness compared with chinese populations fema reported that 57 of us citizens have emergency supplies prepared and ready to be used solely in the case of a disaster 6 as found in the literature poor knowledge and attitudes towards emergency preparedness are the major factors that have contributed to the low level of community preparedness outcomes 22 significant associations between preparedness outcomes and individual knowledge and attitudes have been demonstrated in the χ 2 tests the multivariate regression model and the subjective perception survey in this study more than half of the poorly prepared respondents simply did not know what to do knowledge and attitudes towards emergency preparedness were found to have the greatest or in the multivariate regression model on preparedness outcome indeed knowledge and attitudes are regarded as a key driver of human behaviours in several behavioural theories 23 although financial capability remains as a significant factor influencing emergency preparedness the study participants perceived limited resources and ability to prepare as a contributor for a very small proportion of poor preparedness outcomes nevertheless there is an increased need for help in emergency for the households with low income 24 25 effective education and exercise can help community residents recognise and identify hazards to improve their understanding about how to respond 26 27 this study showed that mass media is perhaps the most important channel for people to obtain information about emergency it is important to note that educational attainments and exposure to awarenessraising were not found to be associated with emergency preparedness obviously educational campaigns need to be carefully designed and tailored to the needs of their audiences an effective communication and education programme should target the most important audience in a way that is most appropriate to the audience women for example may play a critical role in community emergency preparedness 28 29 this study likewise found that women are more likely to be prepared for emergencies than men the finding is somehow different from that of the fema study 6 in which us men were reported having a higher level of emergency preparedness such inconsistency may have actually reflected cultural differences in china women are usually responsible for shopping and housing arrangements and thus determine what items to be stored at home risk awareness should also be a key element in emergency education programmes several studies confirmed that individuals with low risk awareness are less likely to respond to warnings and undertake preparatory actions compared to those with higher risk awareness 30 31 32 risk awareness plays an important role at the early stage of the continuum from information attainment to behavioural changes 33 it encourages people to seek information gisela wachinger proposed a heuristic framework to understand the relationship between risk perceptions and individual behaviours 34 three factors may mediate the relationship experience and motivation trust and responsibility and ability we found that past experience with emergencies is associated with improved preparedness it is understandable that those who have experienced with emergency events may have increased awareness of the importance of preparedness 35 in general they tend to be more proactive in obtaining knowledge and information and taking preparatory actions 36 37 38 39 40 41 however those who have not experienced personal damage during a hazardous event are less likely to believe that a future event may bring harm to them which may jeopardize their preparatory efforts 42 a survey conducted in gansu reported that past experience with disastrous events was associated with risk perceptions but the perceptions failed to translate into preparatory actions 43 some researchers argue that there is not necessarily a direct link between awareness risk perception and desired preparation or behavioural response 27 perceived coping ability may mediate the link between risk awareness and emergency preparedness outcomes external conditions may also alter the course of actions 44 emergency response exercises could help build the link between risk awareness and preparatory actions 13 limitation this study has several limitations the questions measuring awareness and preparatory behaviours for emergency were intentionally made broad covering four types of events the broad notion and nonspecific events may cause unclear or vague responses from some participants especially in those with low levels of education however the questionnaires were administered through facetoface interviews and all of the interviewers had been made aware of this potential problem to minimise such a bias owing to limited resources the survey was

objective this article aims to identify factors that shape the knowledge attitudes and behaviours of community residents in chinas heilongjiang province towards emergency preparedness findings of such a study may provide evidence to support the development of effective public risk communication strategies and education campaigns design a crosssectional household questionnaire survey was conducted in heilongjiang province in 2014 a stratified cluster sampling strategy was employed to select study participants the questionnaires were administered using facetoface interviews 2800 questionnaires were completed among which 2686 959 were considered valid for data analyses a multivariate logistic regression model was adopted to identify the extent to which the independent variables were associated with emergency preparedness results fewer than 5 respondents were well prepared for emergency over half 52 of poorly prepared respondents did not know what to do in emergency women or1691 higher household income or ranging from 1666 to 2117 previous experience with emergency or1552 higher levels of knowledge about emergency or2192 risk awareness or1531 selfefficacy or1796 as well as positive attitudes towards emergency preparedness or2265 were significant predictors for emergency preparedness neither educational attainment nor exposure to awarenessraising entered into the logic regression model as a significant predictor for emergency preparednessheilongjiang residents is very low which is linked with poor knowledge and attitudes of the residents towards emergency preparedness future emergency awareness campaigns should be more focused and tailored to the needs of intended audience taking into consideration of their usual source of information and knowledge in relation to emergency

introduction covid19 has had a major impact on how care is provided with a shift to a greater dependence on telehealth services since the outbreak of the covid19 pandemic there have been over 97 million confirmed cases of covid19 infection and over 106 million deaths in the united states alone 1 hispanics are the second largest racialethnic group in the us making up 189 of the total us population 2 during the initial surge of the covid19 pandemic in 2020 the death toll among hispanics was five times greater than in nonhispanic whites 3 due to the highly contagious nature of the virus and the ease of transmissibility of this airborne disease 4 outpatient healthcare services transitioned to more telehealth appointments and restricted inperson visits it was reported that health centers funded by the health resources and services administration experienced a 154 increase in telehealth visits during the first quarter of 2020 compared to the prior year 5 however the adoption of telehealth has been slower in the field of cancer compared to other fields but the uptake of telehealth has been steadily increasing in cancer care 6 the array of cancer care offered via telehealth ranges from remote chemotherapy supervision to symptom and disease management to survivorship and palliative care 7 cancer patients reported overall satisfaction with telehealth 89 and supported the use of telehealth in the future 910 the reported advantages of telehealth were multifold such as time cost and travel savings 91112 in addition telehealth was perceived as beneficial by taking place in a comfortable home environment 911 as well as avoidance of potential exposure to the covid19 virus 9111314 despite the benefits of telehealth patients with cancer face challenges in adapting to the changing healthcare environment during the pandemic cancer patients concerns and challenges relating to telehealth include limitations in conducting physical examinations 9 15 16 17 building a connection in the patientclinician relationship 91118 providing a hard copy of the prescription for medication 9 and having poor internet connectivity 9 a growing body of literature has found that telehealth use via video is challenging for certain populations such as older adults 19 those with less than a high school education or limited english proficiency and among racial and ethnic minorities due to digital literacy accessibility and the operation of technology 20 21 22 23 compared to whites racial and ethnic disparities in accessing the internet and technology exist where black and hispanic americans are less likely to own a desktop or laptop computer or have a broadband connection at home 24 a previous study found that despite positive attitudes toward the use of telehealth the majority of the hispanic population in the us and along the usmexico border were unfamiliar with the term telehealth 25 in addition most telehealth systems have operational limitations for medical interpreters causing a challenge for patients with limited english proficiency 26 patients with limited english proficiency including hispanics were less likely to use telehealth and experienced an overall decrease in quality of care compared to hispanics who spoke english 14 26 27 28 those with limited english proficiency were associated with lower levels of education higher levels of poverty and being uninsured 22 while previous studies provided valuable information about racial and ethnic gaps in access and the use of telehealth 142628 studies with hispanic cancer patients who may be socioeconomically disadvantaged are limited with the rapid adoption and sustained uptake of telehealth in oncology telehealth services continue to be integrated into the standard care practice beyond the covid19 pandemic 29 hence it is critical to explore the areas of benefits and challenges related to telehealth use from the perspectives of underserved hispanic breast cancer patients this study aims to build upon the existing scientific literature by examining these potential benefits and challenges and highlight proposed strategies to address these challenges thereby improving the patient healthcare experience with the advent of increasing telehealth use materials and methods study design and setting a qualitative study based on indepth interviews was conducted in collaboration with a local nonprofit cancer organization located near the usmexico border in san diego county california this organization mainly serves cancer patients with lowsocioeconomic status by providing healthrelated and psychosocial support participants and recruitment procedures convenience and purposive sampling methods were employed to recruit potential participants the eligibility criteria included selfidentification as a hispanic female at least 18 years of age the receipt of a breast cancer diagnosis and a display of cognitive competence a staff member from a partner organization assisted with accessing and recruiting potential participants and interested persons were provided an irbstamped recruitment flyer initially there were 53 individuals who expressed interest in the study and were referred to a bicultural and bilingual research assistant for further screening five individuals did not meet the eligibility criteria among the remaining 48 potential participants 8 individuals later changed their minds due to various reasons 8 failed to show up for their scheduled interviews and 5 could not be reached thus the total study sample size was 27 the study procedures were approved by the institutional review board at san diego state university data collection indepth interviews were conducted between march and june 2021 the stay athome order was implemented starting in march 2020 in california usa and travel restrictions were put into place including the usmexico border closure during the study period interviews were conducted via videoconference or phone call by a trained research assistant using a semistructured interview guide with probes the questions included how has your experience been of having to interact with your healthcare team via telehealth for your cancer care what has been particularly helpful or challenging about communicating with and receiving care via telehealth how different is your feeling between receiving telehealth and a facetoface meeting what would be needed to make telehealth work effectively for you and what types of help might be needed for communication and cancer care via telehealth interviews were conducted either in english or spanish based on participants preference and lasted an average of approximately 40 min to one hour all interviews were audiorecorded for later transcription quality checks were conducted by the principal investigator in consultation with the research assistant to address any questions supplementary field notes were documented by the research assistant such as description about the setting situational events that occurred during the interview and participants nonverbal behaviors these notes added contextual information and provided insights for improving and maintaining consistency for future scheduled interviews data analysis each interview was audiorecorded transcribed and translated from spanish to english by another research assistant in order to ensure the accuracy of the translation the two research assistants engaged in discussion and validation of the translation of the document when deemed unclear researchers employed a reflexive thematic analysis approach to identify emergent themes and salient patterns from the interview transcripts 30 fn and ek were researchers with prior experience conducting and analyzing transcripts in qualitative research studies the use of two coders helped establish intercoder reliability the manual coding of the data was conducted separately by both coders and open coding was performed independently by these two coders each coder identified and developed an initial list of open codes and corresponding quotes from the transcripts illustrating those codes the coders continually met to discuss and create a final list of agreedupon open codes both coders also formed their own thematic categories based on their open codes and eventually a final set of major themes was generated after the two coders reached a consensus this process which included combining themes that were similar and rephrasing the themes improved the clarity and trustworthiness of data interpretation lastly the selected quotes in the results section were based on an agreement between the coders as to which quotes best illuminate the final set of themes the initial analysis focused on topics in the interview guide and other concepts brought up during the interviews topics included the advantages of telehealth use the challengesdisadvantages of telehealth use and the suggested improvements to make telehealth more effective perceived challenges and potential suggestions to improve telehealth were simultaneously derived then the suggestions proposed were aligned and linked to a reported challenge as a possible strategy to improve telehealth results participant sociodemographic characteristics and cancerrelated information the participants sociodemographic characteristics and cancerrelated information are reported in table 1 the average age of the participants was 544 years old almost half of the participants completed high school followed by some college about 593 reported an annual household income of usd 30000 or less the majority of the indepth interviews were conducted in spanish twothirds possessed a smartphone while 222 had access to both a smartphone and landline phone and 111 only had a landline phone more than half of the sample were diagnosed with breast cancer less than one year before their scheduled interview date and onefourth were diagnosed between one and two years ago about 41 were diagnosed with stage 2 breast cancer and about 22 were unsure about their breast cancer stage advantages of telehealth use a summary of the perceived advantages disadvantages and suggestions to address the disadvantages is reported in table 2 table 2 themes of telehealth use advantages disadvantages and suggestions to address disadvantages advantages of telehealth disadvantages and suggestions to address disadvantages of telehealth simplification of logistical issues telehealth services were perceived as beneficial in various ways that are categorized into three main areas logistical and financial aspects availability of others and personal safety first advantage logistical simplification telehealth was valued for its convenience participants were able to attend the appointment from their home which made it comfortable for them to join the appointment in a familiar environment i didnt have to go to the doctors office so i really enjoyed that i didnt have to leave my house and the doctor was able to tell me though video call my results so it is just easier everything was fast and efficient without having to leave my house telehealth required less time to get ready for the visit and provided more flexibility in scheduling since there was no need to travel additionally since commuting was not needed for the telehealth appointment one participant noted how telehealth can help overcome transportation barriers transportation can be a challenge if participants do not have access to a car or need to rely on others for a ride such as family members who may be busy working the fact that they appointments can be at whichever time is convenient for me and not have to worry about who is going to take me and who is going to pick me up it takes a weight off my shoulders when the appointments are in this method second advantage financial savings telehealth was noted as having the potential for monetary savings participants may avoid having to pay certain fees such as a copay as a cost sharing charge under a health insurance plan for a telehealth visit compared to the customary fee assessed for an inperson office visit saving on the copayi just saved myself 20 bucks and got the same info it makes me happy just knowing i didnt have to spend money at all other people like going in id rather do it on the phone for those same reasons not having to spend money third advantage faster access and longer duration spent with clinicians another advantage reported with telehealth use is being able to have quicker access to clinicians ranging from being offered an earlier appointment date to the time spent during the actual heath visit participants may have preferred a telehealth visit since it was clinicianinitiated and there was no wait time to be seen by the clinician as opposed to time spent waiting in the consultation room during an inperson visit well because you are basically being treated the moment you call them since my blood pressure was really high i didnt know what to do and my doctor was able to help me out immediately i think it was a great experience additionally p54 noted that she felt that the telehealth visit felt less rushed with the clinician due to the potentially longer duration of the appointment it telehealth has been good because i am able to tell my doctor about everything i feel and the consultations are much longer on the phone than inperson during an inperson consultation they check my vitals examine my lungs and heart sometimes the consultations take 57 min but when we are on the phone the consultations usually last 1520 min fourth advantage presence of family members participants identified family support as having an important role in the participants healthcare experience the physical presence of a family member was useful in helping communicate with the clinician such as helping translate asking additional questions on behalf of the patient and providing clarification family members could continue to attend the appointments with the patients via telehealth compared to limitations restricting others to accompany patients during an inperson visit a family member can be there with me listening to what the doctor is saying they might even ask questions that i would not be able to think of because either shocked or still trying to process the situation the fact that i can have someone there helps clear my doubts and ask questions that i might not think about asking the truth is there can be more than one person next to you and that gives you more heads to think when i have them there they are able to remember questions we had previously discussed that i would have completely forget to ask if i had been there by myself fifth advantage safeguard from covid19 exposure safety from potential covid19 exposure was another perceived benefit of telehealth participants were fearful of contracting covid19 at the clinic particularly due to the risk of being around other people during a telehealth appointment exposure to covid was minimized by avoiding a potential crowded and indoor space but right now with covid i think video call is best it is kinda scary when you go to the doctor sometimes because there may be a lot of people of course they take precautions of the times that i have been to the radiology clinic there have been a small amount of people there might have been only four or five and i liked that there werent many people every seat was six feet apart and i liked that disadvantages of telehealth use and potential suggestions to address disadvantages despite the perceived advantages of telehealth the majority specified that they preferred inperson office visits over telehealth visits and if given a choice telehealth appointments via video rather than phone calls there were three general themes identified as disadvantages of telehealth clinical care limitations diminished engagement with clinicians difficulty of interpreter accessibility and technological challenges the main recommendations were aligned with the identified disadvantages of telehealth listed in table 1 and both the identified disadvantages and suggested strategies to address them are discussed below several participants had negative perceptions of telehealth related to the inability to have a physical examination performed some questioned the thoroughness of the health visit due to the lack of a handson clinical checkup such as one participant who expressed some doubt it is not the same looking at a camera and being able to physically be with them on a call the doctor wont be able to see if your throat is swollen or if something is hurting it does generate a form of insecurity for example lets say i feel a lump and we are talking on the phone there is no way for the doctor to look it over because he is just on the phone participants felt more assured if the clinician performed a handson physical rather than only relying on a verbal inquiry about the reported symptomology of the patient particularly for appointments with an oncologist rather than a general practitioner also being able to be with the doctor and have them check up on you as much as i try not to worry i sometimes worry about having something an irregularity so then the doctor can check my breasts and the glands on my throat neck and underarms after she checks and sees that there is nothing irregular i can go home in peace suggestion to address the first disadvantage consider the nature of the visit by purpose and severity of medical symptoms a few participants referred to less urgent visits as simple or general appointments where a discussion between the patient and clinician would suffice via telehealth the types of discussion were based on various purposes that would not require a physical examination such as an explanation about a new prescribed medication a followup visit to touch base with the clinician a discussion of test results or an explanation of upcoming procedures i think a video call should be used when you tell your doctor what is wrong with you and then they can decide if you actually do need to go to the doctors office or they could just give you a prescription over the video call kind of like a screening second disadvantage limitations in building rapport and engagement with clinicians some participants perceived that there was less of a social connection with the clinician when conducted via telehealth particularly in terms of communication and development of patientphysician rapport p64 articulated that telehealth can restrict and limit patients sense of engagement inperson it is much more personal because you get to properly communicate and look at each other face to face i find it very important because i like to see their expressions and just have a facetoface conversation it is very important to trust your doctor and i feel like that can only be achieved by seeing each other in person in addition telehealth visits were perceived to be less effective in fostering trust compared to an inperson office visit between patients and clinicians p9 explained how facetoface interaction provided better emotional support than a telehealth visit it is not the same thing when they see you through video when you have cancer and not have them extend their hand for them to tell you to be honest these results did not turn out how we expected that emotion is not the same one that they transmit through a phone as opposed to a facetoface meeting for example if i get emotional and cry you or a doctor might think what do i do how do i comfort her i cant give her a pat on the shoulder and tell her everything will be okay suggestion to address the second disadvantage initial inperson visit and followup telehealth visits a suggestion that can help foster the patientclinician relationship relates to the timing of offering telehealth services in the continuum of care the first appointment prior to introducing telehealth could be scheduled as an office visit so the patient is able to meet the clinician inperson and then subsequent appointments could be scheduled as telehealth visits after establishing initial rapport for my appointment with the doctor i was asked if i wanted it to be an inperson consultation or on the phone i picked inperson because i wanted to meet her and wanted the doctor to check how i was doing the first time i met her we talked about my medications and everything in my file i personally like to trust my doctors and i also want them to get to know me more third disadvantage difficulties with interpreter assistance being able to have proper access to interpreters was also identified as a challenge in telehealth translation services may have been offered during the health visit but the mechanism of delivery via telehealth encountered issues such as the patient being unable to clearly hear the interpreter p46 recalled an experience when the interpreter connected via a different platform and indirectly communicated with the clinician and patient who were on a separate platform you know what happened the problem was that the nurse had the translator on the phone when one goes to the appointments inperson there is a phone that they use to call in a translator so during our video call i was talking to the nurse through zoom and she had the translator on speaker with one of those phones that they use the translator never actually joined the meeting on zoom because of that i was not able to hear what they were saying suggestion to address the third disadvantage joint telehealth visits with an interpreter one proposed strategy to overcome this barrier is to have an interpreter attend with the clinician onsite at the healthcare facility or to ask the interpreter to directly join the phone call or video chat for improved clarity having the translator actually attend the zoom meeting would be helpful whether it be that they are in the same room with the doctor or nurse that i am talking to or if they could join the meeting using their own separate device fourth disadvantage technologyand logisticsrelated challenges technologyrelated issues were another disadvantage commonly reported by participants when using telehealth services since the use of video chat may be novel for instance digital literacy was low for nearly half of the participants who stated that they were unfamiliar with how to use the technology required for telehealth visits however the issues that were encountered were not only attributed to technological advancements technical problems may arise stemming from unstable internet connectivity and audio issues not being able to hear can hinder a productive visit if the patient cannot understand the clinician this other time i was on a video call with my endocrinologist and translator for some reason my audio sounded so odd i could hear my audio cut off and sound like a robot so it wasnt so easy to have a conversation we just had to repeat everything over again and wait for the audio to sound better it was important we waited until we could all hear clearly because i needed to ask questions about some medications that i was taking participants also expressed the difficulties of having to remember information to log into a video chat for instance zoom was a common video chat platform mentioned among participants for telehealth visits to begin with i dont know how to make a video call i used to have one email account but i forget the password to that one so i had to create a new one so now i get mixed up between those two emails when i am told to provide an email for the zoom i am not sure which one to give telehealth visits also may encounter logistical challenges due to missed appointments missed appointments may translate into scheduling issues that may disrupt the continuity of cancer care i missed my session because i forgot about telehealth appointment and then she accidentally scheduled me for the date i had radiation so it has been like a month since i last saw her i have to contact her department in order to fix that and have her schedule me for other days that dont fall under my radiation days another participant also commented about not being able to properly identify who was calling she felt compelled to answer calls even though she did not recognize the number since she was waiting for the clinician to call theyll tell you sometimes that i have to answer every call that comes through until i get my call from the clinic because i dont pick up numbers i dont recognize scam calls and all that stuff so having to pick up scan scam calls is an inconvenience suggestion to address the fourth disadvantage tutorial and it assistance participants acknowledged that the use of such technology in telehealth services is a growing norm it was suggested that if patients are taught about how to use video chats for telehealth visits then they can learn to adapt and become more selfsufficient in accessing telehealth a suggested strategy is for health systems to provide assistance to navigate the technology used for telehealth visits and improve patients digital literacy such as offering a tutorialtraining or oneonone information technology assistance in general it assistance may not be readily known or available for patients for someone to show me how to use zoom i would like to take a course on thatwe moved to these senior apartments not too long ago and since its only older people who live there there is a classroom where they teach you how to use the computer they are not doing it currently but i think it would be good to take a class like that one day additional suggestion to address the fourth disadvantage calls and appointment reminders one suggestion to avoid missed telehealth appointments was to encourage a phone call reminder about an upcoming scheduled visit for instance p39 recommended a reminder to be sent prior to the scheduled time i would like to have a reminder i think it would be better if they called me like 1520 min prior to my appointment so i could start filling out all those online forms and getting my medications ready so that is definitely something that could really make it easier for me another participant noted that if there was a narrow time frame set for the receipt of the telehealth appointment via telephone then there would be likely less risk of picking up during a scam call i havent encountered any problems other than i have to make sure that if im expecting a call then its going to be between 1 and 2 i dont have to deal with that scam calls then its like ok i got my appointment and now im not answering any other calls discussion the present study aimed to explore the perceived advantages and challengesdisadvantages of telehealth among hispanic females diagnosed with breast cancer the future of telehealth continues to grow and become more commonplace as more patients may use and prefer this medium of care the delivery of telehealth services in this study was discussed by participants via telephone and computers in general the major identified themes were in alignment with the previous literature and potential strategies to mitigate the challenges were reported advantages of telehealth convenience time savings and fiscal savings our participants reported that a major advantage of telehealth was attributed to convenience and time savings as similarly reported in prior research 12141517 participants noted that they were able to save time by avoiding traffic and not having to travel which can be particularly beneficial for those who have a longer commute and must come from a rural area 1214 additionally participants mentioned the convenience of increased flexibility in scheduling and shorter wait times for telehealth compared to inperson visits which is a sentiment that was echoed in other studies 1415 financial benefits were another reported advantage such as travelrelated savings by conserving gas and avoiding parking costs 912 our study participants were of lower socioeconomic status although we did not measure the travel distance to the clinic travel costs including the price of gas can impose a significant financial burden since january 2021 gas prices rose by usd 1 by the end of the year with the highest costs for gasoline being charged on the west coast 31 in addition study participants noted savings from avoiding a copay for telehealth visits waiving copays for a telehealth visit could provide financial relief but this savings may only be temporary for some medical plans 32 any type of savings is important to consider since telehealth studies have shown that those who have lower socioeconomic status tend to use telehealth less 1228 another major advantage of telehealth was the ability to have others present during the appointment in general family members and caregivers have commonly served as ad hoc interpreters for patients in healthcare settings 3334 however during the covid19 pandemic health centers imposed strict visitor policies limiting inperson appointments mainly to patients 14 hence telehealth was highly valued because it allowed family members to attend alongside and assist patients with translation and communication with clinicians it can also reinforce a core cultural value of familism for hispanic patients where collective reliance on the family may play a role in health decisionmaking 35 challenges to telehealth and suggestions similar to previous research 9 15 16 17 our study participants raised a concern about telehealth limiting handson care they may perceive their care as suboptimal due to the clinicians inability to physically examine a lump or to check a physical pain via telehealth currently there are no practice guidelines available or empirical data supporting virtual physical examinations for oncological care 17 to address this clinical limitation participants suggest scheduling inperson visits for appointments when a physical examination may be required or sensitive information needs to be conveyed for instance a poor cancer prognosis or the disclosure of a new cancer diagnosis by clinicians may be preferred during an inperson visit and clinicians would be able to physically comfort patients if needed 91336 appointments via telehealth can be scheduled as a followup after an inperson visit or appointments to discuss medication management it is important to consider the nature of the appointment to determine the appropriateness when deciding between an inperson or telehealth visit 12151637 our study participants also acknowledged the limitations of telehealth use in building rapport between patients and their clinicians a systematic review with cancer patients 18 yielded similar results stating that telehealth can be considered impersonal and lacking in personal engagement with clinicians a proposed strategy is to consider the nature of the relationship with the clinician when scheduling a telehealth visit an initial facetoface appointment could be integral for establishing rapport when meeting a clinician for the first time while subsequent appointments can be scheduled via telehealth for routine visits in order to maximize the benefits of both telehealth and inperson appointments trust can further foster in the patientclinician relationship in telehealth visits after a relationship is first established inperson 38 another challenge of telehealth was the coordination of interpreter services for example one participant noted that the interpreter communicated with the clinician via phone while the clinician was meeting with the patient via video chat rather than all three being on the same video platform together this can create confusion and negatively impact the quality of patientprovider communication reliance on the use of a formal interpreter is essential for healthcare equity in response participants suggested the capability of having the interpreter directly join a telehealth visit via video chat so multiple people are able to attend the appointment in a systematic review comparing patient satisfaction between inperson telephone and video interpreting services the majority preferred the use of a professional interpreter rather than an ad hoc interpreter there was also no difference in satisfaction between the receipt of video and inperson interpreter services where telephone interpreters were least preferred 39 lastly digital literacy is a critical consideration during the onset of a rapid expansion of telehealth services consistent with the findings from previous studies 9212640 participants reported technologyrelated issues such as unfamiliarity with how to use video chat and a lack of stable internet connectivity the digital divide in utilizing ehealth technology can exacerbate disparities for certain populations particularly racial and ethnic minorities lowincome communities and older adults who may not have access or be familiar with such technology 212340 a potential strategy suggested by our participants is the introduction of a helpline that patients can call for it assistance during business hours this type of assistance could assist in overcoming the challenges of low digital literacy and help troubleshoot technological issues for telehealth visits our participants also addressed challenges in remembering how to log onto a video chat and forgetting about a telehealth appointment a study by gomez and colleagues 16 recommended patients receive a call 30 min prior to the telehealth appointment which was similarly suggested in our study as a few minutes prior to the scheduled visit to help reduce missed appointments another potential reason for missed appointments is the inability to recognize the caller which was also a concern reported in a 2022 study by smith and colleagues 9 perhaps having a narrow time frame between the receipt of a reminder and a scheduled appointment could help prompt patients about the upcoming telehealth visit via telephone particularly if the caller identification is not shown overall our study participants suggestions can serve as potential recommendations to help overcome the challenges of telehealth and improve the patient healthcare experience study strengths and limitations this study contributes to the scientific literature by focusing on a sample that is normally not highly represented including those with low english proficiency and minorities with breast cancer and those underrepresented in research such as participants of low socioeconomic status and hispanic descent however it is noteworthy to mention some limitations in our study one limitation is that our participants were recruited from one study site in an urban setting and we used nonprobability sampling methods which can limit the generalizability of findings to other hispanic breast cancer patients living in different geographic locations another limitation is that telehealth capacities may vary depending on the region as rural hospitals were found to be less likely to have robust telehealth systems for patient engagement compared to those in metropolitan areas 41 future studies recruiting participants from multiple sites in both rural and urban areas may expand our understanding of potential barriers and needs for telehealth care in addition future studies can include family members to provide supplemental advantages and challengesdisadvantages of telehealth although family involvement in cancer care is common across raceethnicity the role of family is critical among hispanic populations exploring families experiences and perspectives relating to patient care via telehealth may provide valuable information and guidance for telehealth practice improvement conclusions as we move into a different phase of the covid pandemic as an endemic this study provides insight and recommendations for improvements in telehealth use to better address the needs of patients with cancer with the rapid onset of the pandemic health systems had to quickly adjust and transform how care was provided while cancer patients were faced with the double burden of having to overcome health challenges and racial and ethnic disparities due to telehealth challenges it is imperative for clinicians to assess telehealthrelated concerns among the underserved population and provide culturally appropriate services accordingly although the majority of study participants still preferred the traditional delivery of inperson care over telehealth services healthcare providers should take into consideration the patients preference when possible and ensure equity in the delivery of care when maneuvering through the digital divide more research is also needed to understand telehealths impact on the quality of cancer care it is of equal importance to evaluate issues related to disparities due to the growing use of telehealth services particularly for negatively affected groups including the hispanic community those with low incomes and people with limited english proficiency data availability statement the datasets generated and analyzed during this study are available from the corresponding author on reasonable request institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and was approved by the institutional review board of san diego state university informed consent statement informed consent was obtained from all subjects involved in the study

during the covid19 pandemic telehealth use rapidly grew while its uptake steadily increased in cancer care prior research has reported existing racial and ethnic disparities in telehealth with hispanics reporting lower rates of use compared to other major racialethnic groups our study examined the perceived benefits and challengesdisadvantages faced by hispanic females diagnosed with breast cancer in san diego county california indepth interviews were conducted with 27 participants who were mostly spanish speaking the recordings of the interviews were transcribed and translated from spanish to english reflexive thematic analyses revealed both potential benefits and challenges of telehealth the perceived benefits included logistic and financial aspects such as convenience and timefinancial savings faster access and longer duration spent with clinicians the availability of family members and the minimization of covid19 risk the reported challengesdisadvantages of telehealth and the suggested strategies to address them focused on limitations in clinical care diminished engagement with clinicians difficulty accessing interpreter services and technological access and challenges the covid19 pandemic has greatly affected the landscape of how care is provided with a greater shift to telehealth services more research is needed to further examine the challenges of telehealth particularly for groups that are disproportionately affected to avoid the disruption of patients cancer care and to promote a better patient healthcare experience